Rethink Pain: Osteoarthritis

Knee X-ray

In the first post of the Rethink Pain series, Moving Beyond Muscles and Bones, we discussed shifting your view of pain away from body tissues like muscles and bones towards a more accurate one, of pain as a protective neurological process.

This post will take that concept and apply it to one of the most prevalent and debilitating chronic conditions in the world today, arthritis.

Nearly everyone has heard of arthritis. Arthritis is actually a group of conditions that affect the joints, encompassing a variety of conditions from autoimmune to inflammatory. This post is going to focus on the most common form, osteoarthritis (OA). 

There is a lot of misinformation surrounding arthritis, spread by cultural memes and well meaning family and friends. This leads to erroneous thinking that is likely causing a nocebo effect (the opposite of the placebo effect).

What is Osteoarthritis?

Described as “wear and tear”, osteoarthritis is, more correctly, a condition of joint cartilage degradation and reactive bone growth.

Cartilage covers the surface of most of our movable joints, creating a smooth and gliding surface, as well as providing shock absorption.

Tissues are constantly being “broken down” and then “rebuilt” in our bodies. This is a completely normal process which allows us to grow, heal and adapt.

When someone has osteoarthritis, this rate of degradation is accelerated and not matched by an increase in the rate of cartilage regeneration.

Here’s a simple analogy:

Imagine you are spending $1000 per week and making $25 per hour. To break even, you must work 40 hours.

Next, imagine after a few years your spending increased to $1250, yet you are still making $25 per hour – you now have to work 50 hours per week to cover your costs.

A few more years pass, and your spending increases yet again, lets say to $1500 per week. This time, however, your hourly wage drops to $20 per hour – you now have to work 75 hours to break even.

Eventually, if this process continues you will not be able to keep up. This is similar to what happens in OA – the rate of cartilage regeneration cannot keep up with the rate of degradation.

What Causes Arthritis?

There is no singular causal factor for arthritis. There is a large genetic component along with the combination of other factors (1).

Some of these factors include:

  • Tissue susceptibility/genetics. Cartilage is slow regenerating tissue at best, due to both is structure and its low blood supply. Some people have slower regenerative rates or are more susceptible to increased degradation.
  • Aging. Rates of regeneration decrease as we age, arthritis is more common in older people, and we have an aging population.
  • Chronic systemic stress. Stress hormones are catabolic – they increase tissue breakdown. Stress levels seem to be higher these days, as a result of both economic and cultural/lifestyle changes taking place across the globe.
  • Obesity. People are heavier, on average, and obesity has a correlation to arthritis via two mechanisms: increased mechanical stress on joints and increased inflammatory mediators in the bloodstream (secreted by fat cells).
  • Mechanical stress/”overuse”. We’ll discuss this further below, as “wear and tear” or “overuse” is one of the most common throwaway descriptions of arthritis.

One factor that’s often cited by medical/health practitioners is mechanical stress, commonly termed overuse or wear and tear.

There are a few problems with this language.

First, what is overuse, and how do we measure it?

Second, it doesn’t take into account that different ways of using your body have different effects.

In the case of arthritis, full range of motion through the joints stimulates cells called synovites, which secrete joint fluid to provide nutrition and have a protective effect on the joints.

Limited and repetitive range of motion activities tend to create uneven joint stresses, causing reactive bone growth, and an increased firing of the nerves, which affects joint mechanics and can increase sensitivity and pain.

So yes, certain activities can increase the likelihood of arthritis in susceptible people, but simply using your body does not cause arthritis. This has been demonstrated in runners (2), for example, who have no more arthritis than non runners, despite the myth that “running is bad for your knees”.

 Arthritis Pain

The biggest problem with arthritis is the associated pain. Most people don’t consult a doctor or allied health professional for anything else related to arthritis.

Pain doesn’t correlate well with imaging findings or the severity of joint degradation (my emphasis):

Patients largely present with pain and disability after significant loss of cartilage has occurred, but it is estimated that up to 40% of individuals with radiological damage have no pain. (3)

This kind of blows the “damage causes pain” thought process out the window, doesn’t it?

So how might this be?

Pain is a perception created by our brains in response to a variety of different sensory “inputs” including:

  • “Danger signals” from peripheral nerves in joints, muscles and other body tissues
  • Thoughts and expectations
  • Emotions
  • Brain and body chemistry – for example, hormonal status

We can divide these into central factors (brain and spinal cord related) and peripheral factors (everything else).

