| Category | Osteoarthritis |
What is Osteoarthritis?
Osteoarthritis (OA) is one of the commonest arthritis seen in the general population. It is a painful condition that can involve one or more of the joints in the body. It is commonly a disease that occurs with increasing age.
What actually happens in Osteoarthritis?
Major joints in the body are formed by two ends of bones coming together. This end of bones is covered by a cushion, which is known as cartilage. These bone ends along with the cartilage in between form the joint. This cushion of cartilage is very important in the normal functioning of the joint. However, in osteoarthritis, there is degeneration and wearing out of the out of this cushion or cartilage. In OA the cartilage thins out along with some other changes in the surrounding bone of the joint and this leads to various problems of osteoarthritis.
What are the most common joints involved in Osteoarthritis?
OA most commonly occurs in the knees, hips, spine hands, and feet. Osteoarthritis can virtually affect any joint Of the body.
What Causes Osteoarthritis in the Joints?
OA is strongly associated with increasing age. Hence age-related degeneration of the joint plays a major role. But it is not as simple as that. Many people can develop osteoarthritis at an early age. Many people with osteoarthritis do not have much pain. Many people have osteoarthritis which is much more advanced at an unexpected age. Different patients have variable levels of pain even with the same amount of osteoarthritis. Family history is important as well. We are still trying to understand many of these factors.
What are the risk factors associated with Osteoarthritis?
As mentioned above, we don't totally understand what causes osteoarthritis. However, we do know that certain factors play a role in increasing the risk of having osteoarthritis.
Age: Advancing age is one of the most commonest risk factors for osteoarthritis. In the general public above 60 years of age, at least 80% have some evidence of osteoarthritis, in at least one of their joints. This may be just seen on X-rays and the patient may or may not have pain. However as mentioned above, not everyone with the same degree of osteoarthritis will have the same amount of pain.
Gender: For some unknown reasons, females have more chances of osteoarthritis than males. Females also tend to have more pain compared with the same degree of osteoarthritis in men.
Obesity and Weight: Osteoarthritis occurs more frequently in people who are obese (weight is well above required for that age and height). There is also some evidence that people who reduce weight can decrease the risk of developing osteoarthritis in the future.
Sports and Rigorous Physical Activity: There is evidence that playing excessive injury sports like football, wrestling, or repeated kneeling and squatting jobs can increase the risk of osteoarthritis. Having any injury in the ligament in the knee or any other joint can also crease the risk of osteoarthritis in the future. There is good evidence to suggest that routine, non-competitive running or exercises done for personal fitness do not increase the risk of osteoarthritis.
Previous Ligament or Meniscus Injury: Any person who has had a history of injury to their supporting structures in joints like ligaments, meniscus, etc at a young age, has higher chances of osteoarthritis in the future. This is commonly seen in knee joint ligament and meniscus injuries. Even if one undergoes surgery to repair the same, they are still at higher risk for developing osteoarthritis of the respective joint in the future.
Family History: Osteoarthritis, particularly, nodal OA, can have a remarkable familial predisposition.
Do all patients with age get Osteoarthritis?
No, not all patients get OA and it depends on multiple other factors, some of which have been outlined above. We don’t have exact figures from India, but OA is more common in women and increases after the age of 50 years and plateaus at 70 years. Western literature shows increasing prevalence over time due to longer life expectancy, obesity, and a sedentary lifestyle. It is estimated that 10% and 18% of men and women are affected respectively.
What are the symptoms associated with osteoarthritis?
Pain: Pain is the most common symptom associated with osteoarthritis. When osteoarthritis starts, the pain can be intermittent and variable. It might be aggravated by certain activities. Often it is more common in the late afternoon and evening. The patient can have good days without pain and bad days with pain. For example, The first symptom of osteoarthritis in the knee is usually having some discomfort or pain while the patient is climbing or coming down the stairs.
Site of Pain: Pain more commonly occurs around the joint line except in the hip and shoulder when pain can occur away from the joint
Stiffness or Gelling Phenomenon: Osteoarthritis patients can have a stiffness which is usually aggravated when the patient takes rest in a certain position for more than a few minutes. The patients are stiff in the morning but the morning stiffness is usually less than 30 minutes and not very intense like rheumatoid arthritis. For example, When the patient sits too long with knee osteoarthritis, after getting up, the initial few steps are painful. But after walking a few steps patient is fine.
