OSTEOARTHRITIS

Also known as degenerative arthritis or degenerative joint disease, osteoarthritis involves the degradation of joints, which include articular cartilage and subchondral bone.

  • Symptoms include joint pain, stiffness and tenderness
  • Causes are hereditary or metabolic

What is it?

Arthritis is a joint disorder characterised by swelling. A joint is an area of the body where two different bones meet. Joints are found in the knees, hips, fingers and other areas of the body that bend to ease movement. There are many types of arthritis, one of which is called osteoarthritis.Osteoarthritis is the most common joint disorder in the world. In Western populations, radiographic (X-ray) evidence of osteoarthritis can be found in the majority of people at 65 years of age, and in about 80% of those aged over 75 years.

In osteoarthritis, there is a breakdown of the substance (cartilage) that provides a cushion between the bones that meet at the joint. This breakdown leads to the pain and swelling that occurs when the bones begin to rub against one another.

Osteoarthritis occurs more frequently as we age, and more commonly affects the:

  • Knee
  • Hip
  • Hand
  • Spine
  • Foot

Unlike other forms of arthritis, osteoarthritis does not affect other organs of the body. Symptoms are limited to the joints themselves and manifest most commonly as pain and swelling with repetitive use, with pain usually being worse later in the day. Along with pain and swelling there may be warmth, morning stiffness and creaking of the affected joint.

Who’s at risk?

There are a number of known osteoarthritis risk factors, these include:

Age

  • Incidence of osteoarthritis increases with age but this increase occurs predominately in the knee, hip and hand.
  • A significant portion of elderly adults do not develop osteoarthritis indicating that the disease is not an inevitable consequence of aging.

Gender

  • After the age of 50, women are more likely than men to show signs of osteoarthritis of the knee and hand but hip osteoarthritis seems to occur at the same rate in men as in women.
  • Men under the age of 50 tend to have a higher incidence of osteoarthritis than woman, however this reverses when comparing men and woman over the age of 50.

Family history of osteoarthritis

  • Studies show that, for women, a familial history of hand, hip or knee osteoarthritis makes it more likely to develop the disease. Men are more likely to develop osteoarthritis of the hip with positive family history.

Obesity

  • Review of literature demonstrates that obese patients with osteoarthritis are more likely to have worsening of the disease than non-obese patients.
  • Losing just 5kg of bodyweight has shown to reduce osteoarthritis symptoms by 50%.

Menopause

  • Studies demonstrate that menopause is a risk factor for progression of osteoarthritis. It is unclear if this is related to a drop in estrogen levels with menopause, and research in this area is still ongoing.

Muscle weakness around the joint

  • There is still debate as to whether muscle weakness causes osteoarthritis or whether osteoarthritis causes muscle
  • Long-term engagement in high-impact sports or occupations that require heavy physical work
  • Former elite runners, soccer players and American football players have a higher risk for developing osteoarthritis of the hip.
  • People whose occupation requires kneeling and or squatting have higher incidence of osteoarthritis

Acute joint injuries

  • Persons with previous acute joint injuries have a much higher risk of later developing osteoarthritis of the injured joint, especially if they have osteoarthritis in another joint.

Congenital (from birth) joint deformity

  • An abnormally formed joint can cause osteoarthritis because the joint does not come together properly, and, over time, this malalignment causes stress on the joint leading to a breakdown of the joint.

Other joint disease

  • People with other types of joint disease such as gout or rheumatoid arthritis can develop osteoarthritis as a result of damage from the pre-existing joint.

Prevention

Prevention of osteoarthritis should focus on risk factors one can control, such as maintaining a healthy weight and avoiding occupational hazards that stress the joints. Occupations involving heavy physical work, especially prolonged kneeling and squatting, have approximately twice the risk of knee osteoarthritis.

Lifestyle

Active lifestyles will not only help to maintain a healthy weight but can also keep the muscle around the joints strong. Even a small amount of weight gain can put enough added stress on the joints to make osteoarthritis symptoms worse.

Protect your joints while performing simple daily tasks. Avoid prolonged kneeling, squatting and gripping. Use proper body mechanics to avoid putting excess strain on joints. Avoid high heeled shoes.

Vitamin supplements

Research has shown that people with low levels of vitamin C and D had a much faster progression of their existing osteoarthritis2. One study showed that Vitamin C supplementation may prevent osteoarthritis but did not reveal that it was an effective treatment for those who already had osteoarthritis.