One of the most important central factors is called sensitisation. Basically, this means that the spinal cord and brain become more sensitive and produce pain in response to less and less stimuli.

This mechanism is proposed to be largely involved in arthritis related pain.

This then triggers a positive feedback loop whereby the pain causes negative emotions, reduction or avoidance of movement and an increase in stress hormones which then further aggravates the pain.

An example of a positive feedback loop between pain, cognition and emotions.

An example of a positive feedback loop between pain, cognition and emotions.

In addition to the central factors described above, there are peripheral factors that likely contribute to arthritis pain as well.

Some of these peripheral factors would include:

  • Impaired fluid dynamics of the joint
  • Inflammation
  • Mechanical strain

All these factors would likely increase the frequency and intensity of nociception, the transmission of “danger signals” from the nerves in the joints, causing the brain to produce a protective response of pain and stiffness.

If this cycle continues for long enough, then the peripheral nerves can also become sensitised, leading them to start firing at lower thresholds, much in the way central sensitisation works.

For a more in depth understanding of these processes, read Pain Science BasicsIt describes in easy to understand detail what is actually happening when we experience pain.

Osteopathy For Arthritis

The osteopath’s way of thinking is to look backwards from the presenting symptoms to try to work out why the body would “adapt” in such a way.

In the case of osteoarthritis, we would want to know the answer to the following questions:

  1. What has lead to the increased rate of cartilage degeneration in this person, in this joint?
  2. What has lead to a decrease in the rate of cartilage regeneration in this person?
  3. What potential factors may be contributing to this person’s pain?

As a result of these questions, two different people with knee osteoarthritis may end up with differing treatments, based on their primary causative factors.

Of course, the disease process is common, so there will be a lot of overlap, but treatment will always be tailored to your individual’s needs.

If you were suffering from OA and came for treatment, we would want you to feel a part of the process and be engaged in your care.

This means we’d place a large emphasis on educating you so that you fully understand what is happening, why it is happening and the implications for your life presently and in the future.

We would also present you with your treatment options, their risk, benefits, cost and the likely results of not doing anything.

We would then, use manual therapy to mobilise the entire body. Why the entire body? For starters, if your osteoarthritis is the result of, in part, altered biomechanics, treating the entire body is the only way to restore balance.

You see, whilst there may be altered loading of the affected joint(s), this may be the result of a protective response by the nervous system resulting from adverse tension elsewhere, in other words, your body is compensating for another issue.

Additionally, it is important to recognise that separation of the body exists only in our minds. Our knees are served by the same organs that serve our shoulders and everything is integrated by the one brain. This means it only makes sense to treat the entire body – we are, after all, not body parts, but people.

Our osteopathic treatment for osteoarthritis is gentle, slow and rhythmic, allowing for the body to self correct with movement/relaxation of muscle and joint tension, all the while helping with fluid dynamics throughout the body. It shouldn’t be painful, as we don’t want to increase any sensitisation that may be present.

Further, in addition to manual osteopathic techniques, we would show you how to manage or improve your condition with lifestyle changes, which we will discuss further below.

What Can You Do To Help Yourself?

Although genetic predisposition can play a large role in the development of OA, for most people, it is complex interaction between genetics and environment that leads to the onset of physical changes to the affected joint(s), and an even more complex interaction that leads to the onset of pain.

With this in mind, you can definitely take action to help prevent/delay/manage the onset of osteoarthritis in your life.

Things that you can do include:

Maintain an optimal body weight for your frame

Every body is different. Some people have a large skeletal frame, others are more compact. Some people are naturally lean, others tend to carry more body fat.

What is undeniable, however, is that from a medical point of view, there is an optimal weight range for your frame.

At this weight, you are not so big that there is increased stress on your joints and organs, but not so small you compromise your lean body mass and hormones.

In terms of osteoarthritis, increased weight, as mentioned earlier, is a risk factor both biomechanically and chemically as a result of increased systemic inflammation.

The BMI is a good general guide to maintaining a healthy weight, but it does not take into account body composition (muscle vs fat), only total body weight.

Waist measurements are another good guide to whether you are storing a lot of risky visceral fat (the fat that sits on your organs and leads to conditions like diabetes and heart disease).

