During our seminars, I am often approached with questions. I am commonly asked about "Osteo". I ask, "Osteo-what?" As many of you know, there is osteoarthritis, osteopenia, osteoporosis, and others. Frequently people speak of their condition and merge these problems together as they seek answers to their personal concerns. Each condition is very different and requires different treatments. Some of these conditions can be painful; some are not and each has its own characteristics, signs and symptoms. Let's take a few minutes to discuss the differences and hopefully, you will learn more about yourself and can determine if you are doing everything you can if you have arthritis or osteoporosis or osteopenia.
OSTEOARTHRITIS is a JOINT and CARTILAGE problem
Osteoarthritis, also called degenerative arthritis or wear-and-tear arthritis, is the most common form of arthritis amongst more than 100 types. Physicians often use various terms to describe osteoarthritis. Terms you may hear include joint deterioration, joint degeneration, joint narrowing, bone-on-bone, calcium deposits, bone spurs, joint diminishment or even "just" arthritis. Some patients don't realize they have arthritis because their doctor describes the problem as joint narrowing, never providing a specific diagnosis of osteoarthritis. In the spine, terms can include degenerative disc disease, bulging disc, annular tearing, facet joint arthritis or arthrosis, degenerative spondylolisthesis or vertebral slipping, spinal canal or foraminal narrowing or spinal stenosis.
Osteoarthritis by definition means Osteo=bone, Arthro-joint and Itis=inflammation but these terms don't fully explain the problem. OA is a degeneration of the articular cartilage that covers the bone ends adjacent to each other. Once this degeneration establishes, it can slowly (sometimes rapidly) cause more cartilage loss between the bones which leads to "bone-on-bone" and more pain. OA can be present and painless for years until the loss becomes enough to warrant symptoms. Depending on the severity of the loss, OA can cause a variety of symptoms. First, OA is most prevalent in the joints next to the fingernail (and toe) bed, the middle joints of the hand and the thumb base. It does not cause harm to the knuckles of the hand (like rheumatoid arthritis). It will also affect knees, hips (pain will be in the groin of the leg and inner aspect of the thigh, not on the side or buttock.) and spine. It can affect your neck and, to a lesser degree, the shoulders. Shoulder pain is usually NOT OA unless you have advanced impingement syndrome and have developed rotator cuff damage over the years. OA does not affect the elbow or ankle unless there are other circumstances such as prior fracture or flat feet. OA is a joint problem, not a systemic problem. It is possible to have more than one affected joint but there is no symmetry (as in rheumatoid arthritis). An old injury or smaller repetitive injuries can lead to a degenerative joint such as the knee or spine. Carrying extra body weight will accelerate the damage and symptoms of osteoarthritis.
There is little inflammation in osteoarthritis compared to rheumatoid arthritis. It is possible to have a swollen joint at times but it is usually not long lasting. Swelling tends to occur with joint overuse or exertion and will subside with rest. Blood tests (for blood inflammation) will prove negative because the inflammation is not in the blood but instead local in a joint. Arthritis blood tests will also be negative. Diagnosis is usually confirmed by history, examination and plain x-rays.
X-rays will reveal the joint narrowing and bone spurring but history often leads the physician to the appropriate diagnosis. Caution to those whose physicians do not listen, do not perform a physical examination or take x-rays and say, "Oh, you have arthritis" or "What do you expect? You are getting older." Comments such as these can cause some patients to feel they must "live with the condition". Although you do have to find ways to be comfortable, there are plenty of ways and specific options to help you live actively and fully.
Every condition has a "course or path of treatment". This means there is a limited set of treatments based on your diagnosis and its severity which is more reason why I emphasize the importance of knowing 1) your diagnosis, 2) its severity, and 3) options available. Medical professionals begin with the least and add more as you go along to find the most effective treatment. It is not always easy finding the best combination of treatments. But, if you are a good partner and relate honest responses to your doctor and interact with him/her, you will receive better care. Never be passive and never believe your doctor is untouchable. Doctors appreciate your involvement and do better with your help. If you have concerns, express them, if you have questions, ask them and if you are not satisfied with your treatment, speak up or seek additional help with a second opinion. Also realize there are many specialists that treat specific types of problems. The problem and its severity can help you to seek treatment with your primary care physician, or a specialist in rheumatology, orthopaedics, physical medicine & rehabilitation or more specifically, spine, hip and or knee, hand orthopaedics, or sports medicine.
Rationale of Effective Treatment
Treatment can include anti-inflammatory medications and/or analgesics. Currently there is no medication that slows the progression or damage of osteoarthritis. In all cases, medications are designed to control symptoms. In the earlier stages of a painful condition, you can also try glucosamine sulfate/chondroitin sulfate in regular doses. Simply treating osteoarthritis with medication can make you more comfortable and active but remember it's important to rehabilitate painful joints so they remain functional. We also now know that the best way to SLOW arthritis progression is through strength. Strength that surrounds a joint unloads the joint's stresses and changes the load as it transfers to the muscles. Once you know the correct exercises for your problem, a home exercise program can be excellent in the long-run.
