Osteo-Arthritis
Dr. Weyrich's Naturopathic Functional Medicine Notebook
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Overview
Osteoarthritis (also known as degenerative joint disease) presents as localized joint pain and reduced range of motion; it most commonly affects the knees, hips, spine, hands, and feet. [Buckwalter2006].Etiology
Osteoarthritis is caused by a loss of articular cartilage, and results from a degeneration of synovial fluid [Buckwalter2006]. The onset of this degeneration may be triggered by an acute injury that negatively impacts the structural integrity of the joint, such as a sprain of the anterior cruciate ligament, a tear of a meniscus, or patellar dislocation; in addition, repetitive microtrauma such as found in distance runners may be the trigger. Since obesity increases load on weight-bearing joints, it may also be a contributing factor [ACE-AHFS, pg 377-379]; healthy articular cartilage can tolerate impact forces approximately seven times a normal person’s body weight before damage to the articular surface occurs [Repo1977].The chronic pain associated with osteoarthritis arises from pain sensors in the subchondral bone rather than from the articular cartilage itself, which has no pain sensors [ACE-AHFS, pg 380].
Damage to the articular cartilage causes chemical synovitis, which arises when chemicals inside the damaged articular cartilage are released into the synovial fluid and irritate the type A synovial cells in the inner lining of the joint capsule, which in turn increase production of synovial fluid, leading to swelling of the joint capsule over the subsequent 12 hours and further pain due to the edema [ACE-AHFS, pg 381].
Specific factors leading to increased risk of osteoarthritis include [ACE-AHFS, pg 383] weak quadriceps [Bennell2005; Mikesky2006], valgus or varus knee alignment, weak hip abductors, and obesity [Issa2006].
Dr. Starr has suggested a correlation between osteoarthritis and type-II hypothyroidism.
Diagnosis
According to the Agency for Healthcare Research and Quality, Osteoarthritis of the knee can be diagnosed when joint pain is present plus five or more of the following criteria are met [Samson2007]:
- The patient is over 50 years of age
- Joint stiffness in the morning lasts less than 30 minutes (as opposed to Reumatoid Arthritis, where stiffness lasts longer).
- Crepitus is observed in the joint (due to absence or damage to articular cartilge).
- Bony tenderness is observed in the joint.
- Bony enlargement is observed in the joint.
- Signs of inflammatory disease (e.g. Reumatiod Arthritis) are absent:
- No palpable warmth of synovium.
- Erythrocyte sedimentation rate (ESR) < 40 mm/hr.
- Rheumatoid factor < 1:40.
- Non-inflammatory synovial fluid.
Treatment
For patients with chronic osteoarthitis pain, low-impact exercises (such as aqua-therapy and tai chi) may be useful [ACE-AHFS, pg 383; Ettinger1997; Fransen2007; Hinman2007; Lund2008; Wang2007].
For patients who are relatively pain free, light- to moderate-intensity walking (up to 60 minutes 3 times a week) and light- to moderate-intensity resistance training (up to two sets of 12 repetitions of nine exercises) training three days per week can lower pain scores and increase functional ability [Ettinger1997; Mikesky2006]. The American Council on Exercise gives specific exercise recommendations [ACE-AHFS, pp 383-389].
Although exercise can slow the progression of osteoarthritis, it is not a cure for osteoarthritis. However, there is no evidence that properly programmed and managed exercise will increase the rate of joint degeneration [ACE-AHFS, pg 383], as measured by joint-space narrowing [Mikesky2006] or pain scores [Ettinger1997; vanBaar1999].
Excercise recommendations may be modified to include "the use of wrist straps or ankle or wrist weights and the performance of lower intensity and higher-duration activities" [ACE-AHFS, pg 377].
Dr. Hertogue notes that when treating osteoarthritis due to hypothyroidism, joint pains "improve very slowly and are the last symptoms to disappear" [Hertogue1914].
Evidence suggests that CosaminDS ® (glucosamine sulfate with a low-molecular chondroitin) 2-3 tabs TID provides better relieve of pain due to osteoarthritis and chemical synovitis than nonsteroidal anti-inflammitories such as Celebrex ® 200mg/day [Clegg et al., 2006].
Prevention
It is important to correct any joint misalignment caused by spinal misalignment, antalgic posture or gait, ligamentous laxity, or muscle weakness (e.g. weak quadriceps [Bennell2005; Mikesky2006], valgus or varus knee alignment, or weak hip abductors [Issa2006]) in order to prevent damage and minimize further damage to affected joints.
As discussed above, osteoarthritis is a sequel of repetitive microtrauma and instability of the affected joint, so it follows that avoidance of these insults to the joint by proper exercise aimed at strengthening the stabilizing muscles and ligaments is both preventative and therapeutic [ACE-AHFS, pg 379].
Sequelae
Untreated osteoarthritis can reduce the physical activity of a patient, leading to secondary comorbitities due to a sedentary lifestyle, including: coronary artery disease, diabetes, and hypertension.
ICD-9 Codes
| ICD9-Code | Description | Comments |
|---|---|---|
References
Unless specifically noted above, references used in the construction of this web page include the following:[FDM] Lecture notes from Functional Medicine University.
[SCNM] Lecture notes from Southwest College of Naturopathic Medicine.
[UT] Lecture notes from the University of Tennessee graduate programs in Chemistry and Biochemistry.
[ACE-AHFS] American Council on Exercise. "Advanced Health & Fitness Specialist Manual" Chapter 15: Arthritis.
[Bennell2005] Bennell & Hinman (2005) [cited by ACE-AHFS, pg 383].
[Buckwalter2006] Buckwalter & Martin (2006). [cited by ACE-AHFS, pg 377].
[Clegg2006] Clegg et al. (2006) [cited by ACE-AHFS, pg 382].
[Ettinger1997] Ettinger et al. (1997) [cited by ACE-AHFS, pg 383].
[Fransen2007] Fransen et al. (2007) [cited by ACE-AHFS, pg 383].
[Hertoghe1914] E. Hertoghe. Thyroid Deficiency. Lecture presented to the International Surgical Congress at the New York Polyclinic School and Hospital (April 1914). Copy availaible from Broda O. Barnes M.D. Research Foundation at http://www.brodaobarnes.org [Cited by Starr2005].
[Hinman2007] Hinman, Haywood, & Day (2007) [cited by ACE-AHFS, pg 383].
[Issa2006] Issa & Sharma (2006) [cited by ACE-AHFS, pg 383].
[Lund2008] Lund et al. (2008) [cited by ACE-AHFS, pg 383].
[Mikesky2006] Mikesky et al. (2006) [cited by ACE-AHFS, pg 383].
[Repo1977] Repo & Finlay (1977) [cited by ACE-AHFS, pg 380].
[Samson2007] Samson et al. (2007) [cited by ACE-AHFS, pg 381].
[Starr2005] Mark Starr. Hypothyroidism Type 2: The Epidemic. Columbia, MO: Mark Starr Trust (2005).
[vanBaar1999] van Baar et al. (1999) [cited by ACE-AHFS, pg 383].
[Wang2007] Wang et al. (2007) [cited by ACE-AHFS, pg 383].
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