What is Osteoarthritis?
Osteoarthritis (OA) is a progressive, degenerative joint disease that affects over 25 million Americans. Osteoarthritis is a disease of the entire joint, including bones, cartilage, joint lining, muscles, and ligaments. It affects the ability to move freely without pain and tends to occur in the commonly used joints of the knees, hips, hands, and spine.
Causes and Symptoms
Osteoarthritis begins with the progressive loss of cartilage, the cushioning material that provides a sliding surface between bones. When the cartilage protecting the ends of bones deteriorates, the space between the joints narrows. If the cartilage wears down completely, there may be bone on bone contact.
Symptoms vary depending on where the osteoarthritis is located. Symptoms can be constant or intermittent and may include:
- Joint pain, tenderness or stiffness, especially later in the day, or after periods of inactivity
- Decreased joint flexibility
- Warmth or swelling
- Knobby joint
- Cracking or grinding noise
- Bony spurs, bony enlargements
Risk factors for Osteoarthritis include:
- Family member with OA
- Older age
- Gender, women are more likely to develop OA
- Joint injury from an accident or from sports
- Joint injury from repetitive or overuse of joints
- Joint deformity
Other diseases can increase the risk of developing osteoarthritis as well including diabetes or other rheumatic diseases like gout and rheumatoid arthritis.
Diagnosis of osteoarthritis is confirmed through radiography (X-ray). X-ray may also be used to track the progress of the disease over time, though joints may appear normal in early stages. Other imaging tests, like ultrasound and magnetic resonance imaging (MRI), may be used to find damage to soft tissues like cartilage, ligaments, and tendons.
Laboratory tests are sometimes used to help diagnose OA by ruling out other conditions that have similar symptoms.
Osteoarthritis is a chronic condition that gradually worsens over time. Treatment is based on severity of symptoms, where the arthritis is located, and how well the treatment works. The goal of treatment is to reduce pain and improve function.
- Analgesics include pain relief medications like acetaminophen. They relieve pain but do not have any effect on the inflammation sometimes associated with OA. They are recommended for arthritis pain is mild to moderate. Sudden, painful exacerbations of arthritis may require treatment with a narcotic like codeine.
- Non-steroidal anti-inflammatory drugs (NSAIDs) relieve pain and reduce inflammation. These drugs are available in over the counter medications as well as stronger prescription medicines.
- Joint injections
- Steroidal (Glucocorticoid) injections injected into the joint can relieve symptoms by suppressing inflammation. Because steroids may damage and weaken joints when used too frequently, they are recommended for use no more than three or four times a year, especially in weight bearing joints.
- Hyaluronate. Since normal joint fluid contains a large amount of hyaluronate, this synthetic agent injected into the joint may bring pain relief that lasts several months. Synthetic hyaluronates are generally injected into the knee, but are being studied for use in other joints.
Two other medications are commonly used to treat the symptoms of OA. Colchicine is often recommended for those with inflammatory OA who have frequent flare ups that don’t respond to other treatments like NSAIDs. Hydroxychloroquine is sometimes recommended for those with severe inflammatory osteoarthritis and for those with bone damage related to OA.
Surgery is recommended when arthritis is severe or when symptoms are not relieved with medications or other treatments. Types of arthritis surgery include arthroscopy and joint irrigation, surgical realignment, fusion, and joint replacement. Cartilage grafting is being studied for use in arthritic joints and may be most helpful when damage to cartilage is limited.
Diet and Exercise
Arthritis symptoms are often relieved with rest. However, too much inactivity can lead to muscle loss and joint stiffness. Rest of between 12 and 24 hours is sometimes recommended for an arthritic flare up or exacerbation.
Heat and cold therapy can also be effective. Applying heat to an arthritic joint may relieve pain and help mobilize the stiff joint. It’s important that the heat source is not too hot. Cold therapy relieves muscle spasms and controls pain associated with OA. Cold should only be applied for a short time and those with certain conditions like the Raynaud phenomenon should not use cold therapy.
