Osteoarthritis

Degenerative joint disease is a disorder of cartilage and bone characterised by cartilage loss and bony overgrowth. Other names used are osteoarthritis (OA) when it affects the peripheral joints and spondylosis or spondylitis when it affects the spine.

Classification:

I) Primary osteoarthritis
A) Localised OA
B) Generalised OA (3 or more joint groups involved)
C) Erosive OA (rare)
II) Secondary osteoarthritis
A) Mechanical
1) Congenital and developmental disorders such as hip dysplasias, slipped femoral epiphysis
2) Post traumatic
B) Post inflammatory and/or infective arthritis such as rheumatoid arthritis, septic arthritis
C) Neuropathic joint disease : Diabetes, tabes dorsalis, syringomyelia, leprosy, meningomyelocoele.
D) Endocrine causes : Acromegaly, Cushing’s syndrome
E) Metabolic causes : Gout, pseudogout, ochronosis, Wilson’s disease, haemochromatosis
F) Prior bone disorders, like Paget’s disease, osteonecrosis
G) Iatrogenic causes including intraarticular steroids

Osteoarthritis (OA)

Pathology:

Despite the diverse aetiological factors, certain histological, biochemical and metabolic changes in OA are similar.

The articular cartilage is the site of primary pathology. It loses its glossy appearance and becomes pitted and fibrillated. Focal and diffuse erosions of the cartilage take place, with subsequent thinning and complete denudation. The underlying articular bone becomes sclerosed. Reactive proliferation of new bone and cartilage at the joint periphery leads to osteophyte formation. Biochemical changes in the articular cartilage include increase in water content, alteration of the ratio of chondroitin sulphate to keratin sulphate, decrease in glycosaminoglycan concentration, and disruption of proteoglycan aggregation. There is a progressive loss of chondrocytes.

Mechanisms of cartilage damage

Abnormal stress due to
Obesity
Trauma
Hypermobility
Developmental abnormalities
Avascular necrosis of bone
Paget’s disease
Abnormal cartilage
Ageing
Inflammatory arthritis
Gout
CPPD
Hypothyroidism
Acromegaly
Ochronosis

Clinical Features:

The onset of symptoms is usually insidious. In most patients a limited number of joints are involved. Joint pain is the initial symptom; the pain comes on with use and is relieved by rest. As the disease progresses, pain occurs even at rest.

The most common sites of involvement in primary OA are the distal interphalangeal and first carpometacarpal joints of the hand, first metatarsophalangeal joint of the foot, the hips, knees, and lumbar and cervical spines. Joints usually not involved are the metacarpophalangeal joints, wrists, elbows and shoulders. Joint enlargement occurs in the later stages of the disease, and is due to bone proliferation, spurs and synovitis.

Nodal osteoarthritis:

Nodal osteoarthritis occurs predominantly in middle-aged women. It affects the terminal interphalangeal joints of the fingers with the development of gelatinous cysts or bony outgrowths in the dorsal aspect of these joints. Acute in onset, it may be associated with a good deal of deformity. It may also involve the proximal inter phalangeal joints, carpometacarpal joints of the thumbs, the spinal apophyseal joints, hips and knees. A strong family history is predominant.

Erosive osteoarthritis:

This is a more severe form of nodal Primary Generalised OA characterised by episodic symptoms and signs of local joint inflammation, with the development of destructive subchondral erosions and instability in the proximal and distal interphalangeal joints.

Involvement of specific joints

Hand:

Usually the distal interphalangeal and first carpometacarpal joints are involved. Often the pain is maximum at the beginning. Deformities may develop.

Knee:

The knee is the most commonly affected joint. One or both knees may be involved. Patients experience difficulty in ascending or descending stairs or standing up from the squatting posture. There may be isolated involvement of the medial compartment of the tibio-femoral or patello-femoral joint, or both. Progressive disease leads to the deformities (genu varus) and joint instability. There may be inability to extend and flex the knee fully.

Hip:

In India, OA of the hip is less common than that of the knee. True hip pain is felt on the outer aspect of the groin or inner thigh; occasionally the pain of hip joint disease may be referred to the lumbosacral area or to the knees. There is limitation of joint movement. The patient walks with a characteristic antalgic gait.

Spine:

Spondylosis is the term applied to degenerative changes affecting the disc and vertebral bodies. The osteophytes thus formed may cause mechanical compression of vital structures such as the spinal cord, nerve roots and even blood vessels. The spondylotic process involving apophyseal joints may take place in the cervical, thoracic and lumbar spines. Patients may be asymptomatic even in the presence of radiological changes in the spine. When patients are symptomatic the pain may be localised to vertebral or paravertebral areas. The patient may present with radicular nerve involvement or spinal cord compression. Patients with cervical spine disease may present with vertebrobasilar insufficiency.

Investigations:

A thorough history, supplemented by a detailed clinical examination, is critical for proper diagnosis. The following investigations are useful.

Radiology of the involved joint may show joint-space narrowing, subchondral sclerosis, osteophytes, bone cysts (geodes), altered shape of the bone ends, and periarticular ossicles. Bony ankylosis is uncommon. Gross radiological features may be present even in the absence of clinical symptoms. Computed tomography (CT Scan) and Magnetic Resonance Imaging (MRI) are helpful in studies of the lumbar spine when symptomatic spinal canal stenosis is a diagnostic consideration.

Synovial fluid analysis is not essential and when done may show features of non-inflammatory arthritis, viz., low cell counts (less than 2000 cells/mm3), high viscosity, and low protein content.

Arthroscopy is useful in demonstration and/or removal of loose bodies which may interfere with joint function.

Routine investigations like urinalysis, blood sugar, serum rheumatoid factor, serum iron and serum caeruloplasmin (ceruloplasmin) should be done to rule out secondary causes of OA.

Management:

The main objectives are relief of symptoms, preservation and restoration of function of the failing joint and arresting the process of cartilage destruction.

Treatment at Homeocare International:

We at Homeocare International study each arthritis patient in detail clinically and homeopathically and prescribe an advanced constitutional medicines according to their individual genetic constitution.

Constitutional approach, an excellent method of selecting proper homoeopathic medication for a variety of health issues ranging from common cold to a large variety of incurable cases, especially all chronic diseases, in brief-“Homoeopathic approach is holistic as well as individualistic; holistic in the sense that the medicine is selected for the patients as a whole, but not for individual diseased organs/parts; individualistic from the view point that each individual patient is considered different from others, although all are suffering from the same disease.