Maintaining Your Health on Mackinac
Healthy Lifestyle Can Minimize Arthritis
By Yvan Silva, M.D.

Arthritis is no longer considered a disease of old age. Indeed, osteoarthritis, the most common variety from a list of 100 subtypes of arthritis, may start as early as the second and third decades and continue a painless and relentless course until middle age or later, when the degenerative processes takes hold and symptoms begin to manifest their effects on lifestyle. It can take this time for the cartilage within the joints - that cushions and absorbs shock - to break down. By the time the damage is established, the best treatments available cannot do much more than ease the pain and try to maintain the status quo in the degenerating joints.

A normal joint is enclosed in a capsule lined with a synovial membrane that secretes fluid to keep the joint lubricated. The bone ends in the joint are lined with cartilage, a smooth, firm tissue that absorbs shock and allows for painless motion.

Bony tissues rebuild rapidly when injured, and fractures heal in well-known time frames. Cartilage, on the other hand, does not heal well, if at all. This damage is the prime basis for the disease. As cartilage breaks down, bone ends rub together, they thicken, and spurs form, leading to further joint degeneration and deformity.

Most people over age 60 show signs of arthritic joint changes on X-rays, yet only one-third have symptoms relative to those joints. In most cases, X-rays don't correlate well with the symptoms manifested by people suffering with arthritis.

It was once thought that degenerating cartilage was the only cause of osteoarthritis. Today it is recognized as a complex set of processes affecting muscles, tendons, and bones.

More than half of arthritis sufferers are born with genetic mutations that control cartilage formation and destruction. The strength of muscles around the joints, the alignment of joints, and the tendons and ligaments that support joint movement are all implicated in the processes of degeneration. Other causes may include environmental factors, infectious organisms like bacteria or viruses and imbalance of certain enzymes.

Whatever the cause, most authorities agree that the most important way to prevent ongoing destruction is to strengthen the muscles surrounding the joints by exercise. Strong muscles stabilize the joints and further aid by absorbing shock. Scientists are calling this the "age of arthritis" as research is not only unraveling the biological causes, it is indicating that the best way to live with arthritis also depends on attitude and the way individuals actively manage their lifestyles.

Osteoarthritis is currently believed to affect 20 million Americans who suffer a wide spectrum of symptoms that include pain, loss of mobility, crippling deformities, and a compromised lifestyle as the disease progresses. The disease affects the hands and weightbearing joints - the knees, hips, back, and feet. Osteoarthritis of the knees leads to disabilities in older folks as much as diabetes, heart disease, hip fractures, and mental depression.

Recent technological innovations have led to safe joint replacements with artificial knees and hip joints that can last 15 to 20 years or more. But this is for far-advanced cases, and while research in bone and joint diseases is progressive, prevention and resolution of the processes that lead to cartilage destruction is not yet feasible.

The number of people suffering with osteoarthritis is expected to climb to 40 million by 2020. It includes a sizable number of Americans heading into their 50s, the prime age for arthritis. High impact aerobics and fast-breaking sports like football, tennis, and basketball create torsion in the joints, especially the knees and hips, and with loss of alignment and joint support, there is greater vulnerability. An increasingly overweight population is at higher risk because of the impact on supporting joints. Sedentary lifestyles contribute measurably to loss of muscle mass and muscle tone, osteoporosis, and weight gain.

Rheumatoid arthritis is another type of musculoskeletal disease, and it affects approximately 2.5 million Americans. Although symptoms may be similar to osteoarthritis, this disease is an autoimmune disorder that attacks several joints and can ensue rapidly. The resulting inflammation causes severe pain and deformity, swollen joints and crippling stiffness, most often of the hands and feet. This type also affects other areas of the body, such as the nervous system, the lungs, and eyes. Fatigue, fever, and weight loss can also occur. It is three times more common in women as in men. It affects people between the ages of 30 and 50, yet it can occur in childhood.

