Treatment

Osteoarthritis: Understanding Risk Factors & Effective Management

According to the World Health Organization as of 2019, 528 million people world wide were living with osteoarthritis, a more than one hundred percent increase since 1990. Osteoarthritis is the most common type of arthritis, affecting primarily the knees, hips, hands and spine. In this post I will write about the risk factors for developing osteoarthritis, both the ones you can’t do anything about and the things you can do to reduce your risk of developing osteoarthritis. Since osteoarthritis is so common, I will also write about the best way to manage osteoarthritis if you already have it.

Risk factors you can’t modify

Age

73% of people with osteoarthritis are over 55. The risk of osteoarthritis increases with increasing age. According to data from the CDC, osteoarthritis occurs in 3.6% in adults ages 18–34 to 53.9% in those age 75 and older.

Gender

The CDC estimates that about 1 in 4 women have been diagnosed with osteoarthritis, compared to about 1 in 5 men. The percentage of women with osteoarthritis increases after menopause. For example, among people aged 40–49, about 10% of women and 7% of men have knee osteoarthritis, but between the ages of 60–69, that prevalence rises to 35% in women and 19% in men.

Genetics

There is no gene for osteoarthritis. The genetic risk of osteoarthritis is the result of many genes, each contributing only a small amount of risk. The total genetic contribution to osteoarthritis is about 30%. In other words a little less than a third of cases of osteoarthritis are due to genetic factors.

History of joint trauma or injury

Any injury to a joint or a fracture involving a joint increases the risk of post traumatic osteoarthritis. For example the incidence of arthritis of the knee after ACL tears is as high as 60%.

Risk factors you can modify

Obesity

Maintaining the lowest weight that is practical for you reduces your risk of developing osteoarthritis of the hip and knee. Obesity markedly increased the risk of developing osteoarthritis and also serves as a multiplier for other risk factors.

Sedentary Lifestyle

Aerobic exercise and strength training decrease the risk of developing osteoarthritis. The best practice is to follow CDC recommendations: 150 minutes per week of moderate exercise such as brisk walking or 75 minutes of vigorous exercise such as running or cycling. Strength training twice a week.

Smoking

Smoking causes inflammation and double the risk of getting osteoarthritis. It is best to never start smoking. If you smoke, stopping smoking decreases your risk, although not as much as if you never smoked

Avoiding Certain Occupations and Sports

Occupations that involve long standing, bending and heavy lifting increase the risk of osteoarthritis, especially of the knees. They include workers in construction, firefighting, agriculture, fisheries, forestry, and mining. In a case-control study, men who worked for 11–30 years in building and construction work had a 3.7 fold greater risk of developing knee osteoarthritis.

Certain sports such as American football, soccer, competitive wrestling and competitive weight lifting are also associated with increased risk of osteoarthritis of the knee and ankle. There is conflicting evidence about long distance running. Some studies show increased risk, but one study showed that marathon runners have decreased risk of developing osteoarthritis.

How to manage osteoarthritis of the knee

Weight loss

If you are significantly overweight or obese then weight loss will decrease stress on the knee thereby reducing pain and slowing the progression of the arthritis.

Exercise

Aerobic exercise helps pain from knee arthritis. The best exercise is walking or swimming or water aerobics. Strengthening exercises for the quadriceps muscle are also helpful. Here is a link to a good description of quad strengthening exercises: Knee Arthritis Exercises. Physical Therapy can also be helpful and can provide equipment like braces or heel wedges that can also reduce pain. There is also some evidence that tai chi reduces knee pain from knee arthritis. If you smoke, stopping smoking can reduce inflammation and therefore pain.

Medicines

The first medicines to try with the least potential for side effects are topical medicines that you rub on the knee. The most effective ones are diclofenac and capsaicin. Both of these are available over the counter. Topical lidocaine patches can help temporarily, but don’t last as long as the other two.

Oral medicines that are the most effective are NSAIDs like naproxen or ibuprofen in combination with acetominophen (Tylenol). Long term use of oral NSAIDS can occasionally cause bleeding ulcers or kidney damage. If you are taking NSAIDs long term, these need to be monitored by your doctor.

