Osteoarthritis

Introduction:

Osteoarthritis (OA) is the most common form of arthritis. It is a joint disease caused by the breakdown of cartilage -- the firm, rubbery tissue that cushions bones at joints.

Healthy cartilage allows bones to glide over one another, and cartilage absorbs energy from the shock of physical movement. In OA cartilage breaks down and wears away. As a result, the bones rub together causing pain, swelling, and stiffness.

OA may also limit the range of motion in affected joints. Most often, OA develops in the hands, knees, hips, and spine.

The disease affects men and women nearly equally. More than 20 million people in the United States have OA. Symptoms tend to appear when individuals are in their 50s and 60s.

Signs and Symptoms:

Signs and symptoms of OA may include the following:

• Joint pain (often a deep, aching pain) that is worsened by movement and improved with rest (in severe cases, a person may experience constant pain)
• Stiffness in the morning or after being inactive for more than 15 minutes
• Joint swelling
• Joints that are warm to the touch
• Crunching or crackling noise when the joint moves (crepitation)
• Limited range of motion
• Muscle weakness
• Abnormal growth of bony knobs near joints which cause deformities (such as Heberden's nodes, in which bumps appear on the outermost finger joints)

Causes:

Most of the time, the cause of OA is unknown. It is primarily a disease due to aging. However, metabolic, genetic, chemical, and mechanical factors can play a role in its development.

Risk Factors:

Risk factors for OA include:

• Increasing age
• Genetic predisposition
• Obesity
• Injury to the joint
• History of inflammatory joint disease
• Metabolic or hormonal disorders (such as hemochromatosis and acromegaly)
• Bone and joint disorders present at birth
• Repetitive stressful joint use (such as with occupations like baseball, ballet dancing, and construction work)
• Deposits of uric acid crystals in joints

Diagnosis:

There is no single test to diagnose OA, so most doctors use a combination of methods to diagnose the disease and rule out the possibility other causes. A physical exam can show limited range of motion, grating of a joint with motion, joint swelling, and tenderness. An x-ray of affected joints will show loss of the joint space and, in advanced cases, wearing down of the ends of the bone and bone spurs.

Preventive Care:

The following measures may reduce the risk of developing OA:

• Protecting an injured joint from further damage
• Exercising
• Losing weight
• Avoiding excessive repetitive motions

Treatment:

The goals of treatment are to relieve pain, maintain or improve joint mobility, increase the strength of the joints, and minimize the disabling affects of the disease. The specific treatment depends upon the affected joints. A combination of conventional treatment and complementary and alternative medicine (CAM) may be most effective. Lifestyle approaches, including exercise, and many alternative medical therapies are becoming more popular and are considered safe and effective for the treatment OA.

Several natural remedies are at least as effective as conventional medication for symptom relief, and may help keep the disease from getting worse. Americans spend more on natural remedies for OA than for any other medical condition. Some of the most promising complementary approaches for treating OA include:

• Reducing physical stress on the joint (lose weight and improve posture)
• Lifestyle changes (particularly exercise)
• Supplements including S-adenosylmethionine (SAMe), glucosamine and chondroitin, and antioxidants
• Herbs with anti-inflammatory properties, including boswellia, devil's claw, ginger, turmeric, white willow bark, and capsaicin (cream)
• Acupuncture, including TENS or transcutaneous electrical nerve stimulation
• Chiropractic
• Physical therapy and magnet therapy
• Yoga
• Tai chi

Exercise

Exercise to strengthen, stretch, and relax muscles around affected joints is almost always included in a treatment plan for OA. Several clinical studies support the value of exercise for people with OA. Clinical studies also suggest that in addition to reduction of pain and disability, exercise improves strength, range of motion, balance and coordination, endurance, and posture.

Medications

The most common type of medication used to treat osteoarthritis are nonsteroidal, anti-inflammatory drugs (NSAIDs). They are common pain relievers that reduce pain and swelling. Types include aspirin, ibuprofen (Motrin, Advil, Nuprin), and naproxen (Aleve, Naprosyn, Anaprox). Although NSAIDs work well, long-term use can cause stomach problems, such as ulcers and bleeding. In April 2005, the U.S. Food and Drug Administration (FDA) asked drug manufacturers of NSAIDs to include a warning label on their product that alerts users of an increased risk for stomach bleeding.

