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Granny, your OA!

By: Marc Evans Abat, MD, FPCP, FPCGMGranny, your OA!

Okay, grammar police out there, don’t arrest me! I’ll explain the title!  Sure, some people have this tendency to think that once you get old, you tend to be “OA” or overacting, especially with particular bodily concerns like aches and pains.  Therefore, the title should be “Granny, you’re OA!”.  But I will insist my title is correct because I am actually talking about one condition that is a particular source of complaints among older people, which is OSTEOARTHRITIS, or OA.

This is the most common type of joint disease and the leading cause of disability in older people.  It was previously thought that this type of arthritis (or “rayuma” in local parlance) arises from mainly the breakdown of the cartilage in the joints as a result of “wear and tear”.  The current view now sees osteoarthritis to involve the whole joint organ, including the bone under the cartilage and the joint lining.

Osteoarthritis usually involves joints for weight-bearing, like the hips, knees, spine of the lower back and feet.  It can also affect the smaller joints of the hands, feet, and wrists.  Not only is osteoarthritis related to the typical “wear and tear” mechanisms (e.g. knee osteoarthritis from the prolonged effects of walking and running, especially in old age), but it also results from conditions that may affect joint mechanics or even inflammation (e.g. previous trauma).  In both cases, early osteoarthritis results in some swelling of the cartilage as the cells inside try to make more substances to repair itself.  After several years, the cartilage eventually loses elasticity, soften and thins out, leading to a narrowing of the joint space.  This thinning occurs the worse in areas of the joints experiencing high loads.  In the knees, for example, the joint space narrows more often on the inner side of the joint.  Once the cartilage is totally denuded and the bone exposed, the areas rubbing each other suffer from increased mechanical stress, leading to a thickening of those portions (called eburnation).  Think of it as a sort of a callus forming on the bone surface. 

Other findings that may happen include degeneration of areas of the bones into cysts or formation of bony outgrowths (osteophytes).  Aside from changes in the joints apparatus itself, there are associated changes also in the surrounding ligaments, nerves, and muscles.  Again, taking the knee, for example, changes in the lateral ligaments occur with osteoarthritis.

Let us talk about the main cause for prolonged management of osteoarthritis, knowing that this chronic debilitating condition: pain.  Come to think of it, many people think that older persons are “OA” or overacting when it comes to the pain they suffer from osteoarthritis.  The truth is that pain comes from a variety of mechanisms in osteoarthritis:

  1. Elevation of the bone covering
  2. Congestion of the blood vessels in the bone, leading to increased pressure
  3. Swelling of the joint lining
  4. Fatigue and spasm of muscles around the joint
  5. Limitation in joint range of motion or “contracture”
  6. Joint effusion or increased fluid in the joint
  7. Tearing of surrounding ligaments
  8. Psychological factors
  9. Central pain sensitization – “too sensitive to pain”

Imagine all of these coming together in varying degrees, leading to the pain of fluctuating severity.  We also cannot neglect the amount of disability (and the eventual complications from immobility), and the impact on the older person’s psyche of not being able to do the things that they want.

The “nitty gritty” part is the management of osteoarthritis.  As there is no cure to reverse the changes in osteoarthritis, the goal of management is 1) alleviate pain, and 2) to improve and maintain functional status.  Optimal management involves BOTH non-pharmacologic and pharmacologic measures.  Most even underestimate the benefits of the non-pharmacologic part; but as can be attested by many, it is as integral as popping your pain medications.

Non-pharmacologic management involves the following:

  1. Cardiovascular and resistance exercise (land-based or aquatic), tai chi:  exercising helps improve muscle strength (in order to stabilize the joint, prevent muscle atrophy and prevent falls), endurance (to tolerate fatigue), and improve balance despite the joint problems.  Exercising also prevents further functional decline, especially if practiced in the long-term.
  2. Weight loss to lessen the stresses on the involved weight-bearing joints like the knees and hips
  3. Psychosocial interventions to promote a better psychological well-being and encourage support systems
  4. Thermal agents like warm compresses for pain, although many also find pain relief with cold compresses
  5. Walking aids to help unload the joints, especially joints that are NOT or minimally affected, but are now compensating for the affected joint
  6. Shoe modifications like in-soles or knee taping to manage complications of osteoarthritis
  7. Avoidance of activities that may worsen osteoarthritis (e.g. walking instead of running)
  8. Uses of splints on deformed joints may relieve pain
  9. Acupuncture may provide pain relief for some patients

Appropriate consultations with the particular experts (e.g. rehabilitation medicine specialists, physical and occupational therapists, psychologist, exercise professionals, orthotists and traditional Chinese medicine specialists) are highly encouraged, especially to minimize the use of medications in the long-term.

There are a number of pharmacologic management options:

  1. Topical capsaicin, particularly for hand osteoarthritis
  2. Topical and oral non-steroidal anti-inflammatory drugs (NSAIDs) and oral COX-2 inhibitors:  These have varying degrees of effectiveness for pain and inflammation.  However, the noted side effects include gastric upset and ulceration, possible kidney and heart damage in the long-term use, especially with increasing blood pressure.
  3. Analgesics like paracetamol or tramadol:  These are effective also in varying degrees, especially for mild pain.  Among older persons, tramadol may cause nausea, vomiting, and dizziness, so use should be under supervision by a doctor.
  4. Intra-articular (“into the joint”) injections of corticosteroids, especially for the knees and hips:  This involves injecting corticosteroids in the affected joint, with relief noted in varying potencies and duration.  Complications of these may include bleeding in the joint and infection.
  5. Intra-articular injection of sodium hyaluronate and similar products also provide varying levels of relief among patients if done properly and with the completion of the recommended doses.
  6. Oral glucosamine sulfate with or without chondroitin sulfate has been used popularly for years with varying effects (whether organic or psychological).  In large studies, both agents show limited benefit, especially for severe osteoarthritis, as an add-on therapy.

Other options that may be available include:

  1. Arthroscopy has varying rates of success for osteoarthritis symptoms and should be performed by skilled orthopedic surgeons.  This involves usually the removal of tears and loose bodies in the joint.
  2. Osteotomy involves shifting the weight on the non-affected portion of the joint.  This is done especially in younger patients
  3. Arthroplasty involves replacement of the affected joint with a prosthetic joint.  This is performed if all other modalities are ineffective.
  4. Use of mesenchymal stem cells shows some promise in investigational settings.  This may hold promise in the future but needs further studies.

Management of osteoarthritis is long and arduous.  One cannot be judged as “OA” for it can really be painful.

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