Health Care

By: Nathan Wei

Osteoarthritis (OA) is one of the most common conditions leading to disability and impaired quality of life in the Western world.

Ironically, while more effective disease-modifying therapies have been developed for rheumatoid arthritis, particularly within the last 10-15 years, rheumatologists still treat osteoarthritis with symptomatic and supportive therapies.

As a result, the inexorable progression of this disease results in the performance of more than half a million joint replacements annually in the United States. While joint replacement surgery has made gigantic strides, it is still a major surgical procedure.

Risk factors for the development of OA include: genetic factors, obesity, joint injury, surgery, and the presence of associated metabolic disease.

It is clear from the research that OA is a disease that involves not only the cartilage- the gristle that caps the end of long bones and cushions the joint, but also the synovium- the tissue lining the joint- as well as the bone that underlies cartilage.

While genetic factors play a significant role in the incidence of osteoarthritis, the damage that occurs is a result of a complex interaction of inflammatory messengers. Among these are cytokines, prostaglandins, nitric oxide, growth factors, and proteases.

These substances, which are produced by chondrocytes (cartilage cells) that are subjected to abnormal forces lead to a situation where there is premature aging and destruction of cartilage substance.

The production of these inflammatory proteins also contributes to inflammation of the synovium and excessive amounts of bone growth.

Present therapies, as issued by guidelines proposed by the Osteoarthritis Research Society International (OARSI), are clearly aimed at symptom relief. These treatments include: analgesics, non-steroidal-anti-inflammatory drugs (NSAIDS), topical agents (“rubs”), and joint injections with either glucocorticoids (“cortisone”), or hylauronic acid lubricants.

Current research has been aimed at finding the triggers that cause inflammation to start and also to identify specific markers that might identify those patients who are at greatest risk for rapid progression of disease. These markers would also be useful in measuring improvement once newer drugs that can slow down disease progression in OA can be discovered.

However, all of these investigations are futile unless and until specific disease-modifying osteoarthritis drugs (DMOADS) – drugs that slow down the rate of cartilage loss- can be developed.

Drugs aimed at inhibiting cytokine and protease function show some promise but it is still too early to tell whether they will have the desired effect. Examples of these drugs include: matrix metalloproteinase inhibitors, drugs that block interleukin 1, bisphosphonates, calcitonin, as well as nutritional supplements such as glucosamine and chondroitin.

And it may not be enough to find drugs that simply slow disease progression.

The “holy grail” is still the treatment(s) that will rebuild cartilage. The type of therapy that shows the greatest promise to date is the use of autologous stem cells. These are stem cells harvested from the patient and reintroduced into the affected joint along with a specific matrix to which the stem cells can adhere and grow.

Early results look promising. For more information about stem cell treatment for osteoarthritis of the knee, contact the Arthritis and Osteoporosis Center of Maryland at (301) 694-5800

About the Author
Nathan Wei, MD FACP FACR is a nationally known, board-certified rheumatologist. For more info: Arthritis Treatment and Tendonitis Treatment Tips

Osteoarthritis is the most common form of arthritis. It affects more than 20 million Americans according to some estimates. Because osteoarthritis (OA) is primarily a degenerative process, the incidence and prevalence of this disorder is expected to rise with the surge in Baby Boomers.

OA affects weight-bearing joints such as the knee and hip. It is a disease of articular cartilage, the tough, elastic material that cushions moving parts of joints. OA is the most common reason for eventual total hip and total knee replacement surgery.

It has been felt that early diagnosis of this condition could potentially lead to earlier treatment.

To date, treatment for osteoarthritis has centered on pain relief only. To that end oral non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen (Motrin), aproxyn (Naprosyn), sulindac (Clinoril), piroxicam (Feldene), nabumetone (Relafen), etodolac (Lodine), ketoprofen (Orudis), meloxicam (Mobic), and celecoxib (Celebrex) have been used with varying degrees of success.

Along with these medicines, analgesic medicines such as acetaminophen (Tylenol), propoxyphene (Darvon), and tramadol (Ultram) have also been used to manage symptoms.

