Osteoarthrithis (OA) is the most common type of arthritis in both developed and developing countries. It is a chronic, progressive musculoskeletal disorder characterized by gradual loss of cartilage in joints which results in bones rubbing together and creating stiffness, pain, and impaired movement. The disease most commonly affects the joints in the knees, hips, hands, feet, and spine. The disease is associated with modifiable and non-modifiable risk factors such as obesity, lack of exercise, genetic predisposition, bone density, occupational injury, trauma, and gender.
Osteoarthritis can be classified into two groups primary and secondary. Primary osteoarthritis is a chronic degenerative disease and is related to aging. The water content of the cartilages decreases on increasing age, thus making them more susceptible to degradation. While secondary arthritis usually affects the joints earlier in life due to specific causes such as injury during a job requiring frequent kneeling or squatting for long duration, diabetes and obesity.
Osteoarthritis primarily affects the elderly population. It is a major cause of disability in older adults worldwide. According to World Health Organization (WHO) 9.6% of men and 18.0% of women ageds over 60 years have symptomatic osteoarthritis worldwide. 80% of those with osteoarthritis have limitations in movement, and 25% cannot perform their major daily activities of life.
Osteoarthritis is the second most common rheumatologic problem and it is the most frequent joint disease with a prevalence of 22% to 39% in India. OA is more common in women than men. Nearly, 45% of women over the age of 65 years have symptoms while 70% of those over 65 years show radiological evidence of OA.
The prevalence of OA is increasing due to population ageing and an increase in related factors such as obesity, sedentary life style. The physical disability arising from pain and loss of functional capacity reduces quality of life and increases the risk of further morbidity. As highly effective medicinal management is not available emphasis should be given to preventive aspect of life style measures in the form of healthy diet and exercise.
Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A, Epidemiology of knee osteoarthritis in India and related factors. Indian J Orthop 2016:50:518-22 accessed from www.ncbi.nlm.nih.gov/pmc/articles/PMC5017174/
The main symptoms of OA are pain, loss of ability, and “joint stiffness after exercise or use.” These symptoms are often aggravated by activity or rigorous exercise and relieved during rest. The disease may eventually progress to the point where the patient even feels pain during rest. Some people report pain so intense that it wakes them up when they are sleeping.
Knee or hip pain may lead to reduced physical activity and a sedentary lifestyle that may increase the weight gain and further obesity. Being overweight or obese can lead to the development of diabetes, heart disease and high blood pressure.
People with OA have greater chances of fall and fracture than those without OA due to presence of risk factors such as decreased function of joints, muscle weakness and impaired balance.
Risk Factors for occurrence and progression of osteoarthritis-
i) Age- Normal ageing processes cause increased OA progression. Incidence increases with age but stays at the same level around age 80.
ii) Trauma- Injury to collateral ligament, meniscal tears and joint fractures lead to increased risk for OA.
iii) Occupation: OA is more common in those performing heavy physical work, occupational kneeling or repetitive use of joint during work. Certain occupations such as farming, construction work and physical education teaching are risk factors for the development of OA.
iv) Exercise- High impact sports present an increased risk for OA.
v) Genetics- There is genetic susceptibility to the disease; children of parents with early onset OA are at a higher risk of developing OA.
vi) Obesity- It is a strongest modifiable risk factor, being overweight at an average age of 36-37 years is a risk factor for developing knee OA.
vii) Gender and ethnicity- Women are more likely to develop OA than men, especially after age 50. OA is more common in Europeans than in Asians.
viii) Bone density- Decreased bone mineral density is a risk factor for OA
Commonly the doctor can diagnose OA on clinical examination with the following signs and symptoms:
An X-ray of affected joints will show a loss of the joint space. In more advanced cases, there may be bone spurs or evidence of worn-down ends of the bones in the affected joint.
An MRI scan (Magnetic resonance imaging) may be helpful in distinguishing OA from other kinds of injuries.