Other medications used to treat OA include:

• COX-2 inhibitors (coxibs) -- Coxibs block an inflammation-promoting enzyme called COX-2. This class of drugs was initially believed to work as well as traditional NSAIDs, but with fewer stomach problems. However, numerous reports of heart attacks and stroke have prompted the FDA to re-evaluate the risks and benefits of the COX-2s. Rofecoxib (Vioxx) and valdecoxib (Bextra) have been withdrawn from the U.S. market following reports of heart attacks in some patients taking the drugs. Celecoxib (Celebrex) is available and labeled with strong warnings and a recommendation that it be prescribed at the lowest possible dose for the shortest duration possible. Patients should ask their doctor whether the drug is appropriate and safe for them.
• Corticosteroids -- Also known as steroids, these medications are injected directly into the joint. They may also be used to reduce inflammation and pain. Steroids for inflammation inlclude prednisone (Deltasone) and dexamethasone (Decadron). Steroids, however, may cause side effects, such as weight gain, nausea, and fluid accumulation (edema). Steroids may also cause drug interactions. Ask a pharmacist or doctor.
• Artificial joint fluid (Synvisc, Hyalgan) -- These medications can be injected into the knee. They may temporary relief pain for up to 6 months.

Surgery and Other Procedures

Surgery to replace or repair damaged joints may be needed in severe, debilitating cases. Surgical options include:

• Arthroplasty (total or partial replacement of the deteriorated joint with an artificial joint)
• Arthroscopic surgery to trim torn and damaged cartilage and wash out the joint
• Osteotomy (change in the alignment of a bone to relieve stress on the bone or joint)
• Arthrodesis (surgical fusion of bones, usually in the spine)

Nutrition and Dietary Supplements

Following these nutritional tips may help reduce symptoms:

• Eliminate potential food allergens and foods that increase mucous production, including dairy (milk, eggs, cheese, sour cream, and ice cream), wheat (gluten), soy, corn, potatoes, cabbage, bananas, sugar, preservatives, food additives and excessive salt and meats. Your health care provider may want to test for food sensitivities.
• Eat more foods that decrease inflammation, including garlic, onions, watercress, horseradish, mustard, parsley, celery, rose hips tea, pickles, lemon, and anti-inflammatory oils (nuts, seeds, cold-water fish).
• Eat more foods containing digestive enzymes, such as papaya and pineapple.
• Avoid refined foods, such as white breads, pastas, and sugars.
• Eat fewer red meats and more lean meats, cold-water fish, tofu (soy, if no allergy) or beans for protein.
• Use healthy cooking oils, such as olive oil or vegetable oil.
• Reduce or eliminate trans-fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine.
• Avoid coffee and other stimulants, alcohol, and tobacco.
• Drink 6 - 8 glasses of filtered water daily.
• Exercise moderately, for 30 minutes daily, 5 days a week.

You can address nutritional deficiencies with the following supplements:

• Glucosamine/chondroitin, 500 - 1,500 mg daily, for joint health.
• Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tbsp. oil daily, to help decrease inflammation and improve immunity. Higher doses may be used by health care providers.
• A multivitamin daily, containing the antioxidant vitamins A, C, D, E, the B-vitamins and trace minerals, such as magnesium, calcium, zinc, and selenium.
• Digestive enzymes, 1 - 2 tablets three times daily with meals.
• Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant and immune activity.
• N-acetyl cysteine, 200 mg daily, for antioxidant effects.
• Acidophilus (Lactobacillus acidophilus), 5-10 billion CFUs (colony forming units) daily, when needed for maintenance of gastrointestinal and immune health. You should refrigerate your acidophilus products.
• SAMe (s-adenosyl-L-methionine), 100 - 200 mg before breakfast daily, to help decrease inflammation.

Herbs

Herbs are generally available as standardized, dried extracts (pills, capsules, or tablets), teas, or tinctures/liquid extracts (alcohol extraction, unless otherwise noted). Mix liquid extracts with favorite beverage. Dose for teas is 1-2 heaping teaspoonfuls/cup water steeped for 10 - 15 minutes (roots need longer).