Swelling: Some patients with osteoarthritis can have mild to moderate swelling in the joint. This swelling might be soft and compressible due to the collection of some fluid in the joint. This can also be hard swelling due to the formation of bone spurs (extra new bony protrusions) in the osteoarthritic joint.
Crepitus or Crackling Sound: In osteoarthritic joints, one can have some crackling noise for crackling sound when the joint moves. This is known as crepitus.
For Example, Patients with knee joint osteoarthritis can feel crackling or crepitus from their joints, especially when they keep their palms over their joints while moving. In most young – middle-aged patients, clicking sounds heard from joints without much pain is normal and one should not start fearing osteoarthritis due to the same.
How is osteoarthritis diagnosed?
There is no single test that can diagnose osteoarthritis on its own. Age, weight, family history, and pattern of symptoms aid in diagnosis. Other types of inflammatory arthritis, though less common, needs to be ruled out. Blood tests for osteoarthritis: There is no specific blood test to diagnose OA. Most blood tests done in patients with suspected OA are usually done to rule out other arthritis. Imaging methods for OA: Sometimes X-rays, ultrasounds, and MRIs are helpful in confirming osteoarthritis, but they are not required in most patients. Also, X-rays can be normal in most patients with early OA. Clinical history is most important in early OA. Imaging methods are most useful to identify the degree and severity of OA in a particular joint. And it is important to note that pain or clinical findings may not correlate with X-ray findings. The diagnosis of osteoarthritis is usually made by an expert like a Rheumatologist or Orthopedician doctor after collectively taking into account various factors.
How can osteoarthritis progress and affect daily life?
Most people will have mild to moderate osteoarthritis with progressive age. In most cases, it will lead to mild to moderate pain, and usually this pain is intermittent. Most osteoarthritis patients can function with good quality of life without doing many interventions except for exercises, assistive devices, or being physically active. However many patients will have moderate or progressive osteoarthritis, which can lead to pain and deformities in the future. In some patients, osteoarthritis will lead to disability due to progression. However, there are many non-surgical and surgical treatment options available, even if one has advanced osteoarthritis with a disability.
What is the treatment for Osteoarthritis?
A General Principle of Osteoarthritis Treatment: Osteoarthritis is a chronic disease and there is a component of age-related wear and tear (degeneration) of the cartilage in the joint. Because age is a factor, osteoarthritis usually progresses with advancing age. The progress is gradual in most cases and it takes years for patients with early osteoarthritis to develop advanced osteoarthritis and disabilities. There is no treatment for osteoarthritis that can reverse the damage to the cartilage. But the process can be slowed down. Most important is to lose weight. Most treatment of osteoarthritis is to make the patient symptoms better and to give them a good quality of life. Osteoarthritis treatment can include a range of options, which can include non-medication-based treatment and medication-based treatment and surgery. It is important to understand that every patient is different and every patient with osteoarthritis can have different issues and joints involved. Treatment depends on the patient’s exact problems, daily activity demands, and desired expectations from treatment.
Treatment of osteoarthritis without medication is recommended as a first line of treatment. This line of treatment can be helpful to all patients without any side effects and should be a part of the treatment of all OA patients.
Controlling Excessive Weight or Planning Weight Loss: We have already mentioned that obesity or excessive weight can increase the risk of osteoarthritis. If the patient has already developed osteoarthritis in a particular joint, weight loss may help to slow down the progression. If a Knee or hip joint OA patient loses weight by 10%, there is evidence to suggest that they can have a 50% decrease in pain. If one is serious about weight loss, one should strongly consider showing a dietitian who can guide them accordingly with the weight loss program.
Physical Exercises and Physiotherapy: Exercises are a very important part of the management of osteoarthritis. They don't improve or stop the progression of the worn-out joint. However, they keep to help the surrounding muscles strong and may decrease the pain. So a patient with osteoarthritis who continues to exercise is more active compared to those who do not exercise. Consider starting exercise gradually and taking advice from a trained physiotherapist. They can give specific exercises for the affected joint. Exercise may not give immediate relief and it may take some weeks for exercise to show its benefits. Also, exercises may increase the pain in the initial few weeks before they show benefits. The general rule one should follow is any increase in pain after exercise should reach to pre-exercise levels within 24 hours. If that is not the case, one should be more gradual in building up to a desired exercise regimen or take the help of a trained physiotherapist to modify the exercises. Also, any form of physical activity in these patients keeps their muscle strength and can be very helpful to help their comorbidities like diabetes, heart disease, hypertension, osteoporosis, etc.