Artroscopy: is a common method of diagnosis and monitoring of progression.
Management of the patient with OA should be comprehensive and individualized, taking into account the joint involved, the phase and the progression rate of the disease, co-morbid conditions such as cardiac disease, hypertension, peptic ulcer disease or renal disease, as well as the patient’s needs and expectations. Management plan should be regularly reviewed which is broadly divided into non-pharmacological, pharmacological, and surgical treatments. Non-pharmacological treatments should be started first, followed by pharmacological treatment and then surgery if the first two are unsuccessful.
According to various recommendations, non-pharmacological treatment of OA should include education, exercise, weight reduction and physical aids (such as canes, insoles and knee braces).
It is reported that patient education in disease management, weight reduction and exercise is quite effective in reducing joint pain. Effective educational techniques include individualized education, group education, social support, patient coping skills, and spouse assisted coping skills (coping skills : enhance patients’ ability to control and decrease pain by increasing use of adaptive coping strategies such as distraction, relaxation, and changing activity patterns as pain is affected by thoughts, feelings, and behaviors).
Exercise is the most important intervention in the management of OA. Exercise builds muscle strength and endurance, improves joint flexibility and motion. Exercise is beneficial even to those patients who are at a healthy weight because increased muscle strength can reduce some of the complications of OA. With the doctor’s advice low impact activities that will not increase the chance of exacerbating symptoms of OA should be encouraged.
Overweight and obese patients with osteoarthritis experience more pain and disability than patients who are not overweight. Excess weight adds additional stress to weight-bearing joints, such as the hips, knees, feet and back. Lifestyle behavioural weight management (BWM) interventions such as eating fewer calories and increasing physical activity should be encouraged to lose weight.
Other Non-pharmacological therapy includes a referral to a physical therapist; knee braces, orthotics, and appropriate footwear can reduce pain and improve function in people with poor alignment.
Heat and cold-
Heat or cold (or combination of the two) can be used in OA. Heat can be applied with warm towels, hot packs, or warm bath (it increases blood flow and reduces pain and stiffness). In some cases cold packs can relieve pain or numb the sore area by reducing inflammation.
Massage with lightly stroke and /or knead the painful muscles may be a pain relief approach.
Apart from the traditional non-pharmacological approaches pulsed ultrasound, transcutaneous electrical nerve stimulation, electro-acupuncture, and low level laser therapy are newer therapies.
The primary strategy for pharmacological management of OA is to control pain and improve function and quality of life for the patient, while limiting drug toxicity as there is no cure for OA.
Paracetamol (Acetaminophen): Paracetamol (acetaminophen) is a commonly prescribed oral analgesic to treat mild to moderate OA pain.
Non-steroidal anti-inflammatory drugs (NSAIDs): NSAIDs can be used for relieving pain in OA (However, treatment with NSAIDs is associated with gastrointestinal effects and potential toxicity, especially in the elderly persons). New classes of NSAIDS called Cyclooxygenase-2 (COX’2) inhibitors are also in use (one of the class, refecoxib was found to increase the risk of cardiovascular events and was withdrawn in 2004, celecoxib and eterocoxib are in use). Topical NSAIDs, in the form of cream, patches, gels, solutions, have been found to be effective in reducing pain associated with musculoskeletal conditions, including OA. The benefit of topical NSAIDs is that they eliminate the gastrointestinal side effects of oral treatment. However, they have been associated with certain local adverse effects and they may be less effective than oral NSAIDs.
Opioids may be used for pain relief in patients who cannot use either NSAIDs or acetaminophen; however drug abuse is high with opioids.
Intra-articular corticosteroids: Treatment with corticosteroids injected directly into the joint (intra-articular) has been shown to be effective, especially in OA of the knee.
Viscosupplementation: This involves a series of injections of either hyaluronan or hylan products (hyaluronan is a polysaccharide and is one of the main components of the extracellular matrix).
