Osteoarthritis may seem to be just a symptom of ageing, but like any medical condition, it needs medical attention.

IF you have known or lived with men and women nearing their retirement age or beyond, you will find many who have experienced the agony of muscle and joint pain.

Their complaints are strikingly similar. Common grouses include pain in their elbows after lifting heavy objects, pain in their knees after a day on their feet and inability to bend down or squat. Some even have difficulty in bending their fingers or reaching for things on higher shelves.

Unlike chest pain, pain in the muscle and joints is often accepted as part and parcel of ageing. It does not create the urgency for those who experience them to consult a doctor immediately – at least not until the pain becomes unbearable and their daily lives are affected.

However, if you are above 50 and have joint pains, the bad news is that you may have some form of arthritis (arthro: joint; itis: inflammation). The good news is, you don’t have to worry about joint replacements yet if you get appropriate treatment early.

“Osteoarthritis (OA) is one of the major causes of disability around the globe that is affecting mankind physically, mentally, socially and financially,” said consultant orthopaedic surgeon Dr Saket Jati.

While rheumatoid arthritis are mostly seen in people about 12 to 40 years of age, people who have osteoarthritis are mostly above 35, said Dr Jati.

In Malaysia, an estimated 60% of the population will have some form of arthritis by the age of 60, particularly osteoarthritis (more than 20%). Rheumatoid arthritis (RA), on the other hand, affects 1% of our population and can affect all age groups.

As there is no cure for osteoarthritis yet, conventional treatments are aimed at giving patients the means to achieve pain-control, increase mobility and maintain a good quality of life. Early diagnosis is the first step in ensuring appropriate treatment.

Osteoarthritis

The joints are essentially two bones with cartilage and fluid in between held together by connective tissue to allow movement and provide support to our body.

Cartilage at the ends of bones and (synovial) fluids in between them act as shock absorbers and lubricants to ensure the bones move in tandem smoothly.

When you have OA, you are experiencing a gradual loss of cartilage from your joints as your cartilage loses its ability to repair itself normally. The smooth surface of cartilage becomes rough and causes irritation to your joint. And with less “cushion” in between, bones eventually rub against each other when you move or carry weight, causing pain and difficulty.

There are two types of OA – primary or idiopathic OA and secondary OA. Idiopathic OA has no identifiable cause while secondary OA can be caused by specific underlying conditions – including previous joint injuries, joint conditions that are present at birth and joint conditions that occur during growth.

Regardless of type, OA is a chronic condition that can gradually worsen over time. Common symptoms of OA are:

• Pain in a joint during or after use, or after a period of inactivity
• Tenderness in the joint when you apply light pressure
• Stiffness in a joint that may be most noticeable when you wake up in the morning or after a period of inactivity
• Loss of flexibility may make it difficult to use the joint
• Grating sensation (crepitus) when you use the joint
• Bone spurs, which appear as hard lumps, may form around the affected joint
• Swelling (effusion) in the affected joints in some cases

Any joint can be affected by OA, but the most commonly affected ones are joints in the hands,

hips, knees and spine.

The pattern of joint involvement varies between individuals, but unlike rheumatoid arthritis (RA), it often affects joints on one side of the body differently than the other side. There may also be enlargement of finger joints in some OA patients.

Not just an old people’s disease

According to a review paper published by the American Academy of Family Physicians, the exact etiology (cause) of osteoarthritis is unknown. Although OA is strongly associated with the wear and tear of joints through the course of life, it is no longer considered a normal part of ageing, wrote Dr Kenneth C. Kalunian in his osteoarthritis patient information sheet found at clinical information resource website, UpToDate. “Studies suggest that the risk of OA is also influenced by other factors, including heredity, obesity and occupation,” Dr Kalunian explained.

In the same write-up, Dr Kalunian noted that most people with OA have one or more of the following risk factors.

Age. While statistics show that at least 80% of people over age 55 have some x-ray evidence of OA, advancing age remains one of the strongest risk factors of the disorder. Nevertheless, despite an abnormal x-ray, many people have no joint pain or impaired function.

Gender. For unknown reasons, the chances of women developing OA are between two and three times more than men. However, according to the Arthritis Foundation of Malaysia, more than half of men over 65 also developed osteoarthritis.

Obesity. Although the association between obesity and the risk of OA varies for different joints, studies have found that the risk of developing OA is decreased in women who lost weight. Obesity also appears to increase the risk of pain and disabilities to those with OA.

Other risk factors include previous joint injury, higher bone mass, muscle weakness, occupations that require frequent squatting or kneeling and other activities that require heavy lifting, prolonged standing or walking several miles a day.

Sports could also predispose some to the risk of developing OA. According to Dr Kalunian, the risk of developing OA in people involved in certain sports such as wrestling, boxing, cycling, gymnastics and ballet dancing is increased.

But you do not need to hang up your ballet shoes just yet. The risk of developing OA in these sports depend on the initial health of your knee joints and the type of activity (low-impact or high impact).

Repetitive low-impact activity (activities that do not impose high-impact forces on the joints) like cycling is associated with an increased risk of OA in people who have pre-existing knee abnormalities, but not in those who have healthy knees [2].