Splints and Assistive Devices: Some patients with osteoarthritis, especially osteoarthritis in the base of the hand can be helped by using hand splints. This splint does not prevent the progression of osteoarthritis in the thumb base. However, it is helpful in preventing excess deformity of the thumb base joint. It also helps decrease the pain at the thumb base while moving. Patients with foot and ankle osteoarthritis may have some specific benefits with some specific insoles. This is generally true if patients have specific issues like flat feet or deviated ankles. Usually, knee braces or stockings are not advisable as they make the muscles surrounding the joints weak (patients' muscles are not used and loading is taken by the supportive device). The weak muscles surrounding the joint can further increase the pain and may lead to instability in the patient’s movements. However, one might use the supportive devices for intermittent use to provide stability while walking, for short-term use before surgery, or in cases where surgery is not feasible. Always take the advice of a clinical specialist (like a doctor, physiotherapist, or occupational therapist). In patients with advanced osteoarthritis, the use of walkers, walking cane or sticks for support, etc may be helpful and will prevent falls.
Osteoarthritis treatment with medications/ Pharmacological treatment of osteoarthritis
Most patients with osteoarthritis can be managed with non-pharmacological measures of weight loss, exercise, splints, etc. These things should be a part of patient management even if any medications are given to them. Some patients do require medications for the management of osteoarthritis. Please understand that there is no medication conclusively proven to halt or slow down the progression of osteoarthritis. Whatever medications we have available right now, are to manage the symptoms of osteoarthritis, so that the patients have better quality of life with less pain and more mobility. We again re-emphasize that it is very important for the patient to concentrate on exercise and weight loss in most cases, without which the pharmacological interventions may not have much benefit.
Topical NSAID lotion/gels/therapies for osteoarthritis joints-
Topical anti-inflammatory gels/lotions contain drugs called nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs when applied to the skin over the joint can help in relieving the pain of osteoarthritis. This is especially true in the hands, knees, and other superficial joints. They cannot be used in relieving the pain of hip osteoarthritis as it is a deep joint. Usually, topical gels contain very low quantities of NSAID drugs with very low absorption and hence they usually do not have any major side effects. However, in patients with blood pressure, kidney, or heart issues one should discuss safety issues with their doctors.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Nonsteroidal anti-inflammatory drugs (e.g.: ibuprofen, diclofenac, Naprosyn, indomethacin, etc) are commonly known as painkillers by the general Indian public. They not only help relieve pain but can also help to decrease inflammation (redness, swelling, etc). They are very effective drugs in relieving the pain and inflammation associated with osteoarthritis. However, one should always discuss their use with a doctor as their consumption in patients with acidity (heartburn), heart, kidney, blood pressure issues, etc can be harmful. NSAIDS gels (discussed in topical therapies above) have very low doses of these drugs and are absorbed in very little quantities when applied over joints. They are generally much safer to use than NSAID tablets.
Paracetamol
Paracetamol is generally very safe in the elderly population of osteoarthritis. The maximum total daily dose of paracetamol is 3 to 4 grams per day. Paracetamol is not as effective as NSAID drugs (discussed above) as it does not have an anti-inflammatory and dramatic pain-relieving effect. However, it is much safer if given for prolonged periods also and can give decent relief to OA patients. In recommended doses, it doesn’t tend to affect the heart or kidneys. Paracetamol is commonly used in a dose of 500 milligrams (mg) for fever 3-4 times per day. However, 500 mg is not usually effective for pain. One should use doses of 650mg-1gm two to three times a day for pain relief in OA. One should be careful with paracetamol doses and should not exceed a dose of 3 grams – 4 grams of paracetamol in a day. One should always talk to their doctor before trying to find the maximum possible dose of paracetamol that can be taken safely, and one should take it with regular checking up of liver parameters.
Non-NSAID pain-relieving drugs
Opioid drugs like tramadol (or tapentadol) tablets or capsules, buprenorphine patches, etc are used quite frequently in the Indian context. However, there is quite strong evidence that these drugs may cause dependence, and can cause a variety of issues including constipation, giddiness, nausea etc. They are generally considered to be unsafe for elderly people and should only be used very sparingly. They are generally not recommended to relieve OA pain routinely.
