Modern Health and Wellness with Dr. Derbes….Week 2
This week I am going to take a break from discussing Preventative Health to answer a question from a reader.
My topic today is Osteoarthritis, and the specific question regarded the use of stem cells for this condition.
Osteoarthritis (OA) is a very common condition causing joint pain, stiffness, and disability. It is essentially a “wear and tear” type of destruction of the joints, and most commonly affects the knees (85%) but also commonly affects the hands and hips, and can involve any joint in the body, especially those that support body weight. Patients who suffer from OA will frequently complain of pain after activities that use that joint.
We can frequently diagnose OA by listening to the story the patient tells us and by performing a good physical exam. We can support this diagnosis by performing x-rays of the joint in question, and we are looking to see if the space in the joint is narrowed due to the breakdown of cartilage. The cartilage in joints is meant to cushion and support the bones as they move. Unfortunately, cartilage doesn’t heal very well and can break down with injuries, or even just normal wear and tear as we get older.
In early OA, there might not be much breakdown of the cartilage at all, and the x-ray may even appear normal. This is the best time to get the joint evaluated by your healthcare provider, because at this stage we have the best chance of helping you to slow the progression. Advanced, or late-stage OA can be very painful, and quite debilitating for some people. In advanced OA, the x-ray changes are usually obvious, and you might hear those joints described as “bone on bone”.
Treating OA can be difficult, and it frequently becomes a chronic condition (one that persists for a long time, or forever) for those who suffer from it, so it is helpful to know the full range of options for treating this condition early. Some of the most effective non-medical interventions include getting regular exercise for strengthening the surrounding muscles, weight loss, and performing adequate stretching to keep that joint mobile. Physical inactivity is one of the strongest risk factors for developing OA, so enhancing your physical activity early on is a very important part of OA treatment! Along those lines, physical therapy can also be particularly useful for evaluating painful joints.
My physical therapy colleagues are experts in assessing the way people move and can evaluate patterns of movement that can be corrected to help that joint feel better. It turns out that when you move joints the way they were intended, and with good posture, they don’t hurt as much! They can point out bad habits that lead to joint pain, identify those that would benefit from bracing to help the alignment of their joints, help to modify footwear to help some people walk straighter, and teach patients exercises that helps to re-balance the muscle tension across joints to relieve pain. Your healthcare practitioner should refer you to physical therapy, once they have determined that you have OA instead of another cause of joint pain which might require a different treatment.
Medications that may help include Tylenol and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). NSAIDs include Ibuprofen/Motrin/Advil (these are all the same medication), and Naproxen/Alleve. For someone who has occasional joint pain these are good options for occasional use, but you should discuss with your healthcare provider before taking NSAIDs on a regular or long term basis. NSAIDs can be very hard on the stomach, sometimes even causing ulcers. NSAIDs are also hard on the kidneys and can impair your kidney’s ability to filter your blood if used in too high of a dose or for too long. If long term NSAID use is necessary, your healthcare provider should monitor your kidney function on a regular basis, which can be done with a blood test.
Another medication proven to be beneficial in the treatment of OA pain is called Duloxetine, which is frequently used as an antidepressant, but has also been shown to be effective in assisting with chronic pain management. It is unclear exactly how this works, but is thought to help with neuropathy (nerve pain), and also to reduce your brain’s sensitivity to pain.
It is also possible to perform joint injections for the pain of osteoarthritis. Unfortunately, no treatment is without the potential for side effects. Most joint injections for OA are a combination of a long acting steroid with a numbing medication (lidocaine or bupivacaine). Steroids have a lot of side effects and are not always the best option for long term use. In fact, recent research has shown that while steroid injections do help with OA pain in the short term, they may be making the cartilage breakdown worse in the long run and can cause more rapid worsening of OA with frequent/long term use. Steroids also weaken your bones, elevate your blood sugars (and can actually cause diabetes in some people), and make you retain extra fluid in your body. There is certainly a role for steroid injections, but I think it’s important to consider these as only one component of a comprehensive plan for addressing OA pain and disability that takes your other medical problems into consideration, as well as your possible future needs.
It is also possible to inject Hyaluronic Acid formulations (one of the building blocks of cartilage), as well as Platelet Rich Plasma (PRP), but neither of these have very good clinical evidence to say that they work significantly better than a placebo. Since the evidence supporting these interventions is overall weak, I do not perform them in my practice.
Long term narcotics/opioids also do not have good evidence to support their use for OA pain, and I do not recommend them. Narcotics are most useful in the treatment of acute (short term) pain, to help get someone to a repair that will likely solve their problem, but there is no good evidence that they overall improve that patient’s ability to function long-term.
Future directions for the treatment of OA may include injections with stem cells. In particular, connective tissue stem cells called ‘Mesenchymal Stem Cells’ are being heavily researched to determine if they might be one way of regrowing or repairing cartilage in joints. This field of study is called ‘Regenerative Medicine’ and is part of what I studied in my fellowship. However, I work predominantly with the skin in my practice, and I do not have detailed knowledge of stem cell therapies for joint regeneration. For the moment, this treatment remains experimental, but shows promise for the future!
Surgery is also an option for OA treatment and is generally a last resort for people with advanced OA that is causing significant limitations in their daily life. Detailed discussion of surgical options will have to wait for another day! In the end, there are many ways to treat OA, and you and your healthcare provider should discuss a customized plan that is right for you and your unique circumstances.
I hope that this article was useful for those of you who might suffer from OA, and maybe a few of you learned about another treatment option you weren’t previously aware of. I would like to thank my physical therapy colleagues, Aubrey Peckham and Trevor Horner for their feedback on this article!