Crisis of the cartilage
Multidisciplinary approaches to treating osteoarthritis
By Sunly Coo, Contributing Writer
Painful, stiff, and sometimes swollen joints. The gradual inability to perform everyday tasks. The frustration over the decline in the quality of life. This is the reality for many seniors who suffer from osteoarthritis, the most common type of arthritis, according to studies on North American populations.
"Osteoarthritis is the wearing out of the joints, specifically the degradation of cartilage," says Dr. Alan Leonardo Raymundo, an orthopedic surgeon at the Philippine Orthopedic Institute. "Normally, the end of the bones are capped with cartilage, a whitish layer that is smooth and elastic when you're young. It's the shock absorber for all moving joints, and it deteriorates as you grow older. It can eventually affect the subchondral bone, and you begin to form cystic formations, micro-fractures-and bone spurs." As the cartilage shrinks, the body compensates by growing bony projections, called bone spurs, to increase the contact area in the joint. Unfortunately, the resulting bone-to-bone articulation triggers pain.
"The most commonly affected joints are the knees, hips, and spine, or your major weight-bearing joints, and sometimes we also see it in the hands," he continues. "Usually, when patients come to us with knee pain, it is not early arthritis anymore. More often than not, it's in the moderate stage. That's why it is important to be conscious of the early signs of osteoarthritis: stiffness, that's the first complaint, and on-and-off pain. Patients sometimes tell me that they experience stiffness when they wake up but that it gets better as they start moving around."
Not just for the elderly
Although old age is the predominant factor of osteoarthritis, a condition the medical community calls "primary osteoarthritis," this degenerative joint disease can also strike individuals below 60. "Secondary osteoarthritis is when something else has caused it, some posttraumatic incident or disease entities," he explains.
Such is the case of Raymundo's patient, Dilip Budhrani, a mid-forties entrepreneur and sports buff, who dislocated his hip more than two decades ago. The disjointed left hip was snapped back into place, and he continued to pursue a physically active lifestyle, playing basketball and running in marathons, but it would never be the same again. The trauma, combined with years of subjecting his joints to high-impact and intense friction, had seriously undermined his cartilage, making it painful to live through each day.
"I couldn't walk extensively; I was limping. I couldn't ride my bike. I couldn't lift my leg because of limited range of motion. When I had to put my socks on, I had to really stretch and bend low enough to be pain-free," he recalls. "I was on heavy medication, a minimum of two [tablets of] Celebrex (a cyclooxygenase-2 inhibitor) when I had a party, an event, or a trade show. Sometimes, I take four. Aspirin wasn't working anymore. I also tried everything but surgery-yoga, acupuncture-you name it."
The pain eventually proved to be too much-none of the left hip cartilage remained-so he decided to undergo surgery for hip replacement. "I'm on my fourth year already. It feels about 95-percent okay. It's not 100 percent because they had to cut through muscles to put the implant, so compared to my normal hip, it's not exactly the same. There is no problem with mobility though. I could do almost everything I want," he says. To prolong the life of the implant, he avoids high-impact exercises, such as running and playing basketball, but not badminton. "I play almost three times a week, against my doctor's advise," he quips. "I'm not trying to be radical ... I just want to sweat." He is also careful to not push himself too much, and he religiously goes for his yearly checkup, which includes x-ray. Because the implant is good for an average of 10 to 15 years, and a maximum of 20, Budhrani is scheduled to have his hip replaced in 2025.
Treatments
There is currently no cure for osteoarthritis. No modality has scientifically been proved to reverse or at least arrest the disease. Existing treatments are aimed at managing pain and slowing down joint degeneration. "The first line of treatment is always conservative," says Raymundo. Before signing up for surgery, the last resort, a patient usually undergoes a host of treatments ranging from medicinal to nonpharmacological, including alternative or complementary therapies. It can be a combination of any of the following:
Behavior/activity modification. The goal, to protect the joints, is achieved by spreading the load to larger and stronger joints. Pushing the door by leaning against it; lifting heavy objects by using both hands and, if possible, using the thighs as leverage; maintaining proper posture; and other small changes in daily life can offer significant relief for some osteoarthritis sufferers. Taking frequent breaks from repetitive tasks and pacing oneself are also advised.
Assistive devices. Walking canes, orthopedic or comfortably cushioned shoes, bathroom handlebars, shower seats, pushcarts, and other energy-saving objects can help ease the pressure on affected joints and prevent accidents.
Healthy diet and exercise. Because an overweight or obese body exerts greater strain on the joints, some patients are advised to undergo a weight-loss program that combines healthy diet and appropriate exercise. Some studies suggest that minimizing saturated-fat intake alone can reduce joint inflammation. Similarly, the benefits of exercise extend beyond weight management. The right low-impact regimen, recommended by a doctor or a physical therapist, strengthens the muscles that lend additional support to the weakened joint. Walking, cycling, and swimming are popular choices.
Hot and cold packs. Heat improves the blood circulation to stiff joints and alleviates soreness. Using a cold compress or a bag of ice cubes lessens inflammation or swelling and dulls the pain.
Pain creams. Topical creams and gels numb the pain temporarily by generating a hot or cold sensation. Some varieties have analgesic compounds that work best for joints that are close to the surface of the skin, such as ankles and knees.
Acetaminophens. These over-the-counter analgesics may provide relief against mild to moderate pain, but they cannot reduce inflammation.
NSAIDs. Nonsteroidal antiinflammatory drugs like ibuprofen and acetylsalicylic acid reduce aches and abate swelling. Side effects may include gastric ulcer and gastrointestinal bleeding. COX -2 inhibitors are easier on the stomach but some cardiovascular problems have been documented.
