DESCRIPTION: Osteoarthritis is also known as degenerative joint disease. This is the most common form of arthritis. In the United States there is felt to be over 40 million people with osteoarthritis. This can occur at any age, but increases in frequency with increasing age. In middle age, it tends to be more common in men, but in older age, the balance seems to shift toward women. Osteoarthritis most frequently affects the weight bearing joints, but also those of the hands are commonly involved.

SYMPTOMATOLOGY: Symptoms in osteoarthritis usually develop subtly. These start with morning stiffness or involve stiffness after periods of rest. As osteoarthritis progresses, pain with motion and weight bearing on the joint develops and gradual loss of function of the joint occurs. Inflammation is not the predominant sign of osteoarthritis, but does occur. This is usually manifested with swelling and can vary in intensity with the degeneration occurring in the joint and with activity, stress on the joint and other factors. There develops in the joints eventually local tenderness, joint crepitance, or noise, loss of motion and development of spurring, nodules, and other enlargements of the joint. On X-ray, joint spaces gradually narrow and bone spurs form. In more advanced cases, cystic deformities in the bone or erosions, can occur.

CLASSIFICATION AND ETIOLOGY: Exact cause of osteoarthritis is unknown. Articular cartilage, which is the material covering the end of the bone, forming the smooth surfaces of the joint are comprised of collagen (a fibrous network type of fibril materials), chondrocytes (the living cells of the joint), proteoglycans (large molecules dispersed within the collagen network which bind to the collagen and together are responsible for the physical properties of the cartilage surface), and water. There is no blood supply to the articular cartilage and nutrients to the cells diffuse in and out of the complex. The action of the cells to maintain the surrounding collagen and proteoglycans, maintain the proper balance between these and water content. As this is disrupted and the integrity of the collagen or function of the cells are disturbed, this balance breaks down. The result is degeneration of the joint surface or articular cartilage. Osteoarthritis is generally divided into two categories--primary and secondary. Primary osteoarthritis is generally thought of as the wear and tear that occurs with age without apparent predisposing factors. Secondary arthritis is associated with predisposing factors that are felt to lead to and cause the degeneration in the joint surface. These factors can include developmental abnormalities in the joint structure, trauma, such as a fracture or surgery, inflammation from any cause such as infection or other forms of arthritis classification, such as rheumatoid arthritis, etc., joint ligament instability, and mechanical damage from increased stresses on the joint such as obesity. There is felt to be in some, an underlying genetic predisposition toward arthritis. There is also felt to be more and more evidence suggesting nutritional factors playing a role as well.

TREATMENT CONSIDERATIONS: In approaching osteoarthritis, there are several categories of treatment approach to consider. These include lifestyle factors, dietary considerations, supportive measures, prescription medications, surgery, and nutritional supplementation. Each of these will be discussed below.

LIFESTYLE CONSIDERATIONS: One of the biggest factors in potential aggravations of arthritis symptoms is obesity. Trying to maintain normal weight limits is beneficial. Getting regular exercise to promote the health of the joint, yet not to overload it is recommended. Relaxation type exercises, which help promote mobilization and motion of the joints can be beneficial. Psychological aids to deal with the limitations of osteoarthritis are beneficial.

DIETARY CONSIDERATIONS: In some cases, food allergies can exacerbate symptoms of osteoarthritis and if one does have significant food allergies or reaction to environmental exposures, this needs to be controlled if osteoarthritis symptoms are a part of the reaction. It is generally recommended a diet that focuses on whole grains, legumes, vegetables, fruits, nuts, seeds, etc. are helpful. Avoiding high protein animal products such as red meats, in certain types of arthritis are beneficial. Increasing fish oil sources, can sometimes benefit. Eliminating alcohol, caffeine and high sugar content as well as processed foods are recommended. Nightshade family vegetables, such as tomatoes, potatoes, eggplant in some cases may trigger arthritic symptoms.

SUPPORTIVE MEASURES: Heat, soaking, etc. have been beneficial for stiffness. Physical therapy modalities, such as ultrasound, diathermy, electrical stimulation, etc. have also been beneficial in improving joint symptoms and mobility. Exercises to improve mobility are beneficial. The type of exercises in a non-weight bearing category seem to be best tolerated with osteoarthritis and include isometrics, swimming, biking, etc. Exercises are felt to increase circulation to the joint and certainly strengthening the surrounding musculature of these joints help support and control symptoms.

