The main aim of this article is to is to provide information and advice about Osteoarthritis with an emphasis on self-help. The article is written on the assumption that the reader has been diagnosed with Osteoarthritis by a healthcare professional. If you haven't been diagnosed but you think you might have the condition then its best to get checked out first as there are other conditions that can cause similar symptoms.
You can see my 20 minute video all about Osteoarthritis below
This article addresses Osteoarthritis by answering the 3 most common questions that people ask after they have been diagnosed.
1) What is Osteoarthritis ?
Well the word, like many medical terms comes from the ancient Greek, with 'Osteo' meaning 'related to bones', 'Arthro', 'meaning related to joints', and 'Itis' meaning 'inflammation'. So the whole thing put together means 'inflammation of the joints between bones'.
The name Osteoarthritis has been used since the late 1800's and up until fairly recently we thought that the 'itis' part was wrong because researchers couldn't find any evidence of joint inflammation and instead found the main problem was joint degeneration, prompting some people to use the term Osteoathrosis instead, as 'osis' means degeneration.
However, the very latest research has shown that the condition is actually driven by a chronic low grade inflammation which then leads to degeneration and thinning of the joint cartilage. Cartilage is the slippy grisly substance that covers the bone ends and helps the joint move smoothly. You might have come across it when cutting your Sunday roast.
To understand what happens in Osteoarthritis, we first need to look at the features of a normal healthy joint. And the key features are smooth bone ends covered by an even layer of cartilage. We then have a capsule to protect and enclose the joint space, within which is contained the synovial fluid, an oily substance to help with joint lubrication. Finally we have tight ligaments to reinforce the capsule and support the joint.
A Healthy Joint
In Osteoarthritis (OA), there are a few key changes. Initially, there is thinning and degeneration of the cartilage. This causes the bone ends to come closer together which narrows the joint space and slackens the ligaments, causing extra joint play. The bodies response to this is to extend the edges of the joint, essentially growing extra bone in an attempt to stabilise the joint. We call these Osteophytes and you can see them clearly on X-Ray. The joint capsule then thickens and produces extra synovial fluid to compensate for the lack of cartilage, but this extra fluid can interfere with movement and cause joint swelling.
Osteoarthritis
We can determine the severity of OA by looking at X-Rays and working out how narrow the joint space is, the size and number of osteophytes and the degree of roughening you can see at the bone ends.
OA can effect any joint but is much more common in the hips, knees, spine and the small joints of the hands and feet, particularly the thumbs and the big toes. The symptoms of OA are joint pain, stiffness and difficulty with joint movement. Walking may be uncomfortable when the hips, knees and spine are affected. The pain often occurs with movement but an aching pain can also occur with prolonged rest as the joint stiffens up. Sometimes people may have joint swelling during a flare up, or a feeling of grating during joint movement, which we call crepitus.
Joints commonly affected by OA - from www.pthealth.ca
Pain and stiffness can be worse in the morning when you first start moving but this should settle within 30 minutes once you're up and about. Morning pain and stiffness of the joints lasting more than 60 minutes might be an indication of something different, like an inflammatory disease such as Rheumatoid arthritis, which is a vey different condition. If your symptoms are like this then you should always get checked out by a clinician, as early diagnosis is important.
2) Why have I got it ?
Well the first thing to say is that OA is not a disease. You can't catch it. It's a process of age related degeneration and indeed it will usually affect most of us to some degree if we live to be old enough. It's just that some people might develop it later in life and other people might develop it much earlier in life when they are still active and working.
And whether OA affects us earlier in life depends on a number of different risk factors. We certainly know that genetics plays an important role and so family history is one of the most important risk factors. The other known risk factors are older age, being overweight, previous injury to the joint or a history of other joint related conditions such as gout or rheumatoid arthritis. We also know that OA more commonly affects women.
The other important risk factors relate to lifestyle. We know that normal healthy cartilage depends on regulating the growth of new cartilage cells balanced against the death of old cells. And the latest research has identified that poor diet and a lack of regular exercise can interfere with this natural balanced state, and set into motion a series of chemical events that eventually leads to degeneration and thinning of the joint cartilage.
Sedentary lifestyles can affect Joint Health
And this is where things can get a bit confusing. Because OA sometimes gets called a 'wear and tear' condition, which suggests that the more a joint is used, the quicker it will wear out. And we now know that is just plain wrong. Otherwise everyone who exercises regularly would have lots of OA and every sedentary person would not, and that's just not what we see.