Corticosteroid injections. When the preceding treatments fail to bring the pain to a manageable level, the doctor may suggest injecting corticosteroid to the inflamed joint to deliver immediate relief. Since the synthetic cortisone also drains the minerals from the cartilage, the patient should be subjected to this therapy only sparingly.
Viscosupplementation. For patients with osteoarthritis of the knee, viscosupplementa-tion can help restore mobility and absorb some of the mechanical shocks to the joints temporarily. The compound, sodium hyaluronate, is injected into the joint, providing the cartilage with additional viscosity. "It's a lubricant for the knees. It can be given on a weekly basis in a series of three or five, depending on the brand," says Raymundo. But the treatment is not cheap, he warns. One box (for a series) can cost between PhP20,000 and PhP25,000. Furthermore, viscosupplementation will not work for severe cases where the cartilage is completely gone. Studies are ongoing to explore its application to the hips, shoulders, and other joints.
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Surgery. Bone spurs and floating cartilage tissues in the joints can cause pain and decrease mobility. They are removed through a minor procedure called debridement. If the debilitating pain persists or if the patient simply cannot tolerate the symptoms of osteoarthritis, joint replacement becomes a viable option. "It depends on what functional pain level your patient demands," Raymondo says. Since the prosthesis has to be replaced after 10 to 20 years due to wear and tear, physicians usually suggest delaying the operation to later years. Joints made from cobalt chrome, high-molecular-weight polyethylene, and sometimes titanium are fitted in during the 60- to 90-minute surgery, which delivers results immediately. "You can walk around already. And the only painkiller you need is for the wound," he says. Because an implant can cost anywhere from PhP70,000 to PhP180,000 or more for newer, more sophisticated materials, "only about 20 percent of the patients we see can afford it," he explains.
Popular alternative therapies
Glucosamine sulfate. A popular food supplement for arthritis sufferers, glucosamine sulfate is a key component of joint cartilage. Some studies show that the shellfish-derived substance strengthens the cartilage, helps it absorb and retain fluids, and slows down its deterioration. There is no clinical proof, though, that it can arrest or reverse the disease. Not for patients with diabetes or allergies to shellfish, glucosamine sulfate also takes longer to work compared with NSAIDs.
Chondroitin sulfate. Another food supplement that is a major constituent of human cartilage, this sulfur-rich compound is harnessed from bovine or pork byproducts. Just like glucosamine sulfate, chondroitin sulfate has yielded studies with mixed results. Makers claim it improves the joint's shock-absorbing capability and blocks off the cartilage-degenerating enzymes. Some patients reported experiencing significantly reduced pain and inflammation and enhanced joint function, but not after a couple months or so of therapy. Chondroitin sulfate cannot repair worn cartilage.
Acupuncture. This ancient healing technique is based on the principle that one can control and redirect the flow of positive and negative energies or chi by inserting needles into specific points of the body. Some western studies discovered that the needles actually stimulate the release of endorphins, the body's own painkillers. The amount of relief experienced varies from person to person. The effects are only temporary.
Yoga and tai chi. Both eastern practices combine slow-moving, low-impact exercise with deep breathing and meditation. On one level, the gentle movements help slow down osteoarthritis by strengthening the supporting muscles around the affected area. On another level, it is believed that mild to moderate pain can be controlled through the meditative powers of the human mind.
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Scientists find new compound for chronic pain
PARIS
Scientists have found a substance that, in mice, blocks chronic pain but does not appear to cause any of the unwanted side effects of existing painkillers. Researchers led by Hanns Zeilhofer at the University of Zurich in Switzerland found the compound after exploring the way pain signals travel up to the brain via the spinal cord.
"Normally the spinal cord acts as a kind of filter, ensuring that not all painful signals coming from the periphery of the body reach the brain," Zeilhofer said in an interview. If these neurological gatekeepers were totally absent, even the lightest touch on the skin would make us wince with discomfort, he explained. "We would be in constant pain without them."
But in patients with chronic pain, this filter function is impaired, meaning that the spinal cord is like an open channel for pain signals, he said.
A key role in the inhibition process is played by two nervous-system chemicals called neurotransmitters. One is gamma-aminobutyric acid, also known as GABA, and the other is glycin.
"We thought we could restore the filter function if we pharmacologically enhance the action of GABA or glycin in the spinal cord," said Zeilhofer.
But as no compounds had been developed that target glycin, they focused instead on GABA. In experiments reported in Nature, the researchers induced inflammation in the paws of mice and rats, and then gauged the force needed to make the animal withdraw its leg, creating a rough measure of pain.
First they injected Valium into the spinal cord. As predicted, the drug increased the transmission of GABA, significantly reducing the rodents' aversive reactions.
But the problem with Valium as a treatment for pain is that it also causes drowsiness, impairs memory formation, and rapidly loses its effectiveness, said Zeilhofer.
All these unwanted side effects occur in the brain, he noted, so he and his team wondered if there wasn't another chemical that would act only on the spinal cord. That's when they found L-838,417, a compound that suppressed the pain signals without causing sedation or losing its effectiveness over time.
"During a nine-day treatment in rats, we found the morphine completely lost its analgesic effect, whereas the analgesic effect of L-838,417 was completely retained," Zeilhofer said. Although the drug blunted chronic pain, it did not cause numbness that blocks acute pain-the sharp sensation that comes from burning or a cut, for instance. Acute pain is a vital survival mechanism.
Zeilhofer hopes that pharmaceutical companies will refine L-839,417 so that it can be approved for trials on humans. "We are very keen to test such compounds in human pain models, first healthy volunteers and then in certain pain patients," he said.
M AFP
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