• Green tea (Camellia sinensis) standardized extract, 250 - 500 mg daily, for inflammation, and for antioxidant and immune effects. Use caffeine-free products. You may also prepare teas from the leaf of this herb.
• Bromelain (Ananus comosus) standardized, 40 mg three times daily, for pain and inflammation.
• Turmeric (Curcuma longa) standardardized extract, 300 mg three times a day, for pain and inflammation.
• Cat's claw (Uncaria tomentosa) standardized extract, 20 mg three times a day, for inflammation.
• Devil's claw (Harpagophytum procumbens) standardized extract, 100 - 200 mg one to two times daily, for inflammation.
• Willow bark (Salix alba) standardized extract, 500 mg up to three times daily.

Capsaicin (Capsicum frutescens) Cream

Capsaicin is the main component in hot chili peppers (also known as cayenne). Applied to the surface of the skin, it is believed to deplete stores of a substance that contributes to inflammation and pain in arthritis. Several clinical studies have shown that capsaicin cream provided much better pain relief than a placebo but no improvement in joint swelling, grip strength, or function for people with OA. Pain reduction generally begins 3 - 7 days after applying the capsaicin cream to the skin.

Acupuncture

Several controlled clinical trials suggest that the ancient Chinese practice of acupuncture is an effective treatment for pain associated with OA, as well as for other aspects of the condition, including diminished joint function and reduced walking ability. In fact, a few clinical studies have shown that people with OA experience better pain relief and improvement in function from acupuncture than from NSAIDs such as aspiroxicam.

Chiropractic

Although there is no evidence that chiropractic care can reverse the joint degeneration that causes OA, some clinical studies indicate that spinal manipulation may:

• Increase range of motion
• Restore normal movement of the spine
• Relax the muscles
• Improve joint coordination
• Reduce pain

A comprehensive review of the scientific literature suggests that chiropractic, especially when combined with glucosamine supplements and rehabilitative stretches and exercise, is an effective supplemental treatment for OA. Chiropractors will avoid using direct thrusts or pressure on red, swollen joints.

Physical Therapy

Physical therapy can be useful to improve muscle strength and the motion at stiff joints. Therapists have many techniques for treating OA.

Manual therapy and supervised exercise may decrease or delay the need for surgery in individuals with OA. In a trial evaluating physical therapy and exercise in people with OA of the knee, participants who received manual therapy to the lumbar spine, hip, ankle, and knees showed the following improvements:

• Less stiffness
• Reduced pain
• Improved functional ability
• Improved walking distance
• Less need for knee surgery 1 year later

Magnet Therapy

Exposure to electromagnetic fields has boosted the number of cartilage-building cells and substances in laboratory experiments. One important study found that low-energy AC and DC magnetic fields stimulated the production of cartilage. For therapeutic purposes, users can apply magnets in one of two ways: directly to the skin surface over the bone or joint (capacitive coupling) or via pulsed electromagnetic fields (PEMFs) which induce an electrical current in the target tissue without making direct contact to the body (inductive coupling).

Clinical studies using either type of magnet therapy for arthritis are limited, and the few that exist have used poor methods, making it difficult to draw any definite conclusions. However, in one study of 78 people with OA of the knee, magnet therapy (applied to the knee for 6 - 10 hours per day over a period of one month) significantly reduced pain as compared with placebo.

Balneotherapy (Hydrotherapy or spa therapy)

Balneotherapy is one of the oldest forms of therapy for pain relief for people with arthritis. The term "balneo" comes from the Latin word for bath (balneum) and refers to bathing in thermal or mineral waters. Sulfur-containing mud baths, for example, have been shown to relieve symptoms of arthritis. However, hydrotherapy, which can be performed under the guidance of certain physical therapists, is occasionally used interchangeably with the word balneotherapy. The goals of balneotherapy for arthritis include:

• Improving range of joint motion
• Increasing muscle strength
• Eliminating muscle spasm
• Enhancing functional mobility
• Easing pain

Although balneotherapy is most often used for psoriatic or rheumatoid arthritis, some medical experts believe that it may be beneficial for OA as well. However, one large review of clinical trials found little evidence to support its use.

Ice Massage, Transcutaneous Nerve Stimulation (TENS), and Electroacupuncture

In a well-designed trial comparing the effectiveness of TENS, electroacupuncture, and ice massage for the treatment of knee OA, each of these methods were found toL

• Reduce pain at rest
• Reduce stiffness
• Boost walking speed
• Increase quadriceps muscle strength
• Increase knee range of motion

TENS is a technique used by many physical therapists. When the nerve stimulation of TENS is applied to acupuncture points, it is called electroacupuncture.