Joint replacement surgery: Patients who experience severe pain and show extensive narrowing of joint space and medicines are not effective; these patients are eligible for joint replacement surgery. Joint replacement surgery is removing a damaged joint and putting in an artificial one (A joint is where two or more bones come together, like the knee, hip, and shoulder).
Osteotomy: Osteotomy is the cutting and reshaping of bones with the purpose of altering the area of the joint which bears weight.
Arthroscopic debridement and lavage are two processes that involve removing damaged cartilage, bone, and excess debris surrounding the joint.
Complications of osteoarthritis includes-
· Complete breakdown of cartilage resulting in loose tissue material in the joint (chondrolysis).
· Bleeding inside the joint
· Infection in the joint
· Bone death (osteonecrosis)
· Stress fractures (hairline crack in the bone)
· Deterioration or rupture of the tendons and ligaments around the joint
· Pinched nerve in osteoarthritis of spines
Prevention is a major strategy in addressing the disease burden of osteoarthritis; as no highly effective pharmaceutical treatments exist and surgical options are expensive and not widely available.
Primary prevention of OA includes:
Weight control: Obesity is a risk factor for OA, thus maintaining or reducing weight through altered diet and increased physical exercise can lower the risk of developing OA.
Exercise- Regular physical activity according to individual’s health status and lifestyle can keep the muscles around the joints strong and decreases the bone loss. Exercise needs to be directed for the entire body and not just the joints that are affected by OA. Both aerobic and muscle strengthening activities are recommended for people with arthritis. Exercise programme can be planned with the consultation of doctor.
Occupational injury prevention: Repetitive use of joint should be avoided and proper management of related injuries can help prevent arthritis.
Sports injury prevention: Taking the necessary precautions to prevent injury such as warming up and using proper equipment can help reduce joint injuries.
Misalignment: Improper alignment of the knee or hip can contribute to osteoarthritis and proper treatment such as orthotics or bracing can help reduce the risk of developing the disease.
The best way to prevent osteoarthritis is to exercise regularly, avoid squatting and cross-legged positions, maintain a healthy diet and keep weight in control.
The aim of secondary prevention is early diagnosis and effective and appropriate management that will minimize the health consequences of the disease.
Tertiary prevention is to minimize the complications of disease once it has been diagnosed. Such strategies are aimed at reducing pain and disability due to OA, and improving quality of life. Tertiary prevention strategies for OA include self-management (weight control, physical activity, and education), home help programmes, cognitive behavioural interventions, rehabilitation services, and medical or surgical treatments.
Healthy eating for osteoarthritis-
Reduce extra calories: Take smaller portion, avoid sugar in foods and drinks, and eat mostly plant based foods.
Eat whole grains: Foods like oatmeal, brown rice and whole grain cereals.
Eat more fruits and vegetables, as they contain some antioxidants which may help reduce joint inflammation and reduce pain.
Add omega -3 fatty acids: Omega-3 fatty acids may help relieve joint pain and decrease morning stiffness. Some of the best sources of omega-3 fatty acids among fish groups are mackerel, lake trout, herring, sardines, tuna, salmon. Flaxseeds, chia seeds, fish oils, eggs, cauliflower, canola oil, spinach are also good source of omega -3 fatty acids.
Use olive oil instead of other oils: compound in olive oil called oleocanthal helps prevent inflammation.
Get enough Vitamin C- Vitamin C helps build collagen and connective tissue. Eat foods like oranges, grapefruits and limes.
Eat Garlic- Compound like diallyl disulphide found in garlic may limit cartilage damaging enzymes in human cells.
Low-fat dairy products (like milk, yogurt and cheese), and broccoli, and green tea are also effective in prevention of osteoarthritis.
Watch high cooking temperature-Meat cooked at high temperature makes compounds called advanced glycation end products(AGEs), which are linked to inflammation(in diseases such as arthritis, heart disease and diabetes). Limit Grilled, fried, broiled, (food is cooked directly under high heat) and microwaved meats. It is also helpful to limit processed food.