Causes of Osteoarthritis

CAUSES OF CALCIFICATION DISEASE (OSTEOARTHRITIS)

Osteoarthritis is considered to have started when the cartilage layer that protects the joints begins to deteriorate. The inflammation seen in osteoarthritis is completely different from rheumatoid arthritis, which occurs in the form of attacking its own tissues. Wear and deformity in the joint is always milder than rheumatoid arthritis. Unfortunately, damaged cartilage often cannot grow back to normal. Although arthrosis is most common in weight-bearing joints in the body (knee, hip, back, foot), it can also be found in other joints. The places where osteoarthritis is most common are the load-bearing areas of the body. Knee, hip and spine are the best examples of this.

WHAT ARE THE SYMPTOMS OF OSTEOARTHRITIS?

People with osteoarthritis may experience the following symptoms.

  • Pain (more obvious when first moving) However, pain may also occur when the joint gets too tired.
  • There is stiffness in joint movements that lasts for about 30 minutes or less, especially in the morning. If this morning stiffness lasts more than 1 hour, rheumatoid arthritis and similar syndromes should be investigated.
  • Disruption in some joint functions (complaints begin with the inability to squat, have difficulty climbing stairs, or being unable to open a jar, but gradually become more restrictive in daily life)
  • Deformities (swelling, cystic structures and growths in the bone) occur in the joints. The synovial membrane may react to the resulting cartilage erosion. Then, there is fluid accumulation in the joint, which can sometimes reach extreme levels. While the growths in the bone are initially reversible, over time when protrusions begin to form in the bone, they cannot revert anymore and on the contrary, the problem gradually increases. These protrusions sometimes even turn into giant spurs.
  • Osteoarthritis can sometimes cause significant inflammation (redness, warmth, swelling and pain). In such cases, a differential diagnosis with rheumatoid arthritis must be made.
  • Pain may increase in various situations (in the morning, at midnight, stress, weather change, fatigue, etc.)
  • Pain may radiate further from its original area. Hip pain may radiate to the leg, and neck pain may radiate to the arm.

As the damage to the cartilage increases, the severity of pain increases and the functional capacity of the joint becomes increasingly limited. The patient, who used to be able to walk for 1 hour, can no longer walk more than 100 meters and it may become impossible to even cross a sidewalk.

CAUSES OF CALCIFICATION

Despite years of research, no one has fully established the causes of osteoarthritis. Many factors probably affect this process. Hereditary; Many people may face similar problems in the future in almost the same joints as their parents. For example, “Heberdan Nodosity” seen in the hand joints is quite remarkable in terms of hereditary transmission. Scientists have discovered an inherited abnormality in the gene responsible for collagen production in patients with this condition and some similar ones. This defect may cause premature deterioration of cartilage. Studies are still ongoing to solve the mystery of the issue.

Aging process;The most common cause of arthrosis is known as old age. Here, the osteoarthritis graph increases as the age exceeds 50, and almost peaks after the age of 70. Professions in the risk group; Although problems begin in almost every joint with aging, those with a profession that facilitates some wear have to face this problem earlier. Athletes (wrestlers, boxing, skiing and football), workers, desk prisoners are prime examples.

Past traumas; While this condition is most often the result of old age, it sometimes occurs following an infection or trauma. Previous but forgotten falls and crashes cause these causes to be kept secret.

Sedentary Life; physical inactivity can be harmful to joints. Lack of exercise, weakened muscles, and stretched joint ligaments can easily lead to arthrosis.

Excess body weight; joints are naturally stressed under excess weight. Excessive loads and accidental reverse movements under these conditions may cause early deterioration of the joint and surrounding structures. These problems are especially evident in joints such as knees and hips that bear the weight of the body. On the other hand, the tendency for weight to increase in all individuals as a result of the slowing down of metabolism in parallel with aging makes this problem even more intractable. Research shows that overweight people are more likely to develop osteoarthritis in their weight-bearing joints, such as hips and knees, as they age.

HOW IS OSTEOARTHRITIS DIAGNOSED?

Pain and other symptoms are so common in older people that almost everyone will say the problems are caused by osteoarthritis. However, in order to reach a diagnosis, some steps must be taken at almost every age.X-rays easily reveal osteoarthritis-related deformities in the spine or fingers. But before this, taking a detailed anamnesis and examination is a must.