PRESCRIPTION MEDICATION: The standard approach to control of symptoms of arthritis, it should be understood, are purely for symptom control and do not affect the underlying course of the disease. In fact, there are some studies to suggest that long term use of the non-steroidal anti-inflammatories (NSAID’s) may actually contribute to progression of the osteoarthritis by inhibiting cartilage repair. From a prescription standpoint, basically two classes of medications are used. These include pain medication and anti-inflammatory medication. Pain medication, when used, should be of a mild variety. Certainly, with the stronger pain medications, potential for addiction is concerned. Mild pain medication such as acetaminophen can be intermittently used with good results. Certainly though, the dosage needs to not exceed recommended limits since with higher doses and chronic use, there is a concern with liver injury and other side effects, which should be taken into account. The anti-inflammatory category of prescription medicine includes both oral and injectable medications. Injections for a joint usually involve steroids and should be used sparingly for acute flare-ups to try to regain control. The concern with these is the frequency since if abused, it can aggravate progression of the arthritis. Also, those studies when appropriate dosages are used suggest very low grade systemic absorption, some can react to this or to the impurities in the preparation with other side effects, such as flushing, allergy, headache, palpitations, etc. An additional alternative for injection into the joint is Hyaluronin, under the brand names Symbist and Hyalgan. These are large molecule mucopolysaccharide, which cannot be absorbed orally. This is a normal component in the joint and injecting it into the joint in some people does seem to give temporary relief from inflammation and pain. It seems less effective the more advanced the arthritis is. It is not been shown to alter the course of arthritis. These injections can be repeated at six month intervals if they are effective for symptomatic control. The most common form of anti-inflammatory medication used is oral non-steroidal anti-inflammatories, or NSAID’s. There is a multitude of various NSAID’s on the market, such as Ibuprofen, Naproxyn, etc. The newer NSAID’s including Celebrex and Vioxx have more specificity of action to the joint, (namely COX-2 activity). The benefit of this is that it does decrease some of the side effect incidence, but one should be aware it does not eliminate them. With the NSAID’s, the main and well-known side effect risk potential is that of gastro-intestinal upset, gastritis, ulcer formation, even bleeding ulcers, kidney and liver disease, death, and some lesser complaints such as headaches, dizziness, etc. These factors have to be taken into account when utilizing these, as far as the risk/benefit ratio considerations.

SURGERY: Total joint replacement surgery as a treatment measure for osteoarthritis is reserved for end stage arthritis where symptoms cannot be controlled and function is compromised and the joint is worn completely. In the earlier phases of osteoarthritis where the structures in the joint are degenerating and tearing, causing uncontrolled symptoms, arthroscopic techniques can be used to, so to speak, clean up the joint, improving symptoms and making it functional again, when they have not been controlled with non-operative measures. When mechanically the joint deteriorates, causing uncontrolled symptoms and functional compromise, cleaning out the mechanical derangements, not only relieves symptoms and improves function, but can slow down the otherwise more rapid progression caused by ongoing gross mechanical irritation in the joint. One must have expectations correctly focused and realize that surgery does not cure arthritis, but is used to improve symptoms and function when other measures have failed. There are other surgeries that can be used when the effects of arthritis have distorted the normal alignment if it is felt by correcting these will re-direct the weight bearing forces on the joint to relieve symptoms. These procedures generally fall into a class called osteotomies. Other procedures used when the joint is not felt to be salvageable by any other techniques are called fusions. This surgery basically eliminates the joint by fusing the two ends of the bones together so that they are solid. This eliminates pain basically by eliminating the joint.

NUTRITIONAL THERAPIES: There has been much attention given to this more recently because of the studies with various nutritional factors which have shown benefit in arthritis and are becoming more widely used. Nutritional therapies can be broken down into several categories of approach discussed below. More extensive information on each can be obtained in the specific section for each of these nutrients, but will be commented on below.