Alternative treatments like glucosamine, ginger and S-adenosylmethionine (SAM-e) seem to help some people and are safe long term. Chondroitin has not been shown to reduce pain.

Joint Injections

Steroid injections in the knee can give temporary relief. This can last for months. These are generally safe every 3 months for up to a year. These injections are easy to administer and can be done by most family physicians without need for referral. Over time, as arthritis worsens they tend to not work as well. Multiple steroid injections have been shown to worsen arthritis, so fewer injections are better.

Cartilage injections have shown no difference from placebo in controlled trials. Some people get some benefit, but this may well be a placebo effect.

Surgery

The only surgery shown to be effective is total or partial knee replacement. Arthroscopic knee surgery to “clean out the joint” has been shown to have no more than placebo effect.

How to manage osteoarthritis of the hip

Exercise

All of the aerobic exercise options for knee osteoarthritis also work for osteoarthritis of the hip, but water exercise or cycling is better than walking. Avoiding certain activities that stress the hip such as stair climbing, or active sports like tennis can reduce pain. Tai chi can also be helpful for hip osteoarthritis. Canes or walkers can be helpful, but need to be prescribed by a physical therapist who can decide on the best appliance and show how to use it properly.

Medicines

Topical medicines do not work as well for osteoarthritis of the hip as well as they do for the knee. Oral medicines are the same as medicines for osteoarthritis of the knee.

Joint Injections

Steroid injections of the hip can be helpful but have to be done using ultrasound or x-ray to make sure the needle is in the hip joint. They are much more difficult than steroid injections of the knee.

Surgery

Hip replacement is the only surgical option. It tends to be less painful post operatively than knee replacement and requires less rehabilitation by physical therapy.

How to manage osteoarthritis of the hands

Home management

Home management includes periodic resting of the hands when doing repetitive activities such as typing. Heat also helps. A warm compress or paraffin wax hand bath can soothe affected joints.

Some adaptations of daily activities may be helpful. Here are some suggestions from Arthritis Health by Veritas:

  • Wear coats and shirts with zippers instead of buttons
  • Use long zipper pulls which are also larger than regular zipper pulls and therefore easier to grasp. Specialized zipper pulls are made with looper cloth or nylon and allow the user to stick a finger through and pull down.
  • Choose lightweight cooking and gardening tools that are easier to lift and hold
  • Buy slip on shoes to avoid having to tie shoelaces

Occupational therapy can provide hand exercises as well as splints and other home aids.

Medicines

Topical medicines also work well for hand and wrist osteoarthritis. The other medicines for knee osteoarthritis also can be helpful.

Joint Injections

Steroid injections can be very helpful, but are somewhat more difficult to do than knee injections. Hand or wrist steroid injections are usually done by an orthopedist or rheumatologist.

Surgery

Surgery for hand osteoarthritis is not done very often and when done usually involves fusion of a joint to relieve severe pain.

Management of Osteoarthritis of the spine

Osteoarthritis can happen in any part of the spine, but osteoarthritis in the lumbar spine is the most common. The symptoms are back pain, and if a nerve root is compressed, then the pain can radiate down one leg (or one arm if the arthritis is in the cervical spine). Treatment depends somewhat on the symptoms, but like other forms of osteoarthritis non-medication treatment includes exercise, weight loss, tai chi, and physical therapy. Acupuncture helps some people. TENS units sometimes help as well. If you smoke, stopping smoking decreases inflammation and therefore pain.

Medicines

The same topical and oral medicines for knee arthritis also help for spinal osteoarthritis.

Injections

Epidural (just outside the spinal cord sack) injections can be helpful and when they work can last for months or even years. They have to be given by a pain management specialist under x-ray guidance.

Surgery

There are several kinds of spinal surgery. If the spinal osteoarthritis is severe enough to cause pressure on the spinal cord, then part of the vertebrae compressing the spinal cord are removed and the vertebrae are fused. If just the opening between the vertebrae is pressing on a nerve, then that opening is enlarged to take pressure off the nerve root. Surgery can also involve fusion of vertebrae at one or several levels to decrease pain. This kind of fusion surgery is not always successful long term and should be avoided if possible.