Staying physically active and maintaining a healthy weight can reduce the symptoms of OA. In arthritis of the weight bearing joints like the hip and knee, weight loss may reduce symptoms. Physical therapy, occupational therapy and exercise programs may be recommended. Activities that strengthen the muscles around a joint and increase flexibility can improve symptoms of osteoarthritis.
Gentle exercises that help to maintain a full range of motion such as Tai Chi have been found in multiple studies to be effective at reducing pain and improving physical function. Aquatic exercises have been shown in a few trials to be effective at pain reduction, improving physical functioning, and reducing morning stiffness, trails have been small and more studies needed.
Orthotic shoe devices, braces, or splints can relieve the stress on joints and reduce symptoms. Assistive devices, like walkers, canes, raised toilet seats, tub and shower bars, or electric powered seat lifts can reduce the stress on arthritic joints and make the activities of daily living easier.
Dietary advice for osteoarthritis primarily focuses on losing weight if overweight or maintaining a healthy weight. Some health practitioners suggest a diet that is free from nightshade vegetables,, or low in common food allergies. Neither of these approaches has been well studied and might be difficult to suggest for most patients to undertake.
Boswellia has been well studied for osteoarthritis. In general, supplementing with Boswellia has been shown to reduce pain (by up to 30-60 percent in some studies), as well as increasing walking distances, knee flexion, and overall improvement in activity levels. A 2008 review concluded Boswellia may be effective for a variety of inflammatory conditions (including asthma, rheumatoid arthritis, Crohn’s disease, osteoarthritis, and collagenous colitis). A 2014 Cochrane review of herbal therapies for osteoporosis concluded that, although preliminary, only Boswellia (and avocado-soybean unsaponifiables (ASU)) had enough good quality studies to be considered effective therapy for osteoporosis.
Glucosamine, Chondroitin Sulfate
Glucosamine and chondroitin sulfate are both glycosaminoglycans which when supplemented have been shown to increase type II collagen production and proteoglycan synthesis in chondrocytes and appears to also reduce the production on some inflammatory mediators.  Pre-clinical trials report the ability of both these compounds to impact many arears in the osteoarthritis pathophysiological process. A 2006 New England Journal of Medicine study involving 1583 patients with OA, were supplemented with 1500 mg glucosamine, or 1200 mg chondroitin, or both glucosamine/chondroitin, or 200 mg of celecoxib, or placebo for 24 weeks. The study found no improvement overall for any single or combination, but a sub-group analysis suggested improvements in patients with moderate-to-severe knee pain. A 2014 meta-analysis of glucosamine and chondroitin reported an overall small, but significant reduction in rate of joint space narrowing in the studies they reviewed.
S-Adenosyl-Methionine (SAMe) is an amino-acid derivative that principally plays a role as a methyl group donator in various enzymatic reactions throughout the body. SAMe is thought to reduce pain associated with osteoarthritis through unknown mechanisms. A 2009 Cochrane review of four trials (n = 656) comparing SAMe with placebo suggested many difficulties with included trials but still proposed a small pain-reducing effect possible, but need for more trials.
Vitamin B3 (Niacin)
While not extensively studied, niacin has shown improvements in, inflammatory mediators ( i.e. reduced erythrocyte sedimentation rate), increased joint mobility, and reduced anti-inflammatory medication use in a small (N=72) pilot study using niacinamide 500 mg six times per day (very high dose).
While vitamin C is essential for the production of collagen and would make sense as an adjunct therapy in osteoarthritis, it hasn’t been shown to be helpful in the few studies available to date., Future studies should help elucidate its role in osteoarthritis.
An analysis using Framingham participants (N=556) showed both low intake of vitamin D and low serum vitamin D levels were modestly correlated progression of osteoarthritis of the knee following 4.5 years of follow up. Studies have also shown a high prevalence of vitamin D deficiency in elderly patients with advanced knee osteoarthritis scheduled for total knee replacement. A 2013 review found only two randomly controlled trials, but both were methodologically challenged. The review did report a strong association for serum vitamin D levels and radiographic measurements of cartilage loss, but no correlation with symptomology.
Other Professional Resources
Arthritis Foundation http://www.arthritistoday.org/
Osteoarthritis Centers of America http://www.oacenters.com/
National Osteoarthritis Foundation http://nof.org/
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