Neuromodulators for relieving pain:
Pain in osteoarthritis and any other disease can be multifactorial. There is some evidence that some patients with OA have over-sensitization of their nerves and this may lead to increase pain. Some experts recommend a trial of low-dose neuromodulator drugs like duloxetine, pregabalin, gabapentin, etc to give symptomatic relief in OA patients. They might be especially useful in patients with osteoarthritis of the spine, especially if there is some compression of nerves. Technically these are not pain relievers, but they possibly work by modulating the pain carried in nerves. Again, these drugs should always be taken under expert guidance.
Joint injections
Glucocorticoid or steroid injections can be useful in certain patients with osteoarthritis. They are especially useful in those with some amount of inflammation in the form of swelling and warmth. They are generally considered to be safe. However, some evidence says that repeated steroid injections in the knee may lead to a slightly faster progression of osteoarthritis. Hence, usually, doctors don't give more than three to four injections in a year for a given osteoarthritic joint.
Platelet-rich plasma injections in the knee:
In this procedure, the patient's own blood is collected and platelets are separated and injected into the affected joint (mostly the knee). It is uncertain if it has any significant benefits. Many patients claim relief but again it's uncertain whether they would have got relief anyways from conventional therapies.
Stem cell injections in the OA joints:
Off late many centers in India have been propagating the use of patients' own stem cells to be injected into the OA joint. These are expensive, there is no conclusive benefit, and there is no clear-cut guideline or regulatory authority for such kind of procedures. One should at this moment refrain from using these kinds of injections. In most cases utilizing the expenses meant these kinds of procedures on replacement surgery is far more beneficial. This is especially true in cases of advanced knee and hip OA.
Glucosamine and other similar supplements:
Various tablets/supplements containing glucosamine and chondroitin sulfate are routinely prescribed to or used by patients with osteoarthritis. Many practitioners also prescribe diacerein for patients with osteoarthritis. However, there is no conclusive evidence that any of the above supplements work in relieving the pain of osteoarthritis. There are some good trials that have shown benefits and some good trials which have not shown benefits. There is generally no major harm in using them, but again one should consult their doctor.
Herbal remedies and natural substance supplements for OA:
A lot of herbal/natural therapies are there in the market which is claimed to give miraculous relief in osteoarthritis patients. Some patients also claim a lot of relief from these therapies. The list includes many supplements. For example, Turmeric tablets, curcumin tablets, fenugreek tablets, Chinese herbal therapies, herbal topical agents, Boswellia extract, rose hip extract, Ayurveda therapy tablets or oils, etc. These therapies are usually expensive and there is no proven conclusive benefit. However, since they are generally safe the doctors generally do not aggressively discourage the patients from taking these supplements. One should always be careful of herbal therapies which have the potential to damage the liver or kidneys. Many of them claim to have no side effects which can be untrue. Patients should always discuss/disclose their herbal therapies with their respective expert doctors.
Osteoarthritis surgery
Surgery is usually used as a last resort in osteoarthritis patients especially who have advanced osteoarthritis and are not benefited from conservative management. Patients with advanced osteoarthritis have severely worn-out cartilage, and deformities of the joint, and the pain is much more severe. The various type of surgeries available:
Replacement surgeries:
The most common surgery done is knee and hip replacement surgery which can be a partial replacement or a complete replacement. Replacement is usually done after 55 to 60 years of age as usually replaced joints last for an average of 15 years. Patients usually require a repeat replacement after that. Generally speaking, repeat replacement surgeries are more difficult. As the average Indian age lifespan is around 70-75 years of age, doctors recommend surgery for osteoarthritis patients at around 60 years of age or later. This is so that they are less likely to require another surgery on the same joint in their lifetime.
Fusion surgery:
Fusion surgery (medically known as arthrodesis) is recommended in very severe osteoarthritic joints where there is no possibility of a replacement and there is a lot of pain. Fusion surgeries are usually done in ankle joint OA where. In fusion surgeries joint margins are fused so that this leads to restriction of joint movement and much lesser pain. However, the movements are obviously restricted after fusion surgery. Such surgeries are more for pain relief at the cost of the flexibility of the joint. They can be very helpful in properly selecting patients.