INSPECTION; If there is severe pain, severe deformation and swelling in the joint, rheumatoid arthritis and similar syndromes are more likely to come to mind. But it is essential for the doctor to ask each patient about any illness, infection or trauma he or she has had in the past.

QUESTIONING THE PATIENT; For this purpose, the location of the pain, its spread, what causes it to increase or decrease, where it spreads, etc. It must be questioned in detail.

INSPECTION; The second stage during the examination is inspection. During this information and observation-based procedure, the doctor should see swelling, deformity, redness, heat, tenderness and rashes one by one and record the results.

MUSCLE STRENGTH TESTS; Possible weaknesses in the muscles surrounding the joints should be investigated with the help of muscle strength tests. As a result of the test to be performed on the muscles suspected to be problematic, values ​​between 0-5 are recorded.

JOINT CIRCUMFERENCES AND RANGE OF MOTION MEASUREMENT; Joint circumference should be measured with a tape measure, finger circumference should be measured with a special device, and joint movement capacities should be measured with a goniometer, and the results should be recorded carefully. Because the development of the disease can be easily monitored during check-ups.

EVALUATION OF ADLS WITH VAS;The patient’s ability to perform activities of daily living (ADLs) should be questioned. Even quality of life (QOL) should also be questioned. Although various scales have been developed for this purpose, it will be possible to record both the degree of pain and the quality of life, the simplest of which is the visual analogue scale, which shows satisfaction from 0 to 10.

NEUROLOGICAL EXAMINATION; Sensation and reflex examination should be performed in all patients and it should always be checked for any motor deficits.

When DIAGNOSIS is made in a patient who is suspected of having a problem in their joints, a detailed questioning is first performed. Following this, the examination begins. Inspection is followed by joint examination. After completing the neurological examination, procedures such as taking fluid from the joint or imaging the joints are used to obtain more detailed information about the joints.

VIEWING
X-rays should generally be used in imaging to diagnose osteoarthritis in the joints. CT and MRI are less frequently used methods. Because x-ray methods can often give sufficient results for the diagnosis of arthritis. The findings seen in the graphs are very meaningful.

  • Narrowing of the joint space; This condition is caused by cartilage loss. For example, in the medial region of the knee joint, the joint distances may be close to each other. The first stage here is cartilage loss, and as this progresses, the subchondral bone in the lower layer may be exposed. The appearance in this circuit cannot be seen on graphs. This period, which can only be observed macroscopically, is called “eburnation” because it is in the shape of ivory.
  • Marginal sclerosis; Osteocyte density increases on the contact surfaces of the joint, resulting from the joint protection reflex. For this reason, these areas appear more dense on radiographs.
  • Osteophytosis; This is a meaningless solution to increase the attachment area of ​​the joint.In short, this is a natural development that occurs to protect the joint.
  • Subchondral Bone Cysts; These may develop in the layer of the cartilage wear area in the joints descending towards the bone, cysts that are in contact with the joint fluid and cause local weakness in the bone.
  • Local Osteoporosis;There may be local calcium loss in the bones.
  • Deformities; In certain areas of the joint, growth occurs in parallel with the deformity.The natural angle between the bones in the joint is disrupted. The outward or inward angle increases. (Like genu varum deformity in the knee)

LABORATORY TESTS
If there are questions about joint swelling, the physician should perform a puncture to remove and examine the fluid inside the joint. The fluidity (viscosity) and composition of the liquid are tested. If there is any doubt, it should be determined whether there is blood or infection in it. In crystal arthropathies, the search for mono-urate crystals may be on the agenda, especially to exclude gouty arthritis.

Joint fluid is not always a routine examination method. However, some blood tests can give us important clues in the differential diagnosis between arthritis and arthrosis. Analyzes such as sedimentation, CRP, ANA, RF, uric acid can give us important clues in the differential diagnosis between arthrosis and arthritis.

TREATMENT

Basic purposes; The main goals in osteoarthritis treatment should be as follows. Reducing pain, regaining joint movements and restricted functions, and above all, producing all the necessary solutions to stop or slow down the course of the disease.

The main treatments are:

  1. Rest and movement restriction during certain periods
  2. Physical Therapy Methods (Heat or cold treatments – electrotherapies)
  3. Pain relieving medications (local-oral-rectal-IM/IV/IA)
  4. Thermal springs and in-water treatments
  5. Various assistive devices (knee brace, bandage, joint corrector, shoe support, corset, cane, etc.)
  6. Stress control, patient information meetings
  7. Surgical methods (arthroscopy, arthrotomy, arthroplasty, arthrodesis, tenotomy, Release op etc.)