If you are overweight, it’s a good idea to speak to your doctor as a starting point, to get blood work done and then any referrals you need to other health professionals who specialise in weight loss, because, aside from OA, there are many other health conditions made worse by being over weight.

Lead an active lifestyle

Some people love to exercise, others don’t. That is completely fine.

Leading an active lifestyle doesn’t mean you must spend hours every week in the gym or running the streets. If you don’t like exercising, and you otherwise have a sedentary lifestyle, it is in your interests to increase your activity levels.

This could be as simple as walking or cycling more as a means of transport.

Incorporating some form of work with resistance is also important for health, again, if you don’t like the gym, this could be doing physical work in the garden or around the house that involves lifting, pushing and pulling.

Now, if you are suffering from OA pain, this can be hard to do, so as always, prevention is better than cure. However, there are generally ways you can increase your activity, even with OA.

Live with purpose

As humans, we need meaning in our lives. This meaning, or purpose, gives us reason to get out of bed a do things each day. Without it, we waste away, mentally and physically.

Everyone will have different things that give them meaning, this doesn’t matter, it’s what makes us great. What does matter, is living with purpose.

Research is unequivocal – those who live with purpose have longer and healthier lives in almost every meaningful measure, including pain.

Maintain strong social networks

Whether you have a huge family or a strong network of good friends and acquaintances, maintaining social ties is not only linked to better health and wellbeing, but less pain.

Whilst living in pain can feel isolating, living without social contact is quite bad for us in both the long and short terms.

One study showed that adolescents in isolation demonstrated increased levels on inflammatory mediators in their blood, which affected their physiology for their entire lifespan! (6)

Open up to your existing friends and family more, reach out to those you’ve lost contact with and get engaged with like minded people to make more connections.

The internet has make connecting so much easier, but staring at a social network on a screen does not replace face to face interaction.

Increase Your “Physiological Buffer Zone”

The physiological buffer zone is a concept described by Patrick Ward, MS, an American sports scientist currently working with the Seattle Sounders FC.

In simple terms, it is basically the buffer you have between physiological stress and the onset of injuries and symptoms.

To increase this, an analysis of your physical status is required and then a prescription of exercise, lifestyle, nutritional and recovery advice is given, aiming to improve your resilience.

Whilst this concept was developed for athletes, it is certainly applicable to everyday people with everyday pain.

Medications

Medications to help manage arthritis pain do exist, but most are not very effective. Some relief can be expected, but it is very rare for medications to provide complete relief from osteoarthritis pain.

One medication that seems to be promising, is topical capsaicin. Capsaicin is the active ingredient in chillies. Extracts in topical creams stimulate particular nerves that have been shown to decrease pain. (8) The promise with capsaicin is that the side effects are quite minimal, unlike other many other common medications used to manage osteoarthritis pain.

You should consult your doctor for options about medications, asking about their effectiveness along with their side effects.

Conclusions

Osteoarthritis is a multi-factorial condition that affects a large number of people. By far the most common complaint is pain, which doesn’t seem to be directly caused by the extent of joint changes, but rather by increased sensitivity, both centrally and within the joints.

In general, the best way to treat/manage osteoarthritis long term is to strive to improve your health in all aspects whilst utilising specific treatments to reduce your pain and other symptoms.

Together with right environmental factors, you give yourself the best chance to lead a full life.

If you suffer from OA and would like to add anything, we’d love to hear your story in the comments below.

 

This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.

 

 

References

(1) Kumar, et al, Robbins and Cotran Pathologic Basis of Disease,  Elsevier Saunders, 2005, PA

(2) Running and osteoarthritis: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2556152/

(3) What makes osteoarthritis painful?: http://rheumatology.oxfordjournals.org/content/50/12/2157.long?view=long&pmid=21954151

(4) Positive feedback loop in pain : http://www.nature.com/nrn/journal/v14/n7/fig_tab/nrn3516_F1.html

(5) Obesity and arthritis: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3406287/

(6) Obesity and arthritis: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2573886/

(7) Social networks and long term health: http://www.pnas.org/content/early/2016/01/02/1511085112

(8) Social networks and pain: http://www.ncbi.nlm.nih.gov/pubmed/15561396

(9) Topical capsaicin for pain: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3169333/