DISEASE MODIFYING AGENTS: Contained in this category are primarily glucosamine and chondroitin sulfate, which are fairly well popularized and known. S-adenosylmethionine (SAMe) is less well-known, but is gaining more interest in study and in popularity of use. There are multiple studies in the foreign literature regarding glucosamine sulfate and chondroitin sulfate. These are much more accepted and much more frequently used in Europe and other countries. While this has been popularized over the last five years, particularly in the U.S. from a marketing standpoint, we are starting to see also studies in the U.S. base confirming the efficacy of these nutrients. Glucosamine stimulates the chondrocyte metabolism and reparative process in the joint. It also has some anti-inflammatory activity. Studies have shown it is well-absorbed and well-tolerated. In studies, no significant side effects were reported, though a very rare indigestion seems to be the most significant side effect and in some studies, even had less side effects than placebo groups. In many comparative studies with the NSAID’s, this has shown to be as effective and in some cases, more effective in control of symptoms and function. Generally the dose recommended for glucosamine is 1500 mg. per day. Chondroitin sulfate is another compound like glucosamine that has been well-studied in foreign countries, well-accepted and used in European countries and other countries and more recently, popularized in the U.S. and we are beginning to see studies come out in the U.S. base confirming this. Chondroitin sulfate is felt to have an anti-inflammatory effect by inhibiting degrading type enzymes. It also helps to increase the peri-articular circulation by preventing clots or thrombosis in the small vessels. It has been shown to have good absorption and on comparative studies with the NSAID’s comparable in effect in control of symptoms. It also has been suggested as far as it’s effect on stimulating the reparative response in the articular cartilage. It’s general dose recommended is 1200 mg. per day. Form of chondroitin sulfate is something of which to be aware. The extract is recommended since this is more purified. This is generally obtained from bovine cartilage. Shark cartilage contains chondroitin sulfate, but is much less purified and in most preparations, variable in dosage of contained chondroitin sulfate and has been reported associated with more side effects of reaction to these impurities. In most studies of the used extract, side effects have been rare as with glucosamine sulfate and usually along the line of gastrointestinal upset if they occur at all. These two compounds, glucosamine sulfate and chondroitin sulfate do work synergistically and the effect with both is felt better than with either alone, and as with all dietary supplements, purity is a factor to be aware of and a reputable manufacturer is recommended that uses quality control programs. Effica!cy will be related to purity content. One should be aware that with both these components onset of effect is slow, taking 4-12 weeks and is a consideration that needs to be taken into account in giving this adequate trial of use. By these effect, these two compounds are felt to potentially alter the course of osteoarthritis, slowing down the disease course as well as symptom relief. SAM is another compound which is gaining more interest in osteoarthritis. This is felt to demonstrate some pain relieving and anti-inflammatory effects, as well as possibly affecting cartilage formation positively.

ANTI-OXIDANTS: There is a significant amount of research that shows that vitamins, minerals and some phytonutrients are also beneficial in the treatment of osteoarthritis and control of inflammation and for the health of the joint articular cartilage. In a series of reports taken from the famous Framingham study, it was shown particularly the importance of Vitamin C, Vitamin E and Vitamin D. This study showed, over a decade that patients with higher intake of these three vitamins had less progression of their arthritis, less pain and swelling and better function. Several vitamins and minerals are known to be important for the formation and maintenance of cartilage, and these include Vitamin A, B6, zinc, copper, boron, manganese, and Vitamin B5. Studies have shown arthritis sufferers particularly are deficient in Vitamin B6, zinc, manganese, copper and folic acid and Vitamin D. Other studies have shown improved symptomatology with supplementation of niacinamide, B12, and folate, and deficiency in selenium has been shown to increase rheumatoid arthritis symptomatology. Anti-oxidants are felt to prevent oxidative stress by neutralizing free radicals. In animal studies, copper has been shown to have an anti-inflammatory effect. Boron supplementation does prevent calcium loss and bone demineralization. Phytonutrient research has shown that the flavonoids as a group have an anti-inflammatory effect. Quercetin, which is a bio-flavonoid is felt to inhibit some of the release of prostaglandins and have an anti-inflammatory effect by this mechanism. Tumeric has been shown to have an anti-inflammatory effect and is used in Europe widely for inflammation associated with sprains, etc. Omega-3 fatty acids have also been shown to work as an anti-inflammatory and to have some benefit in arthritis as well.

BOTANICALS: There are several herbs which have been historically used in the treatment of osteoarthritis. These include yucca, boswellia, serrata, devil’s claw. Several topical treatments have been symptomatically beneficial, including the menthol based creams. Creams which contain capsicum (a derivative from chili peppers) has been shown to be effective when applied to joints in decreasing pain of arthritic joints. There are several commercially available creams which contain capsicum and have been effective. DMSO, when applied to the skin also seems to have an anti-inflammatory effect. There does seem to be an absorption through the skin though, and with chronic use, there have been reported some side effects such as a tendency toward cataract formation with use of this.

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