1-Restriction of rest and movement

In some cases of osteoarthritis, the patient may need to put aside all his work and rest for a while. Rest is the best solution during these intermediate periods when pain increases and joints swell. Sometimes completely restricting the movements of a painful shoulder or swollen knee with a splint or similar device can also speed up the healing process. Their duration can be extended or terminated depending on the patient’s response to the treatments.

2-Physical Therapy Applications

HOT-COLD APPLICATIONS

Heat and cold have been used to treat osteoarthritis for thousands of years. It should not be forgotten that the results expected from these methods, which are used during periods when pain, stiffness and swelling increase, are temporary.

HOT APPLICATIONS; It is generally used to relax the muscles before starting exercise or other physical therapy procedures. Heating is provided either by hot packs or infrared rays. Some people prefer “moist heat” in the form of hot towels or a hot bath. Painful conditions on the hands can be treated by dipping them in hot paraffin.

COLD APPLICATIONS; Cold ice or cold packs can be used locally on inflamed tissues. Cold should never be applied directly to the skin. It would be appropriate to place a towel or cloth in between. Additionally, cryotherapy, as a modern cold application method, provides positive solutions.

The cold application time should not be too long. Because, just like in the heat, burns may occur on the skin. In more serious and permanent cases, cryotherapy methods that are more effective but less noticeable and do not cause skin irritation may be preferred.

Many different methods, especially electrotherapy, are used in the treatment of osteoarthritis. Ultrasound, radar or short wave treatments are actually heat treatment methods. The first one occurs as sound waves, the others as electromagnetic vibrations. TENS, Diadynamic, interference and other current types are facial bleaching methods in painful situations that frequently occur in cases of osteoarthritis. The tingling sensation that occurs under the electrodes attached to the skin is quickly replaced by a painless state.These methods have almost no side effects.

In cases of osteoarthritis, low-intensity electrical signals that occur during electrotherapy applications such as Transcutaneous Electrical Nerve Stimulation (TENS) eliminate pain and enable the resumption of restricted joint movements.

Apart from this, in some rare cases, applications such as magnetic fields are also used.

In physical therapy; The goal is not just to relieve pain. Because it supports regeneration efforts that will allow the tissues within the joint to renew themselves. It ensures the removal of metabolites accumulated in the tissue from the environment and reduces the tension of the surrounding tissues. Increased elasticity allows movements that were previously difficult to perform more comfortably and without pain.

3- Drug Treatment in Osteoarthritis

There may be acute or chronic pain in osteoarthritis. Various medications are used to control this pain.For very severe pain, even narcotic analgesics can be used, provided that they do not last longer than 1 week. More commonly used drugs are non-steroidal anti-inflammatory (NSAI) drugs. The dosage, duration of use, possible side effects of these drugs, and their interactions with the drugs they are used with should not be overlooked. The main side effect occurs in the gastro-intestinal system. Therefore, just as it was said for cortisone, NSAIDs should be considered a “double-edged sword”. Because, while it treats the disease on the one hand, it can also cause serious side effects that can kill the patient. It should also be taken into account that it will cause kidney damage, increase blood pressure, and increase the risk of bleeding by reducing platelets.

To reduce the GI side effects of NSAIDs, some supportive medications such as antacids and “Proton pump inhibitors” can be given together.

Apart from this, muscle relaxants, vitamins, externally applied ointments, glucosamines that support the reconstruction of joint cartilage, and intra-articular hyaluronic acid injections, which increase the lubricity of the joint fluid and reduce the friction coefficient in arthrosis, are also successfully applied in cases of osteoarthritis.

4- Thermal Springs and In-Water Treatments

Exercises that are less stressful on your joints are “Aquatic exercises”. It is especially recommended for patients with osteoarthritis in large joints (hip, knee). It is quite remarkable that a number of movements that cannot be performed outside of water due to the buoyancy of water can be performed more easily in water. Whirlpool applications in water and pressurized showers are other applications that increase the effectiveness of the treatment. Hot springs; It is a treatment method that provides the highest therapeutic level in in-water applications due to its mineral composition, radioactivity and temperature. Is it worth reminding that our country is very rich in terms of hot springs?