Having said that, there are circumstances where excessive joint use can cause OA but this tends to be in a minority of cases involving prolonged strenuous activity usually seen in heavy manual jobs over many years. It's also not unusual to see OA affecting people who have done high impact sports such as rugby or football but we think this is due to the injuries associated with these sports rather than the sports activity itself.
An example of excessive overuse might be OA of the lower back due to years of heavy lifting in poor postures, or knee OA due to years of kneeling on hard surfaces. For the vast majority of people though, it is under-use rather than over-use, that contributes to the development of OA.
Movement and exercise are vital in keeping joints healthy and unfortunately, modern lifestyles and inactive jobs often don't use our joints enough. Joints, like many other parts of the body are 'use it or lose it' structures and they require regular use in order keep them healthy. So as you can see, for most people, wear and tear is not a good term to describe OA, as it sends the wrong message. As such, we really shouldn't be using it any more.
3) What can I do about it ?
Well unfortunately you can't cure OA. It's a chronic long term condition, but there are plenty of things you can do to help with symptoms and to improve your quality of life. The first, and most important thing you can do is address any of the risk factors that might have led to you developing the condition in the first place. Of course you can't change your genetics, or your age but you can certainly try to lose weight and increase your activity levels, and these are the single most important things you can do.
Image from www.coastalorthoteam.com
Even a 2kg weight loss can significantly reduce the amount of stress through the hips and knees and help reduce symptoms. People often tell me that they struggle to lose weight as they can't exercise due to pain. I'm going to address exercise in the next section but as far as weight loss go's, the vast majority of weight loss occurs through diet and so that's where your focus should be. If you've tried and struggled with weight loss in the past then do get help. It can be a hard battle to fight alone and those who succeed usually do so by building a strong network of support around them. Your family doctor or local weight loss groups will be happy to help you.
As for increasing your activity levels, well let's start with the basics. Firstly, your job might be a factor. As we've mentioned before, this is usually because of inactivity and associated muscle weakness, poor posture and stiffness. Desk jobs are probably the most common culprit, especially in people who do no regular exercise in their free time. Sitting for long periods day after day is not healthy for you or your joints, especially if your posture or desk set-up is poor.
Poor Desk Ergonomics
Improving your desk space and getting a work place assessment can be helpful but the most important thing is to get up and move around regularly. Even better is to get a standing/riser desk. These move quickly between sitting and standing positions. Standing for 50-75% of the day can have significant health benefits including; better posture, improved muscle tone, weight loss (due to using more calories), better circulation and reduced muscle & joint pain. Many companies are starting to realise the importance of work place ergonomics on the health and well-being of their staff. As a result, Riser Desks are becoming an increasingly common site in modern offices and in the home.
On the other hand you might have a job that involves very strenuous or repetitive activities and so you might need to think about ways of reducing the strain on your joints. For example, using lifting equipment to help with back strain or using knee pads or a kneeling cushion to help reduce knee cappressure.
Ok so onto Exercise, and this is the important bit because if there's one thing I've learned in my 24 years as a physiotherapist, no matter how severe your OA is on X-Ray, how bad your joint pain is, or how much creaking or grinding you feel, some form of regular exercise will nearly always be helpful in reducing symptoms. It's just a case of working within your abilities and following some simple rules.
Firstly, exercise must be done regularly. A 10 minute programme of stretches and exercises done 5 times a week would be a bare minimum. 20-30 minutes of regular exercise is ideal and you can break this down into two or three 10 minute sessions through the day if that works better for you. Spending 30 minutes on your feet most days can also be really helpful, either walking, using stairs or just pottering around the house. If you have to use a stick or a walking aid, well that’s fine. Exercise should become routine, just like brushing your teeth. It won't work well if it's done occasionally, or in bursts of activity followed by periods of rest lasting days or weeks. Joints respond best to a regular predictable amount of exercise.
Secondly, the type of exercises that will help you and the intensity that you do them will depend on your individual abilities. It's difficult to give specific exercise advice in an article aimed at general OA because what you do will often depend on what joints are involved and how bad your symptoms are. But as a rule of thumb, you should be trying to strike a balance between doing too little (where you find them really easy) and too much (where you're really struggling to manage them). And this will be very individual for you. You'll only find your level by trying and seeing.
A simple but effective flowchart from www.thesports.physio
Some good general video's for general OA can be seen by clicking the links below. You certainly don't have to do all 10, just pick the ones that suit you. For hips and knee joints, try to work towards the majority of your exercises being in standing. After all, that’s where you need those joints to be strongest if you want to improve your mobility.