Joints and the spine do better when we maintain a desired weight. A cane can unload a joint as well. These will not only make it less painful, it will slow the progression which is key to long term treatment. Osteoarthritis stays with us for life so we should always remember the important question: What will life be like ten years from now? Don't sit on the sidelines watching yourself grow older and lose ground when there is much we can do. Don't wait and wish for a better day. Joint damage will continue, muscles will weaken, balance and coordination can be further impaired. Treatment is most successful when combined in multiple ways. Passive treatments such as medication, topical creams, heat or cold can help temporarily but active treatment, such as appropriate and weight loss, is most helpful in protecting the joint(s) and reducing pain. Other active treatments that can provide long-term relief include using a cane, protective injections called viscosupplementation (knees only) or surgery to correct the problem. Last, be careful about remedies that aren't backed by clinical research and outcomes. People with arthritis are often prey by those who try to financially gain from selling "snake-oil" and other unproven products in the arthritis market.
OSTEOPOROSIS is a BONE problem
Osteoporosis is most often confused with osteoarthritis since often people have both. While OA is a degeneration of a joint, osteoporosis is the loss of BONE mass which causes risk of fractures, even spontaneously. Osteoporosis is PAINLESS and if you indeed have pain, let's say in your back, you could have both conditions. In the spine, it is called degenerative disc disease and it is part of the arthritic process. Osteoporosis on the other hand (and while you have degenerative disc disease) can affect your bone quality. Bone density testing called, DXA, or dual-energy-x-ray-absorptiometry, most accurately determines your bone health. Osteoporosis is painless until you sustain a fracture. Osteoporosis begins with low bone mass usually around age 50. In women, it's common after menopause. Low bone mass, called osteopenia, is the precursor to osteoporosis and can lead to osteoporosis. Bone mass peaks around 35 years of age.
For example, if you have about 100% of your bone mass at age 50 (menopause), you will lose about 3% of your bone mass silently for about 5 years after menopause. That's 15%. Then as you grow older, you will lose about 1% every year. Over a 20 year period that computes to an additional 20%. By the time you are 75, you could reach 35% bone loss. When you have about 30% bone loss, fractures can begin to occur. To determine your bone density, never rely on a plain x-ray. Plain films will not identify bone loss until there is a loss between 30-50%. We all experience these changes differently but a DXA scan can help you know where you stand. Once you have had your DXA, learn what a "T-score" is so you can monitor your own bone health along with your doctor. If you do indeed have a diagnosis for osteoporosis, you will require medical treatment to slow this problem and prevent a fracture. Osteoporosis is not uncommon; half of all women over 65 have osteoporosis. Be aware, not all physicians routinely test for osteoporosis and some even will wait until you ask for the scan. There are specific risk factors for osteoporosis including being Caucasian or Asian, being thin or small boned, smoking, drinking alcohol, not ingesting enough calcium or vitamin D, a sedentary lifestyle and certain medications. Medications include steroids of any kind, some blood thinners, excessive thyroid, and some anti-convulsants. If you have had a hysterectomy before your menopause, you are also at an increased risk.
If you learn you have osteopenia, you have options. Some may need treatment, some don't. Calcium and vitamin D supplements can be provided to those who lack enough calcium in the diet. There are many fortified foods you can rely on as well. Be careful about unproven remedies. Many dollars are spent on alternative supplements that have no track record except the testimonial, which is quite different from clinical research. Testimonials are claims from those who have something to say but clinical research tracks every patient and every event and under controlled conditions.
Options for Improving Bone Health
Treatment for osteoporosis is pretty simple. It includes 1) sufficient calcium and vitamin D, 2) weight-bearing exercise, and 3) medication. First, one must have sufficient calcium and vitamin D. Next, weight-bearing exercise stresses bone, making it stronger. Last, medication is prescribed if you have full-blown osteoporosis. You cannot do less and expect improvement of your bone mass.
There are effective medications available that are safe for most. First line of treatment using medication includes Actonel, Fosamax, Boniva or Reclast (all of the category called biphosphonates). There is a new medication call Prolia. For those who either can't take these medications or they are ineffective, you can consider another option. Forteo (parathyroid hormone) requires a daily injection for 2 years but is effective when biphosphonates fail. Your physician can help you decide which is best for you with the least risk. Most importantly, don't ignore osteoporosis because it is not painful. Instead, think of osteoporosis like hypertension (high blood pressure). Uncontrolled hypertension can cause a heart attack or stroke while osteoporosis can cause a fractured bone. If you are not sure where you stand or you are losing bone in spite of treatment, consider consulting with a rheumatologist or endocrinologist, both of whom specialize in osteoporosis. Some spine specialists also treat osteoporosis of the spine.
If you experience a fracture of a spinal vertebra, it usually heals in a few months. This is acceptable as long as you are being treated for the underlying condition. However, if the pain is severe, you can consider a simple surgical procedure called Kyphoplasty, which restores the vertebral height and helps you stand straight. Kyphoplasty includes a very small incision (2) at the fracture level, the insertion of a balloon and then it's inflated. The balloon is withdrawn and a small amount of cement is inserted. By the time you wake up after the procedure, your pain is gone and you can go home and resume your usual activities the next day. Another procedure, vertebroplasty is also available for these types of fractures but it's noted not as safe. Vertebroplasty does not restore vertebral height. To undergo these procedures, see a spine specialist before the fracture is fully healed. An MRI helps determine the degree of healing so the spine specialist knows whether you can be considered for one of these procedures.
As you can see, osteoarthritis and osteoporosis are very specific diseases and require proper diagnosis and treatment. There are very effective options for these conditions. It's simply a matter of knowing about the conditions and which options are best for you.