Saturday 23 July 2011

Managing Osteoarthritis

Published in "Panorama"



Managing Osteoarthritis:



28 year old Simon fell off a ladder and sustained an acetabular fracture. It was the underlying cause of osteoarthritis in his right hip, much to his family’s surprise who believed the disease to be associated with ageing.

Osteoarthritis (OA) is a disease of the joints that causes the cartilage tissue covering the ends of the bones, to wear away, explains Dr.Abdul Ahad Khan, Specialist Orthopaedician, Zulekha Hospital. It is condition that affects the joints in the knees, hips and lower back, most commonly. “It was earlier considered as a degenerative disease, an inevitable consequence of ageing and trauma. However, it would be more appropriate to say that OA is a metabolically dynamic, essentially reparative process that is increasingly amenable to treatment.”

What causes OA and who are the individuals prone to the problem? While it may not be possible to pinpoint the exact cause of OA, metabolic, genetic, chemical, and mechanical factors play a role in its development, reveals Dr.Khan. “The risk factors include positive family history, obesity, injury and repetitive heavy joint loading, among others.”

Dr.Khan elaborates, “It is not simply the attrition of joint structures. Ageing is a very important disposing factor no doubt, but OA can happen to very young people also, for certain reasons. Injury is one such triggering factor. Also, there are children born with joint problems, who if not managed appropriately and at the right time, will develop OA at the age of 20! For instance, Congenital Dislocation of Hip (CDH) is a very common problem in this part of the world, which if not managed properly will result in the child developing OA at the age of 20. There are a galaxy of problems associated with childhood, including infective hip which could lead to a deformity of the hip and consequently OA at the age of 20.”

Continuing with the risk factors contributing to OA, Dr.Khan explains that obesity is one of the major factors to play villain in the disease. “These days this is a common presentation in my OPD that the young people are coming with knee pain and on X Ray examination, we find there are there in the joints. I don’t see any other reason for these changes except that these individuals are overweight.”

In addition to these causative factors, there is gender bias to the problem, reveals Dr.Khan. “There is pronounced female preponderance and the reason could be because of menopause. If you look into the ethnic factor, OA of hip is uncommon in Black and Asian populations as compared to the White people. However, due to lifestyle changes, now even some of the Asian population seems to suffer from OA.”

Mechanical derangements in certain joints, also make these joints more prone for OA, opines Dr.Khan. “Up to a fourth of people over the age of 65, have knee or hip problems and this percentage is on the increase in the UAE because of the greater incidence of obesity, diabetes and gout. However, this is a globally accepted fact, not restricted to the UAE alone and is the major cause of pain and disability among the elderly people.”

Elucidating on the symptoms of osteoarthritis, Dr.Khan reveals, “If you are looking into the symptoms and the functional impairment and signs, you will always see that there will be a considerable discordance amongst these three. Pain and stiffness are the predominant symptoms. Swelling in the joints, bony enlargements, deformity, instability, restricted movements are other symptoms which may occur in any combination.

Can the symptoms of OA mimic symptoms of some other disorder? “Most certainly,” admits Dr.Khan. “This is where differential diagnosis is very important because oftentimes a patient may have Rheumatoid Arthritis (RA) co-existing with OA. Similarly we need to rule out gout and crystal induced conditions while treating patients of OA.”

What are the earliest symptoms which people should look out for to suspect OA? Dr.Khan emphasizes, “Any painful joints should not be ignored, especially at the age of 40-45.”

What about rate of progression of the disease once the first symptoms have occurred? Dr.Khan is unequivocal: “How rapidly the disease progressed depends upon the individual’s family history, weight, occupation, working habits, lifestyle, sex and constitution. People can come up with the end stage OA within 5 years of the first pains arising! There are other in whom the disease has not progressed for 20 years!