Nutrition

Foods rich in vitamin C include, but are not limited to peppers, guava, fresh thyme and parsley, dark green leafy vegetables, broccoli, cauliflower, brussel sprouts, kiwi, papayas, oranges and strawberries.

Good sources of vitamin D include cod liver oil, cooked salmon, cooked mackerel, canned tuna, fortified milk, beef liver, sardines, egg yolk, and sunlight.

Diagnosis

Various medical societies have come forward with recommended guidelines for diagnosis of osteoarthritis. The guidelines are specific for each joint and generally use a combination of clinical symptoms, laboratory data and radiographic imaging results.

Osteoarthritis may be diagnosed by viewing the structure of the joint using imaging, evaluating joint symptoms or a combination of both [1].

Diagnosis can be made using X-ray of the affected joint. X-ray findings in osteoarthritis include:

  • Loss of joint cartilage
  • Narrowing of the joint space
  • Bone spur formation

A detailed medical history and physical exam can also assist in diagnosing osteoarthritis. Careful examination of symptoms, such as pain progression over time, pain aggravating factors and pain alleviating factors can aid in proper diagnosis. Additionally, arthrocentesis (removal of joint fluid) may be used to rule out other possible causes of joint pain.

Treating Osteoarthritis

Currently there are no proven treatments that can halt cartilage damage or repair damaged cartilage. The focus for osteoarthritis treatment is on reduction of pain, stiffness and swelling as well as patient education that can improve quality of life.

Conservative measures that may reduce symptoms

  • Rest
  • Exercise; especially swimming, walking and stationary cycling
  • Applying heat before and cold packs after exercise
  • Weight reduction
  • Physical therapy
  • Occupational therapy
  • Mechanical support devices Pharmacological treatment options
  • Oral pain medication
  • Pain relieving creams
  • Cortisone joint injections
  • Hyaluronic acid joint injections Surgical treatment options
  • Arthroscopy (to repair cartilage)
  • Osteotomy (bone removal)
  • Total joint replacement

Therapeutic options in osteoarthritis

Non-pharmacological treatment

  • Education (patient and family)
  • Social support
  • Physiotherapy (physical therapy)
  • Occupational therapy
  • Weight loss
  • Exercise
  • Orthotic devises
  • Ultrasound
  • Transcutaneous electrical nerve stimulation (TENS)
  • Acupuncture
  • Nutrients Herbal remedies
  • Vitamins/minerals

Pharmacological treatment

  • Paracetamol/Acetaminophen
  • NSAIDS (Non-steroidal anti-inflammatory drugs) [plus misoprostol, or a PPI for patients at increased GI risk ]
  • COX-2 inhibitors (cyclo-oxygenase-2 selective non-steroidal anti-inflammatory drugs) Opioid analgesics
  • Hormones
  • Glucosamine sulfate, Chondroitin sulfate Diacerein
  • Topical NSAIDS Topical capsaicin

Intra-articular treatment (injection into joint)

  • Corticosteroids
  • Visco-supplements (hyaluronic acid preparations)

Surgical treatment

  • Arthroscopy Osteotomy
  • Joint replacement surgery
  • Joint fusion

Living with Osteoarthritis

You don’t need to let osteoarthritis prevent you from leading an active life. In fact, getting out and exercising can help you manage this disease. There are number of important  considerations for living with osteoarthritis. Treatment involves exercise, rest, maintaining an ideal body weight, the application of heat or cold, certain medications and surgery.

The support of friends and family members is vital for minimizing the effect of osteoarthritis upon your well-being and your ability to perform daily activities. You need to be realistic about your limitations, while remaining committed and optimistic about the ability to manage your osteoarthritis through lifestyle changes, medical, surgical or rehabilitative care.

You can also look after you joints by choosing a good cane, walker or walking aid. You should also take steps for avoiding falls.

The following is a story of someone living with osteoarthritis.

“I am a 39 year old woman, married, mother of two. I have been living with osteoarthritis since my late teens. It all began with a knee injury at the age of 9 that led to the discovery of a congenital malalignment in my knee. As a result of the injury, I suffered loss of muscle strength and further malalignment of the knee joint. The combination of muscle loss, congenital patellar malalignment and the continuation of many years of sport activity, led to my current diagnosis of severe degenerative osteoarthritis of my right knee.

