Osteoarthritis is the medical term to identify degenerative arthritis often seen with aging. We do not have the same tissue that we were born with. There is constant turn around of every cell and tissue. Old cells die and new cells form. Some cells turn around faster example blood cells, gut wall lining cells turn around in a few days while others such as cartilage cells and bone cells take a few years. However with aging the new tissue formed is not as healthy and tends to be weaker causing gradual loss of function. As one ages, the cartilage cells produce less and less of the cushioning substance found in between the bones in a joint. The quality is also poorer. As a result the 2 bones in the joint start rubbing against each other and this cause pain. What causes this aging of the cells and why the cushioning substance or the matrix is altered remains unknown. Genetics, excessive weight, previous injury, high calorie diet, lack of exercise, weak muscles resulting in more load on the joints are some of the reasons for early degeneration.
Clinical Presentation:
Patient typically presents with pain in the joint upon loading the joint such as climbing, coming down the stairs, getting up from sitting position. Later as the degeneration progresses, pain can occur with walking. Usually the knee is affected,one more than the other. Osteoarthritis can also affect the hips, ankle, base of thumb, fingers and the bones in the spine. Some swelling may be observed but the joint is usually not warm and pain at rest is not observed. Joint seems to get stuck after sitting in a position for some time, referred to as jelling, that gets better upon moving around for 5 minutes or so. In the advanced stages, the bone may be sitting on the adjacent bone and cause pain with any movement.
Diagnosis:
- Xrays are used most frequently to identify osteoarthritis.
- The gap between bones is the cartilage. As it does not have any calcium, the cartilage is not visualized in an xray. As the cartilage degenerates and thins out, the gap between the 2 bones reduces and this is known as joint space narrowing. In advanced disease the bone is seen on bone.
- Blood tests are usually done to rule out other causes of joint pain such as rheumatoid arthritis, gout or SLE.
- Blood tests to assess general health such as blood sugar, serum creatinine to assess kidney function may be done.
- There are no blood test to diagnose osteoarthritis.
- MRI gives a lot of information regarding the health of the meniscus, ligament, bone etc.
Treatment:
Significant weight loss from very low calorie diet reduces the pain and improves functionality in patients with osteoarthritis. Studies looking at different types of exercise have shown some improvement in some patients. Mild to moderate aerobic activity, muscle strengthening exercises, balancing exercises, Tai Chi and Yoga may help some patients.
Hence my advice for diet is:
Reduce the calories in your diet: Avoid oil (Which means avoid vegetable masala’s, fried food and snacks, juices, sweets, biscuits and bakery products such as puffs). One teaspoon of oil (5ml) has about 45 calories of energy. I have seen cooks frequently use 3 tablespoons (45 ml) to saute vegetables. That is 400 calories in a vegetable dish. Avoid sweets,sugar. Measure your rice intake and avoid more than 1 cup in a meal. Excessive refined sugar will make you hungry in an hour. Some person’s pain may be aggravated by gluten or eggs. Hence try avoiding wheat and eggs to see if it makes any difference. Plenty of vegetables and adequate water will help eliminate acids from the body. As the kidney cannot concentrate the urine beyond a PH of 5, adequate water and less sugar in diet will ensure removal of acids and prevent their build up in the body which can be detrimental in the long run.Avoid fruit juices as well as syrup based drinks. Fruit juices are usually made from about 3 times the amount of fruit one would eat and the fiber is removed. This results in higher fructose levels and quicker absorption than seen with eating the fruit. For this reason I prefer patients eat the fruit in moderation rather than drink fruit juice. Low fat milk is necessary for most vegetarians to meet their protein requirements. Anti-oxidant rich green tea may help.
My advice for exercise:
Generally my advice varies depending on the age of the patient, their level of fitness and based on how advanced the osteoarthritis is. However all patients can and must exercise.
Range of motion exercises: Every joint can move certain degrees.Example the knee’s range of motion is fully straight to bending to touch the gluteal muscle. If the range of motion is restricted, movement and functionality is restricted.One should therefore move every joint. Ankles, shoulder and spine tend to get stiff with aging and attention to these joints would be helpful.
Aerobic exercises: Exercises which make one short of breath are aerobic exercises Eg. walking, cycling. With Knee arthritis this can be a challenge. But I believe this is very important. One can do boxing like action with their hands, leg lifts etc. It is while one is breathless, the body produces signals for growth of tissues. One should walk however much they can slowly increasing the duration and frequency.