5- Various Auxiliary Devices

Osteoarthritis patients are often people with limited mobility. For this reason, at least a cane or crutches or even a walker that they can carry in their hands should be recommended as solutions that make their daily lives easier. Apart from this, knee braces, corrective devices on the knee or shoes to prevent genu varum deformity, various splints and corsets have helped many patients embrace life more tightly. The aim here is to keep the disease under control with conservative methods. Or to offer practical conveniences that will make the lives of patients for whom we can never apply surgical methods even easier. Shopping bags that can be used by patients with finger problems, special reading devices that prevent neck pain, using extra thick pens when writing, using long-handled tools for home and garden work, and using special sitting chairs are the methods used in osteoarthritis rehabilitation. Special walking shoes while walking, equipment to be used in the kitchen and bathroom (e.g. raised toilet, handles, shelves, special forks, openers, plates, etc.) are other examples of these.

6- Patient Information Meetings

Emotional stress sometimes causes worsening symptoms in osteoarthritis. There are various challenges imposed by daily life. These may be family problems, financial problems, traffic congestion, shopping difficulties or future concerns. In such cases, which lower the pain threshold, various measures should be taken, from simple sedatives to the help of a psychologist or psychiatrist. Some proven techniques for stress management may also be recommended. Relaxation and correct breathing techniques, Biofeedback, and disease coping training are methods that can be used from time to time. Sometimes training provided by bringing together people with the same problems gives very positive results. In these meetings, which are group therapy, the practical solutions that other people find for their illnesses and their objections to the problems are adopted by the other audience, allowing a more positive outlook on life. In these meetings, also called “Patient Schools”, what needs to be done for the disease, what precautions to take in case it progresses, general information about treatment methods and newly developed treatment solutions are explained in detail.

Living with osteoarthritis

WEIGHT CONTROL; Weight control is very important to be successful in the fight against osteoarthritis. According to research; Being overweight is a risk factor for osteoarthritis. To achieve weight loss, more physical activity and a strict diet are required.

REGULAR EXERCISE; In order to say that we have had a productive exercise, we have to spare at least 30 minutes for it every day. Individuals with osteoarthritis need to change their living habits and include exercise in their lives. Here, first warm-up and relaxation exercises should be done, and then strengthening and stretching exercises should be done. Exercise both relieves pain and increases joint movement. It has another purpose, such as protecting the joint by strengthening the muscles around the joint. Joint range of motion (ROM) exercises are also performed during stretching exercises. This maintains joint flexibility and helps increase restricted movement capacity. Exercises that stretch the muscles to move them against resistance for a period of time without changing their length are known as isometric exercises. People with osteoarthritis of weight-bearing joints should avoid activities such as jogging and tennis. This sport requires you to put a lot of load on the feet or make sharp turns and twisting movements. Additionally, exercise bikes should be used with caution by people with arthritic knees.

7- Surgical Methods

Despite the successful results in joint surgeries, operative interventions should always be a last resort in osteoarthritis. People who have severe pain that does not improve with conservative treatment methods, joint instability, and have lost significant mobility are candidates for surgery. Regardless of age, surgery should be considered as a solution for patients who have severe difficulty in performing daily living activities.

ARTHROSCOPY; In cases of advanced osteoarthritis, the first approach is the least invasive arthroscopic methods. Here, by entering the joint from the outside, the problem can be observed better and solutions for treatment, which can sometimes last longer, can be produced.

ARTRODESIS; In patients with severe pain and difficulty in performing more invasive surgeries, joint freezing or fusion operations, also called arthrodesis, can be performed. Lack of movement is the most serious disadvantage of this operation. Sometimes movement in another joint can compensate for the existing problem. The joints where it is most commonly applied are small joints such as feet or fingers.

OSTEOTOMY; In order to stop the cartilage loss of some joints or to position them more accurately, some bones are cut and new positions are given to them. Osteotomy can provide relief from pain and does not limit joint movement capacity. It may be preferred to prevent existing joint damage and postpone the prosthetic operation that is required in the future.

ARTHROPLASTY;A joint that is so damaged that it can no longer be used is completely removed and replaced with an artificial joint. Very successful results are obtained in surgeries performed using high-tech prostheses made of vitalium or titanium alloy and high-density polyethylene parts. On the 3rd or 4th day, the patient is discharged from the hospital and the preoperative severe pain disappears and the lost functions are largely regained.