In contrast, repetitive high-impact activities like wrestling and boxing is associated with an increased risk in both people with or without pre-existing knee abnormalities.

Diagnosing osteoarthritis

It is difficult to identify a definitive diagnostic test because the signs and symptoms could be caused by various kinds of diseases.

Therefore, the diagnosis of OA is based on a consideration of several factors, which include the evaluation of signs and symptoms, results of laboratory tests and x-rays.

Laboratory tests indirectly aid the diagnosis of OA by helping to rule out conditions with similar symptoms. Common tests are the erythrocyte sedimentation rate (ESR) test, rheumatoid factor, and synovial fluid analysis (examination of the fluid in the joints).

Blood tests like the ESR and rheumatoid factor can help doctors distinguish whether your arthritis is a case of OA or RA.

“OA usually do not show blood abnormality,” said President of the Arthritis Foundation of Malaysia and consultant rheumatologist Dr Chow Sook Khuan.

She also added that a synovial fluid analysis will only be performed to exclude other associated conditions like septic arthritis and co-existing inflammatory arthritis. X-rays are helpful for determining the severity of OA in advanced cases, but it is not routinely done for people without symptoms because changes may not be present on x-rays in the early stages of OA.

Treatment and practical solutions

To find out the nature and extent of muskuloskeletal (muscle and bone) pain in Malaysia, consultant rheumatologist Dr Kiran Veerapan, along with Richard Wigley and Hans Valkenburg embarked on a COPCORD (Community Oriented Programme for the Control of Rheumatic Diseases) survey in year 1988.

The survey results, published in the Journal of Rheumatology in the year 2007, showed that 58.8% of those who have rheumatic pain in the study self-medicate with over-the-counter analgesics or other medications that they acquired without prescription.

But is self-medication advisable? According to Dr Chow, although mild analgesics like paracetamol is allowed to relieve pain, if a person has persistent joint pain, especially with signs such as joint swelling, significant morning joint stiffness (more than 30 -60 minutes from awake in morning), loss of joint function (regardless of one or more joints affected), this person must seek medical advice as all those signs and symptoms imply more serious arthritis.

“Early treatment of a serious arthritis can prevent structural damage of the affected joint,” Dr Chow said.

If you are diagnosed with OA, make sure you are well informed about the natural course of osteoarthritis. You can learn about ways to manage your condition and have realistic expectations of the treatments your doctors can offer.

For mild OA pain that is bothersome, but not enough to affect your daily activities, your doctor may prescribe rest, exercise, losing weight, using heat and cold to manage the pain, physiotherapy, over-the-counter pain creams and braces or shoe inserts [1].

While applying heat is often the common method used for pain relief in our community, cold packs can also do the trick. However, if you have poor circulation or numbness, do not use cold treatments. Heat treatment should also be warm, not hot [1].

If the pain persists despite initial treatment, you may require medications for pain-control or to slow down cartilage degradation. “Medicines are used to provide a pain-free, more mobile, efficient and effective lifestyle,” said Dr Jati, adding that analgesics (painkillers) and anti-inflammatory agents should be used with caution as they have possible side-effects.

While there are no proven disease modifying agents for OA, glucosamine, chondroitin sulfate, diacerin and esterified fatty acids may ease pain in some individuals and slow down cartilage degradation in some early cases if they combine the use of medication with non-drug measures, says Dr Chow.

According to Dr Chow, intra-articular steroid injections (injecting small amounts of steroid to the affected joint) can also be used to treat the inflammatory flare-ups associated with knee OA, but it must be done by a trained doctor in accordance to certain guidelines.

However, studies show that the injections are effective only for the short term.

“Early treatment in the form of knee strengthening through exercises is useful. Drug therapy does not halt OA, but since exacerbation prevent people from exercising, pain relief is important,” says Dr Kiran, who is a consultant rheumatologist now based in Canada.

Surgery may be an option for severe OA that is not relieved by other treatments. Joint replacement and debridement (removing loose pieces of cartilage and bone from around your joint) are among the surgical options available [1].

Although medical advances have provided physicians means to help you relieve or lessen the pain caused by OA, a major component of OA treatment lies in your attitude towards the condition.

A positive attitude will go a long way to help you cope with OA. More importantly, it determines how much impact OA will have on your everyday life, despite the pain and disability.

For more information about osteoarthritis, you can visit the Arthritis Foundation of Malaysia website www.afm.org.my.

References:

1. Osteoarthritis, by Mayoclinic.com; http://www.mayoclinic.com/health/osteoarthritis/DS00019

2. Patient information: Features and diagnosis of osteoarthritis, by Kenneth C Kalunian, M.D.; http://www.uptodate.com/patients/content/topic.do?topicKey=arth_rhe/2266

3. Osteoarthritis: Diagnosis and therapeutic considerations, by Ralph Hinton et al., American Academy of Family Physicians; http://www.aafp.org/afp/20020301/841.html

4. Musculoskeletal Pain in Malaysia: A COPCORD Survey, by Dr Kiran Veerapen, Richard D Wigley, and Hans Valkenburg, The Journal of Rheumatology. http://www.jrheum.com/abstracts/abstracts07/207.html