I have endured 6 knee surgeries to date. Some to help with realignment and many to simply remove pieces of cartilage and bone that continue to find their way into my joint cavity as my knee cartilage and bone slowly degrade.

I live with pain daily, but have learned what I can do to avoid severe pain and swelling and how to better control my symptoms without the use of medication. My doctors advised me early on to avoid weight gain especially with pregnancy. I have fortunately been able to maintain a healthy weight but can attest that even the smallest amount of weight gain significantly worsens my symptoms.

I am an avid skier and love physical challenges of all types. I have struggled to maintain my ability to participate on a level which I would like as any decrease in physical training and exercise significantly affects my ability to enjoy these activities. I faithfully follow a regime of icing and elevating after any strenuous activity. This practice significantly reduces any incidence of swelling, which would lead to worsening symptoms.

When my oldest daughter was just 6 years old, she was diagnosed with a congenital knee problem that may affect her the same way my problem has affected me. It upsets me to know that she (sport loving as well) may face the same challenges as I did, but at an even younger age. I find comfort in knowing that I can help her by teaching her about exercise and maintaining a healthy weight to ensure that she has the best chance possible to avoid the daily discomfort and lifestyle altering effects of osteoarthritis.”

OSTEOPETROSIS

  • Osteopetrosis is an inherited disorder with a variety of genetic causes, resulting in abnormally high bone mass for dysfunctional bone remodelling.
  • This bone disease is divided into two main groups: autosomal recessive and autosomal dominant types. The autosomal dominant form of osteopetrosis is less severe and often discovered in young to middle aged adults.
  • There are two types of autosomal dominant forms. The osteopetrosis, autosomal dominant type 1 (OPTA1) is extremely rare and secondary to a defect of the LRP5 (low density lipoprotein receptor 5), causing an increased uniform sclerosis. The disease commonly has onset in late childhood or adolescence, and primarily involves the cranium.
  • Clinical signs can include: chronic bone pain and disorders of the cranial nerves, such as trigeminal neuralgia, facial palsy, and hearing loss.
  • Diagnosis is based on clinical and radiographic evaluation. Radiographically, the hallmark of osteopetrosis is increased density within the medullary portion of the bone with relative sparing of the cortices. In OPTA1, there is a uniform sclerosis of the long bones, skull, and spine.
  • The treatment is primarily supportive. In the future, the gene therapy may play a role in the future with an identifiable gene defect.

Diagnosis
In consultation with a doctor, osteoporotic fractures can be prevented. Your doctor will take a thorough medical history that includes information on any recent fractures and may determine the next step is to have a bone mineral density (BMD) test.

RHEUMATOID ARTHRITIS

Rheumatoid arthritis may affect many tissues and organs, but it mainly attacks joints. It is an autoimmune disease that results in a systemic, chronic inflammatory disorder.
This disorder is diagnosed on the basis of symptoms, a physical exam, radiographs (x-rays) and labs. Treatments are both pharmacological and non-pharmacological.

PAGET’S DISEASE

This chronic disorder can result in enlarged and mis-shapen bones.

  • Paget’s disease is caused by an excessive breakdown and formation of bone and disorganised bone remodeling.
  • This disease is normally localised to only a few bones in the body – the most common being the pelvis, femur and lower lumbar vertebrate.
  • Medications are often successful in controlling the disorder, especially when started before complications begin.

OSTEOGENESIS IMPERFECTA

Osteogenesis Imperfecta (OI) is a genetic condition characterised by bones that break easily, often from little or no apparent cause. The condition can vary quite drastically from person to person so a classification system has been identified to describe the different types of OI which is commonly used to help describe how severely a person with OI is affected. For example, a person may have just a few or as many as several hundred fractures in a lifetime.

What causes the condition?

OI is caused by a genetic mutation that affects the body’s production of collagen, which can be found throughout the body, especially in a person’s bones and other tissues

What are the symptoms?

As well as frequent fractured bones, people with OI often have muscle weakness, hearing loss, fatigue, joint laxity, curved bones, scoliosis, blue sclerae, dentinogenesis imperfecta (brittle teeth), and short stature amongst other medical problems.

Does OI only affect the bones?

Though fragile bones are the hallmark of OI, other medical problems, including loose joints, early hearing loss, brittle teeth, respiratory problems and easy bruising are also part of the condition.

Does OI only affect children?