Muscle strengthening exercises: With ageing the muscles lose their strength and more forces are felt by the joint cartilage. Excessive loading of the cartilage can cause faster degeneration.Hence it is important to strengthen muscles. Flexibility and balancing exercises are important to prevent injury to joint as well as to prevent falls. Yoga, Tai Chi exercises help with these. I believe a combination of exercises along with low calorie diet will help to reduce the risk of arthritis and treat pain.
Medications:
No medication has shown to prevent or slow down the degeneration. The following may be helpful for some and can be tried.
- Local liniments: Like voveran gels, irritant liniments like methylsalicylic acid, capsaisin.
- Glucosamine and Chondroitin sulphate (Evidence based medicine does not support their use). However I suggest my patients try it for some time and then decide.
- Diacerein may be helpful for some.
- Boswellic acid may help.
- Hydroxy chloroquine sulphate can be used for some time.
- Analgesica and Anti-inflammatory drugs.
Intermittent use of paracetamol, pain killers and required to reduce inflammation. While continuous use is not advisable,using them sparingly and intermittently helps maintain mobility and increases healing and improves functionality.If one does not have kidney problems, they can take pain killers for a short duration.Paracetamol or acetaminofen (Both refer to the same drug) can be used by patients with borderline kidney function. Tramadol can also be used.
Other Modalities:
Ice therapy, Knee cap, Knee brace, Lateral wedge soles in shoes, Medial shoe inserts, Use of canes may benefit a few. Joint injections with corticosteroids (sometimes called cortisone shots) or with a form of lubricant called hyaluronic acid can give months of pain relief from OA. This lubricant is given in the knee, and these shots may help delay the need for a knee replacement by a few years in some patients. Surgery – Surgical treatment becomes an option for severe cases. This includes when the joint has serious damage, or when medical treatment fails to relieve pain and you have major loss of function. Surgery may involve arthroscopy, repair of the joint done through small incisions (cuts). If the joint damage cannot be repaired, you may need a joint replacement.
LIVING WITH OSTEOARTHRITIS:
There is no cure for OA, but you can manage how it affects your lifestyle. Some tips include:
- Properly position and support your neck and back while sitting or sleeping.
- Adjust furniture, such as raising a chair or toilet seat.
- Avoid repeated motions of the joint, especially frequent bending.
- Lose weight if you are overweight or obese, which can reduce pain and slow progression of OA.
- Exercise each day.
Use arthritis support devices that will help you do daily activities. You might want to work with a physical therapist or occupational therapist to learn the best exercises and to choose arthritis assistive devices.
POINTS TO REMEMBER:
OA is the most common form of arthritis and can occur together with other types of arthritis.The goal of treatment in OA is to reduce pain and improve function. Exercise is an important part of OA treatment because it can decrease joint pain and improve function. At present, there is no treatment that can reverse the damage of OA in the joints. Researchers are trying to find ways to slow or reverse this joint damage.
Diet to reduce uric acid:
The uric acid can be lowered with diet. Uric acid is formed from purines and dying cells. Previously diet was aimed at reducing purines in the diet. Purines are different from proteins and vegetarian proteins need not be avoided. Now more information suggests fructose, high calories and sugar content in diet reduce the uric acid reduction. Beer and alcoholic beverages have high purine content.
Avoid high calorie,meat rich diet
Avoid the following
- Beer and hard liquor
- Organ meat: liver,kidney, brain
- Sea food and prawns (shrimp)
- Sugar syrup drinks
- Fresh fruit juices: occasional is okay ( you can eat the fruits)
- Reduce sweets and high calorie food
Following may be helpful
- Vitamin c rich fruits Amla
- Low fat dairy products
Following can be taken and will not aggravate gout
All vegetarian protiens such as legumes, dal, peas, as well as all vegetables including peas, beans and cauliflower. If you are a vegetarian and do not drink beer, you only need to avoid juices and have a low calorie high protien diet. Reduce rice and sweets and don’t avoid any dal, channa etc.
Please note even with strict diet you can only reduce the uric acid by 1-1.5 mg/dl. So if your blood uric acid level is 8-9 mg/dl,you will need additional drugs to reduce uric acid to achieve the goal of 6 mg/dl.