Other modalities such as physical therapy, braces, lateral wedge insoles inside shoe, arthroscopy (entering the joint with a small telescope to remove damaged and diseased tissue), injections of glucocorticoid (“cortisone”), and injections of lubricants, called viscosupplements, have also been used to alleviate symptoms.

Despite the mixed effectiveness these various treatments have had as far as pain control, they have not been completely successful.

The reason? The Holy Grail of OA treatment has been to identify treatments that can slow down and possibly reverse cartilage deterioration.

This is predicated on diagnosing the condition early. To date, diagnostic methods such as x-ray and magnetic resonance imaging (MRI) do not detect the disease until OA is in advanced stages when joint damage may already have occurred.

Arthroscopy can detect early disease but is not practical because of the invasive nature of the procedure.

A method for earlier diagnosis could open a window of opportunity for preventing or reducing permanent damage. Recent evidence suggests that dietary supplements like glucosamine/chondroitin might prevent further joint deterioration. A recent study demonstrating a new medical imaging technology may provide physicians with an accurate test for early diagnosis of OA, scientists from New York reported at the 236th National Meeting of the American Chemical Society

"Our methods have the potential of providing early warning signs for cartilage disorders like osteoarthritis, thus potentially avoiding surgery and physical therapy later on," says Alexej Jerschow, Ph.D., who reported on the research jointly with Ravinder R. Regatte, Ph.D.

He adds, "Also, the effectiveness of early preventative drug therapies can be better assessed with these methods."

Cartilage consists of collagen and proteoglycans. Proteoglycans are long chains of linked sugars and proteins.

The new method uses a modified form of magnetic resonance imaging to determine the concentration of a polymer known as glycosaminogycan (GAG), a proteoglycan that holds lots of water and gives cartilage its tough, elastic properties. GAG also is a recognized biomarker for osteoarthritis.

According to the scientists, a low concentration of GAG is known to correlate with the onset of osteoarthritis and other cartilage disorders.

The diagnostic test utilizes a method that "tags" the hydrogen atoms attached to the GAGs in a way that makes them emit a signal that can be picked up by an MRI machine to determine the concentration of GAG and assess cartilage status.

The advantage of such a test is not only to detect early OA but also to assess the effectiveness of newer disease-modifying osteoarthritis drugs (DMOADS), which are currently being studied by a number of companies.

About the Author
Nathan Wei, MD FACP FACR is a nationally known board-certified rheumatologist. For more info: Arthritis Treatment and Tendonitis Treatment Tips

Osteoarthritis (OA) of the knee is one of the most common problems seen by both rheumatologists as well as orthopedists in the office. The standard forms of therapy include maintenance of proper weight, exercise, application of cold, bracing, analgesics (pain killers), anti-inflammatory medicines, steroid injections, and viscosupplementation. This latter type of treatment involves the injection of a lubricant directly into the knee.

These lubricants consist of a purified form of a protein called hyaluronic acid (HA). These preparations are effective in relieving pain. pain relief from OA of the knee starts between the 5th and 13th week follwoing injection. While HA is felt to be effective for pain relief, it has been unclear as to whether there are any other benefits.

Two recent studies have demonstrated that viscosupplementation may actually forestall the need for eventual knee replacement surgery and also may represent a long term cost savings.

The first study from Louisiana State University surveyed patients from a large orthopedic practice. A total of 863 patients (1187 knees) were evaluated. All patients had grade 4 changes, meaning they had “bone on bone” and were candidates for total knee replacement.

Using survival analysis of the data, it was estimated that total knee replacement was delayed approximately 3.8 years in 75 percent of the knees receiving viscosupplementation (Waddell DD, et al. J. Managed Care Pharm. 2007; 2:113-121.)

In another study, investigators in Thailand studied one hundred and eighty three patients with knee OA (208 knees) who failed conservative treatments and did not have contraindications for surgery were enrolled. All patients were treated with one course of three hyaluoronic acid injections at weekly intervals and followed up for a minimum 2-year period. In case of successful treatment (response group), repeated doses were recommended. If the patients did not improve within one month after completion of the injections, they would be classified as a non-response group and total knee replacement surgery was considered. Cost of direct medical costs (drugs), hospitalization, and resource utilization were recorded and analyzed.