Treatment is often approached aggressively with steroids, injections of gold salts, and, more recently, combination therapies including cancer-fighting drugs like methotrexate and newly developed "biologics," which are genetically engineered versions of naturally occurring molecules that block cytokines, products of inflammation.

There are other related forms of inflammatory, autoimmunebased arthritis, such as systemic lupus erythrematosus (SLE), that can affect all joints as well as organs like the lungs, kidneys, and blood vessels. Scleroderma, polymyositis, polymyalgia, and giant cell arteritis are others in this similar category. Other forms of arthritis include ankylosing

spondylitis, which leads to a stiff, rigid spine, gout, that affects the joint at the base of the big toe and other joints, and infectious arthritis, that causes a red, swollen joint owing to bacterial infection.

At a recent international meeting of scientists, evidence was presented to show that vigorous exercise helps arthritis. One hundred people were the subjects of a long-term study. Two exercise regimens were compared. The first was typical for arthritis patients and included isometric exercises that involve pushing against fixed resistance without bending the joints, and range of motion exercises designed to improve mobility. The research subjects further followed a more vigorous regimen of fast walking, bicycle riding, and step-up exercises. The more intensive routines led to increased joint mobility and muscle strength and decrease in severity of symptoms.

In another study, conducted over nine years, the joints of 28 middle-aged runners who exercised at least five hours a week showed less evidence of skeletal damage compared with 27 sedentary subjects of similar ages. Normal joints were thus shown capable of withstanding a good deal of weight-bearing stress.

What can one do?

While there is no cure, the first step is to determine the type and extent to which the disease has progressed. A physical examination, blood tests, and certain imaging tests like X-rays, arthrography (dye is injected into the joint and images obtained,) CT scans, and MRIs may be indicated. Joint fluid may be aspirated for study.

General guidelines include pain control, weight control, designing and following an individualized exercise program, a healthy diet, and appropriate assistive devices when needed.

Experts claim that exercise is most important and does not, as was previously believed, lead to deterioration by wear and tear. Exercise is known to play a direct role in keeping cartilage healthy because turnover of fluid in the joint spaces provides healthy nutrition to cartilaginous tissues. Swimming or exercising in a warm swimming pool is especially good because it provides an excellent workout without putting stress on weight bearing joints. Walking, stationary bicycles, and proper weight training are beneficial. Maintaining a healthy lifestyle can help. While not proven, high-fat intakes seem to relate to joint inflammation and, surely, obesity is known to contribute to arthritis.

Lifestyle adaptations are useful in making activities of daily living easier and less painful. Raised toilet seats, wall bars in the bathroom, and other adjuncts also lead to fewer accidents. Pain management techniques should be used, and prudently. Hot baths, showers, and heat packs can help to relieve joint pain and soreness. Cold gel packs help with pain in acutely inflammed joints. Pain medications, commonly acetaminophen, and antiinflammatory agents are used by the majority.

Americans spend $1 billion a year on alternative therapies for arthritis. Some of them may have potential. Acupuncture may be a reasonable pain management option. Some physicians are trained and certified to provide acupuncture. Dietary supplements like glucosamine and chondroitin are naturally occurring substances that are in common usage.

Although there is no guarantee that osteoarthritis can be prevented, there is little doubt that the following steps work to keep cartilage healthy. Joint motion in the form of activity and exercise helps in lubrication. Weight control helps in preventing extraordinary stress on the hips, knees, and ankles. Maintaining muscle tone helps stabilize shoulders, hips, and knees.

There are several ways to obtain relief. They include proper selection of drugs, exercise regimens, alternative therapies, and, when indicated, surgery in the forms available - arthroscopy, tissue repair, joint replacement, and joint fusion.

Finally, taking charge with education is a practical way to deal with the great individual differences that occur from time to time in the same individual and between individuals in the degrees of compromise of normal daily living for people with arthritis.

Dr. Silva is a professor of surgery at Wayne State University and a resident of Woodbluff on Mackinac Island.