If you struggle to see the value of regular exercise then have a look at the video below which illustrates beautifully how exercises can be tailored to help improve your daily activities.
Video from dustinjones.dpt
Don't be frightened of feeling some pain or aching during and after exercise but this should settle down fairly quickly and certainly within a few hours. If you get persistent joint swelling after exercise then your are definitely doing too much for that joint. Take a step back and start with really gentle movements until your joints get used to the activity.
The third rule is to be patient. Exercises are a long term investment in your joints. You're not going to get instant results. In fact it's common to feel worse for a few weeks while your joints are adapting to the new regime. So knowing this, always start easy and progress slowly. Think of exercises as being like the rungs of a ladder. You have to allow your joints to get used to the basics before taking the next step up in activity.
Taking baby steps in this way and slowly progressing over the weeks and months is the best way. If you push too hard and too fast then you run the risk of a flare-up and this will knock your confidence and give you the wrong idea that exercise doesn't work for you. If that happens, then don't give up, just take a step or 2 back down our imaginary ladder until things settle for a few weeks and then you can start stepping it up again but more slowly this time. It's all a balancing act. It can take a good few weeks before your joints settle into the routine so try not to give up or lose focus during these crucial early stages when your joints may feel like they are grumbling or that you're not making progress.
The importance of persistence
So be patient but also be persistent and resolute. I will get round to making my own articles and videos to address each individual joint, but until then i'll put a link to some great websites. In particular, versus arthritis and the chartered society of physiotherapy, who have some excellent resources including good basic exercise programmes for the different arthritic joints.
The only joints that sometimes don't respond as well to exercises are some of the small joints of the hand and feet, particularly the base of the thumb and the big toe. This may be because these joints are generally so active in nearly everyone and therefore they rarely suffer from under-use. In fact splints, to help limit thumb activity or insoles to support the feet are usually a better option in managing OA in these smaller joints.
The take home message for the majority of OA joints, and in particular the hips, knees and spine is that regular low impact exercise is one of the most important weapons against the symptoms of pain and stiffness. They won't change the appearance of your joints on X-Ray but they can help you to build strength and resilience and enable your joints to cope better with the daily activities of life. Remember, your joints are 'use it or lose it' structures. Use them regularly and sensibly they will respond in kind.
The other common treatments used for OA are tablets and creams, injections and surgery. To help find out what other treatments might be worth trying, it can be helpful to first divide your symptoms into one of 2 categories. If your joint pain is fairly stable day to day, but has perhaps been slowly worsening over time, then we call this a 'quiet joint' and a regular painkiller under the advice of a pharmacist or health care prescriber can be helpful. Recent studies have also found that using a cream derived from Chilli peppers, called capsaicin cream can help with joint pain when used regularly. In the UK, this is a prescription only medicine and so you will need to see a prescribing clinician.
On the other hand if your joint has become visibly swollen or has significantly worsened beyond its usual level of background pain then you may be experiencing a 'flare up', and this can interfere with your ability to exercise. A flare up is usually due to a degree of joint inflammation and so a short course of anti-inflammatory tablets or rubbing gels can be helpful in reducing the swelling and settle the flare up. Again, please see a pharmacist or health care professional for advice regarding anti-inflammatories as not everyone can take them.
For a persistent joint flare up, a cortisone injection can be a very effective treatment. They are usually provided by a specialist clinician and should be used sparingly as regular use of steroids can be harmful. Another type of injection that shows promise for mild to moderate osteoarthritis are the viscosupplementation injections. These are based on a substance called hyaluronic acid, which is found in normal synovial joint fluid. The common brand names are Ostenil, Monovisc and Synvisc. They're thought to improve joint lubrication and have been shown to be a safe and effective treatment for some arthritic joints, particularly mild to moderate knee OA.
There are also a number of other injections currently undergoing clinical trials, including the use of stem cells and various growth factors (eg. PRP - platelet rich plasma) but as yet they haven't shown significant benefits above standard treatments. But its early days for these treatments and it's an active area of research, so let's keep our fingers crossed!
And finally, if your joint pain persists and your quality of life is being significantly affected then you may need to talk to an orthopaedic surgeon about the surgical options including joint replacement.
Total Knee Replacement - front and side views
A pair of Total Hip Replacements - from radiopedia.org
And that's it! Well done for making it to the end. It’s a big subject but I've tried to provide all the basic information needed to help you manage the condition yourself wherever possible and we've mentioned some of the other treatments that can be considered if you're struggling. I do hope you've found the article helpful. Thanks very much for reading.
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