Bottom Line

Osteoarthritis is the most common form of arthritis and prevalence increases with age. Over half of people over 75 have osteoarthritis. Women are more commonly affected than men, especially after menopause. Thirty per cent of osteoarthritis is genetic and the rest due to other risk factors including previous joint trauma, obesity, smoking, sedentary lifestyle, certain occupations and certain sports. Avoiding obesity altogether or losing weight if you are overweight, regular aerobic exercise as well as strength training twice a week and stopping smoking if you smoke all decrease your risk of developing osteoarthritis. For those who have osteoarthritis Non-medication treatments should be tried first. Surgery is a last resort when other methods have failed.

Misinformation about SARS-COV-2 and COVID-19 -Misinformation about Masks and Treatment

Misinformation about Masks

Mask Misinformation 1: Masks don’t work, so there is no point in wearing one

This is false, of course. The most recent information is from a review of all the studies about mask use from the Journal of the American Medical Association. The conclusion is that masks decrease the risk of catching COVID-19 by 70%. Masks that fit snugly, have more than one layer, and have a tight weave are the most effective. Masks especially protect other people when they are worn by people who are infected. They also, however, protect the wearer from becoming infected. Since people are most infectious before they develop symptoms, universal mask wearing provides the most protection for everyone. Here is a link to the article in JAMA.

Mask Misinformation 2: Masks can make you sick

The claim is that bacteria build up inside the mask and that can cause infection. There is absolutely no evidence to support this claim. People who wear masks have no higher incidence of any infection than people who don’t wear masks. People who consistently wear masks, though, have a 70% lower chance of catching COVID-19 than people who do not wear masks consistently.

Misinformation about Treatment

Treatment Misinformation 1: Hydroxychloroquine and/or azithromycin prevent and treat COVID-19

This is one of those pieces of information that is like a zombie. No matter how much it is discredited, it never seems to die. There have been a number of very well designed studies to evaluate hydroxychloroquine as both a treatment and for prevention of COVID-19. All of these studies show absolutely no effect of hydroxychloroquine for either treatment or prevention of COVID-19. The same is true of azithromycin. There is no evidence of any effect for treatment or prevention for it alone or in combination with hydroxychloroquine. People who took hydroxychloroquine in these studies had more side effects and actually did worse than the control patients who did not get hydroxychloroquine.

Treatment Misinformation 2: Large doses of vitamin D prevent COVID-19

There is some evidence that people who have below normal levels of vitamin D have a slightly increased risk of serious COVID-19. Low levels of vitamin D are more likely to occur in northern latitudes where there is less sunshine. There is no evidence that people with normal vitamin D levels benefit from taking extra vitamin D for either treatment or prevention of COVID-19. If you live in the north, it might be worthwhile to ask your physician to check a vitamin D level. If you live in the south you are very unlikely to have anything other than a normal vitamin D level, so a test is probably not worth it.

Treatment Misinformation 4: Nutritional supplements such as vitamin C and zinc help prevent and treat COVID-19

Once again, there is no evidence that vitamins and nutritional supplements either prevent or treat COVID-19. A recent article in the Journal of the American Medical Association reported on a randomized controlled trial (the gold standard in study designs) evaluating vitamin c and zinc as treatment for mild COVID-19. The trial showed no effect. Here is a link to that article.

Prevention

The only interventions that have been show to prevent COVID-10 are wearing a well fitted cloth mask with multiple layers, social distancing of six feet or more, and avoiding closed indoor spaces. Vaccines have been shown to prevent serious disease. It is possible that they also prevent infection, but it will be several more months before we can be confident of that.

Treatment

There are several treatments that have proven to be somewhat effective in the treatment of COVID-19:

  1. Remdesivir has a modest effect on decreasing duration of illness.
  2. High dose steroids, such as dexamethasone are helpful in people hospitalized with severe disease.
  3. Monoclonal antibodies (bamlanivimab, casirivimab and imdevimab) are helpful in high risk people who have early COVID-19.

There are no “natural” medicines that treat or prevent COVID-19. Hydroxychloroquine and/or azithromycin are ineffective for treatment or prevention and hydroxychloroquine seems to cause increased harm.

In the next post I will talk about how misinformation spreads on social media and how to recognize it. I will also provide some reliable online sources of real information about SARS-COV-2 and COVID-19.