What are the investigative measures used to confirm diagnosis of OA? “Diagnosis of OA is purely clinical and can be easily diagnosed through a thorough clinical examination and history taking of the patient. Having said that, there are certain investigative tools which confirm diagnosis. In this respect we first take radiograph of the patient in a standing condition just to see how much the disease has damaged the joints, particularly if it is the knee that’s been affected. In the early stages, if the changes are not evident on plain X Rays, we go in for MRI scan since this gives a very clear cut picture, not only of bones but of the cartilage too.”

Further explaining the diagnostic process, Dr.Khan explains, “Arthroscopy is another tool to look into the condition of cartilage. Besides, we also do lab profile to exclude systemic involvement of disease.”

Untreated or ill-managed OA can lead to several complications says Dr.Khan. The patients may become crippled, suffer intractable pain which will not respond to any non-operative modality, the diseased joints become prone to infection and progress to septic arthritis, particularly in diabetics, and, deformity.

What are the treatment modalities available for patients of OA? Dr.Khan emphasizes: “Osteoarthritis is not a curable disease, but it can be managed. Early diagnosis and treatment at the initial stages can help reduce long-term damage to the joints and bones. If treatment is begun when the integrity of the cartilage is not much disturbed, you can expect a lot of good results without surgery. The goal of every treatment for OA is to reduce pain and stiffness, allow for greater movement and slow the progression of the disease. Management of OA is four-fold: patient education; relief from pain; optimization of function to make the patients mobile enough to carry on their routine activities to the extent possible and finally to minimization of the progression of the disease.”

Treatment of OA may be categories into non-surgical and surgical modalities. The non surgical management would firstly require weight reduction if the patient is over-weight or obese. Losing weight reduces the stress put on the affected joints and can mean the difference between needing surgery or not, emphasizes Dr.Khan.

Strengthening and aerobic exercises which include walking, cycling, can help support and stabilize joints and also reduce pain and disability, especially for people with hip and knee OA. "Physiotherapy certainly plays an important role in the management of OA but this requires complete evaluation and assessment of the patient’s condition and disability and therapy must be accordingly individualized with due attention being paid to the ergonomics of it all.
Strengthening of local muscles, use of appropriate footwear and walking aids are also advised.”

On the management of pain, Dr.Khan admits, “Because of the potential side effects of many drugs that are used for treating osteoarthritis, medication is usually recommended only after weight loss and exercise have not been effective in relieving symptoms. Most of the pain-relieving medication used are Non-steroidal anti-inflammatory drugs (NSAIDs) and are known to cause peptic ulcers, inflamed intestines and other gastric problems. However, more recently, COX-2 Inhibitors have been introduced which are effective in treating OA and are also stomach-friendly. But their safety profile on the heart has not been fully established.”

So when does one go in for surgery? Dr.Khan clarifies: “Surgery is recommended only for severe, disabling arthritis that interferes with a person's ability to carry out ordinary daily activities. This may happen when there is a history of joint locking, that is, the joints get locked in a particular position, causing intractable pain. At this stage I would consider an arthroscopy for the removal of loose body. These patients will have some extra bones which are accumulating in the joints and the joint is trapped at some movement. If we get these patients at the early stage, then arthroscopic intervention in the form of cleaning of joint and removing loose bones, will help.”

“Secondly, there are patients who get persistent swelling because of inflamed membrane inside joints, called synovitis. Again we consider arthroscopic wash-out or radio-isotope synovectomy, though this procedure is not much attempted these days. Then we go in for prosthetic joint replacement. The success of this surgery has greatly advanced management of hip and knee OA.

This is especially done in cases where people come to us when their joints are totally worn out and finished, in the terminal stage of OA. At that stage we have no option but go in for joint replacement. And the procedure works well and the patient is without problem for 10years after which the situation has to be revised. Of course, when we talk of surgery, the results are not very glamorous because lifestyle becomes quite sedentary, though the pain is much reduced.”

Dr.Khan adds, “There’s a definite role of fish oil in the treatment of OA as indicated by a lot of research. Also, it is my personal belief that a positive, holistic approach to the problem to include herbal and other alternative therapies, would be the best way to manage OA as these alternative systems have recorded significant success in treatment.”


******

No comments:

Post a Comment