Mechanical Aids

A variety of mechanical devices, called orthoses, are available for people with OA to help support and protect joints. Made from lightweight metal leather, elastic, foam, and plastic, orthoses allow some movement within the affected joint and do not restrict nearby joints. For example, splints or braces help align joints and properly distribute weight. Shock-absorbing soles in shoes can help in daily activities and during exercise. Physical therapists use these mechanical aids most frequently to treat arthritic hands, wrists, knees, ankles, and feet. Orthoses should be custom-fitted by a physical or occupational therapist.

Homeopathy

Although very few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following treatments to alleviate respiratory symptoms (such as those experienced from cystic fibrosis) based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account a person's constitutional type -- your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for each individual.

Although people with OA are best treated with an individualized homeopathic remedy chosen by a professional homeopath, several trials have found that some common homeopathic combinations may be at least as effective as conventional medications for OA. Potential remedies include:

• A topical homeopathic gel containing comfrey (Symphytum officinale), poison ivy (Rhus toxicodendron), and marsh-tea (Ledum palustre)
• A combination homeopathic preparation containing R. toxicodendron., Arnica montana (arnica), Solanum dulcamara (climbing nightshade), Sanguinarra canadensis (bloodroot), and Sulphur
• A liquid homeopathic preparation containing R. toxicodendron, Causticum (potassium hydrate), and Lac vaccinum (cow's milk)

Other Common Homeopathic Remedies for OA Include:

• Calcarea carbonica (carbonate of lime or calcium carbonate)
• Bryonia (wild hops)
• Graphites
• Guaiacum

Mind-Body Medicine

Chronic pain and disability can make daily functioning difficult. A holistic approach to care in these clinical circumstances may positively affect both lifestyle and how one feels overall. Many people report that relaxation techniques, such as guided imagery and meditation, are an important part of comprehensive, holistic care, and help to alleviate pain and other symptoms of OA.

Yoga

This ancient Indian practice is well known for its physical, psychological, emotional, and spiritual benefits and is often recommended in the West to relieve musculoskeletal symptoms. In one clinical trial studying OA of the hand, the group practicing yoga showed significant decrease in pain and improved range of motion compared to those participating in non-yoga stretching and strengthening sessions. Certain yoga "asanas" (postures) strengthen the quadriceps and emphasize stretching, both of which benefit people with OA of the knee. People with arthritis should begin asanas slowly and they should be performed only after a warm up. Yoga is best performed under the careful guidance of a reputable instructor.

Tai Chi

This ancient form of classical conditioning practiced in China for centuries has been reported in clinical studies to produce a number of benefits, including the following:

• Improved fitness
• Increased muscular strength
• Enhanced flexibility
• Reduced percentage of body fat
• Diminished risk of falls in the elderly

In a clinical trial of subjects with OA of the knee or hip (ranging in age from 49 - 81), those who practiced tai chi twice a week for 3 months showed significant improvement compared to those in the control group in the following areas:

• Overall sense of quality of life
• Diminished feelings of stress/tension
• Increased satisfaction with general health
• Decreased fatigue
• Easier self management of arthritis symptoms

Other Considerations:

Pregnancy

Many of the herbs used in treatment for OA have not been tested on pregnant women and some are known to be unsafe for women who are pregnant. For this reason, pregnant women should take substances for pain and other symptoms only under the supervision of their obstetrician.

Prognosis and Complications

Complications of OA include:

• Inability to walk due to very advanced hip or knee OA
• Gastrointestinal bleeding and decreased kidney function resulting from long-term NSAID use

Many people are able to control OA and prevent the condition from worsening over time. Joint deterioration in OA tends to be slower than that of rheumatoid arthritis, but knee OA is still the number one cause of disability in industrialized countries such as the United States. Increased fluid in joints and joint enlargement occur later in the course of the disease. In the most advanced stages, OA can cause full cartilage loss. In some cases joint replacement may become necessary. While OA can be a debilitating condition, current treatments have shown great promise in reducing pain and improving mobility.

Alternative Names:

Arthritis - osteo; Degenerative joint disease; Osteoarthrosis

• Reviewed last on: 11/30/2007
• Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, NMD, private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

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