They concluded that IA-HA (joint injection with HA) should be considered as a medical intervention before surgical procedures in knee OA patients who failed conservative treatments. Even though the cost of IA-HA treatment would increase the total costs of treatment and some patients might fail, it was only 6.44% of the total costs. On the other hand, if patients responded to IA-HA treatment, then the surgical procedures were not required. This treatment would represent a savings of 63.26% of total costs. (Turajane T, et al. J Med Assoc Thailand. 2007; 90;1839).

While, the exact analyses and conclusions of these two studies are different, they do suggest that HA may be cost effectve in delaying the need for total knee replacement.

There are five HA preparations available. They are Hyalgan, Synvisc, Supartz, Orthovisc, and Euflexxa. Only Euflexxa is not derived from a chicken source.

The number of injections required varies from 3-5 depending on the preparation used. Hyalgan and Supartz generally are given as weekly injections for 5 weeks while Synvisc, Orthovisc, and Euflexxa are given as weekly injections for 3 weeks.

Thes injections should be administered using either fluoroscopic or ultrasound needle guidance to ensure accuracy.

Side-effects are minimal when administered by trained specialists.

HA injections are worth a try even with grade 4 knees if patients wish to delay surgery.

Osteoarthritis (OA) is the most common form of arthritis and affects roughly 30-40 million Americans. The condition is due to a metabolic disorder of cartilage, the gristle that caps the ends of long bones. Cartilage functions to cushion the joint against impact and also to allow gliding of the joint with movement.

Cartilage consists of cells called chondrocytes that sit inside a matrix- much like grapes inside of gelatin. Normally, chondrocytes produce substances that build up and nourish the matrix. When osteoarthritis develops, the chondrocytes begin to function abnormally and no longer elaborate normal matrix.

Instead, chondrocytes begin to produce destructive enzymes that weaken the matrix. Small cracks in cartilage develop. At the same time, the lining of the joint (synovial capsule) is stimulated to produce inflammatory enzymes that further weaken cartilage. The end result is loss of cartilage. As cartilage wears away, the joint begins to become mechanically unbalanced leading to more damage.

Conventional treatment for osteoarthritis of the knee consists of patient education, maintenance of ideal weight, supplements such as good quality forms of glucosamine/chondroitin, bracing, lateral wedge insoles, non-steroidal anti-inflammatory drugs, injections of glucocorticoids (steroids), injections of viscosupplements, and sometimes surgery. (All of these have been described in previous articles by me).

One often neglected but critical component of treatment is exercise. A recent review discussed the importance of exercise and reached some interesting conclusions. (Bennell K, Hinman R. Current Opin Rheumatol. 2005; 17: 634-40)

Benefits of exercise appear to be additive when exercise is delivered with other interventions such as weight loss.

Types of exercise include strengthening, stretching, and non impact aerobic exercise, all of which are important and which work synergistically.

It appears that supervised exercise sessions are superior to home exercises for pain reduction. The challenge is to convince patient so the importance of exercise. One interesting question is whether exercise can prevent disease or slow its progression.

Also it is apparent that certain patient subgroups that may respond differently to treatment. It has been substantiated that one major risk factor for the development and progression of knee OA is weak quadriceps muscles. This is especially true for women. As a result, if strength training is administered to this high risk group, it may be able to prevent knee osteoarthritis.

According to the authors, novel exercise programs that strengthen hip muscles or alter impairments in knee neuromuscular control may also influence disease progression.

They conclude that "Future studies must identify cost-effective exercise modes, strategies to maximize exercise compliance and optimal treatment combinations. The role of muscle strength and altered neuromuscular control in the prevention and development of osteoarthritis must be evaluated with the view to devising and testing novel exercise interventions."

As a rheumatologist who sees many many patients with OA of the knee, I encourage a comprehensive exercise program along with many of the other treatments described above. No one treatment will work for a patient. However, the right combination of treatments will work for almost all patients. Exercise is an oft-neglected but important component of a comprehensive knee care program with OA.

Source: http://www.articlesbase.com