OI is a genetic condition that is present throughout a person’s lifetime. The frequency of fractures may decrease after puberty, when growth stops. Later, it may increase again in women with the onset of menopause and in men due to age-related changes in their endocrine system.

Is OI hereditary?

Yes, genetic conditions such as OI are passed on from parents to children and this can occur in a number of ways, for instance, just one parent may pass on a defective copy of the gene or, in some cases, both parents. As we all have two copies of each gene with each parent passing one copy each to the new child there are instances where the condition is not passed on.

Can people at risk of passing on the condition be tested?

Yes, people with OI or with known OI in their family can seek genetic counselling to discuss the chances of the condition being passed on to any children.

Other resources:

http://www.oif.org/

http://www.oife.org/

http://www.oife.org/index.php/EN/other-oi-organisations

http://www.brittlebone.org/

SARCOPENIA

Sarcopenia is a disease associated with the aging process. Loss of muscle mass and strength, which in turn affects balance, gait and overall ability to perform tasks of daily living, are hallmark signs of this disease.

Scientists have long believed muscle loss and others signs associated with aging are an inevitable process. However, researchers are looking for ways in which we can slow the aging process, specifically in relation to loss of muscle mass and strength.

Loss of muscle mass, strength and function

Normal muscle mass on left, muscle wasting on right

Normal muscle mass on left, muscle wasting on right

Sarcopenia is, in its most literal sense, the loss of muscle mass, strength and function related to aging. We are now discovering this loss is a complex and multifaceted process. Most commonly seen in inactive people, sarcopenia also affects those who remain physically active throughout their lives.

This indicates although a sedentary lifestyle contributes to this disease, it’s not the only factor. In addition, as we age:

  • hormone levels change
  • protein requirements alter
  • motor neurons die
  • and we tend to become more sedentary

Prevention and treatment

These factors in combination are what are thought to cause sarcopenia. Scientists are searching for ways to treat and prevent progression of this disease process by developing treatments targeting individual factors.

In a review of literature, worsening sarcopenia followed trends in losses of muscle strength as well as impairment of daily functioning2. In one study, the prevalence of sarcopenia increased dramatically with age from 4 % of men and 3 % of women aged 70-75 to 16 % of men and 13 % of women aged 85 or older.

fig1
Fig. 1 Life course changes in muscle mass and strength. Note environmental changes can lower the disability threshold.

More importantly, when sarcopenia is coupled with other diseases associated with aging, its affects can be even more pronounced. Loss of muscle mass and strength is a significant risk factor for disability in the aging population. When patients suffer from both sarcopenia and osteoporosis, the risk of falling and subsequent fracture incidence is higher. Therefore, treating sarcopenia will in turn help to lessen its burden on co-existing diseases.

Who’s at risk?

As sarcopenia is a disorder related to advancing age, the condition is generally attributed to four key risk factors: being of an age 40 years and older, a sedentary lifestyle, malnutrition, and a diet high in acid-producing foods. While each of these factors is distinct, they combine to produce an age-related loss of muscle coordination and mass.

40 years of age and older

  • Muscle loss as we age is regulated by our neuromuscular system (which controls our movement), hormones, protein synthesis, and lifestyle factors. Research has revealed that sarcopenia tends to start at the age of 40 and progresses more rapidly after the age of 40.

Sedentary lifestyle

  • A sedentary lifestyle puts you at risk for a multitude of diseases. Muscle inactivity reduces muscle mass, even in young healthy adults.
  • Those who lead a sedentary life are more likely to have an acceleration of sarcopenia than those who lead an active life.

Malnutrition

  • Malnutrition can claim culpability for a multitude of health problems, and the degeneration of muscles (also known as muscle wasting) is just one of many results of malnutrition.
  • Older adults are particularly prone to reduction in food intake and as a result, malnutrition.
  • For a sarcopenia sufferer, malnutrition can cause protein deficiency, fuelling the further loss of weight.
  • An American survey indicates in adults aged 50 years and older, 32 to 41 % of women, and 22 to 38 % of men consume less than the recommended dietary allowance of protein.
  • A 3-year study showed protein intake maintained lean muscle mass in women and men aged 70 to 79 years. Individuals with the highest daily protein intake during the study lost 40 % less muscle mass than those with the lowest protein intake.

Diet high in acid-producing foods and low in fruits and vegetables

  • Diets rich in acid producing foods (meat and cereal grains) and low in non-acid producing foods (fruits and vegetables) have been shown to have negative effects on muscle mass.