Osteoarthritis

What is osteoarthritis?
With the term arthritis refers to a wide variety of ailments that have in common that affect the joints, both seniors, like those of younger people. Arthritis can be caused at least 200 conditions, which cause pain and other symptoms significantly.
However, it is very common to use the word "arthritis" to refer to any of these pathologies. For example, rheumatoid arthritis often confused with osteoarthritis. Both diseases cause, usually, pain, stiffness and immobility, but rheumatoid arthritis is an entirely different condition.
Osteoarthritis, or degenerative joint disease, is the most common diseases of the joints. It occurs most frequently in people of middle age and elderly, and affects the neck, lower back, knees, hips and joints of the fingers.


Approximately 70% of those over 70 years show evidence of radiation sickness, but only half of them developed symptoms. Osteoarthritis can also affect joints that have previously been damaged by prolonged overuse, infection or rheumatic disease already exists. Patients with osteoarthritis suffer pain and functional impairment.

Definition
It is a degenerative joint disease, which occurs in older people, characterized by erosion of articular cartilage, hypertrophy of the bone margins (osteófitos), subcondral sclerosis, many biochemical and morphological alterations of the synovial membrane and articular capsule.
It is a degenerative disease of hyaline cartilage that is gradually eroding, cracking, thinner and even in advanced stages, it can disappear.
The loss of cartilage causes changes in the bone adjacent to the articular cartilage (subcondral), which reacts to produce deformations and attempted regeneration. It also triggered secondary inflammatory phenomena, which are often the cause of osteoarthritis that produces symptoms like pain and stiffness.
All this adversely affects mobility and the normal functioning of the joint, leading to the patient to a progressive disability to perform their daily activities.
Classification
Osteoarthritis is a heterogeneous disease and its classification to serve the latest proposal by the American College of Rheumatology, which basically considers:
1. Primary or idiopathic osteoarthritis, those who do not obey a known cause and which are divided into:
a) Located either in the hands, feet, hips, knees, shoulders or spine, mainly.
b) Generalized as they affects at least three of the previous joint groups.
2. Osteoarthritis secondary, are those that are due to a cause or pre-existing disease known as trauma, metabolic processes, endocrine, deposits microcris-Talin, congenital diseases, among others.
It is important to know that osteoarthritis, according to the degree of impact of mobility and damage to cartilage in joints, is classified as mild, moderate (in both cases can manifest inflammation and / or pain, but there is no such difficulty to move ) Or severe (if there is little degree of mobility).
Epidemiology
In Mexico, more than five million people over 50 suffer from osteoarthritis, which is ranked as the most common rheumatic disease around the world, as well as one of the most disabling, impeding the fulfillment of a life with quality and cause costs Families high. It has been observed that only a third of the large percentage of patients with radiographic evidence of degenerative changes introduced a joint symptoms attributable to osteoarthritis.
In our country, in 2001 the fourth leading cause of disability in the opinion of the Mexican Social Security Institute was in ankylosing spondylitis.

Risk Factors
They are classified into general risks (non-modifiable and modifiable) and local.
General non-modifiable:
1. Age: 45 years and over is lower, but increases by up to 80% after 80 years.
2. Sex: up to 50 years is similar in both genders, and thus began a dominance in women, both anatomic and clinical. In man-show in metacarpofalángicas and hip joints, and in women, in the proximal interfalángicas and knees.
3. Genetic susceptibility, some subgroups of osteoarthritis seem to have a genetic determinant, particularly the nodules of Heberden and those of Bouchard, more prevalent among women than in men, appearing in an familiar with autosomal dominant pattern for women and inheritance in men.

Modifiable risk factors:
There are factors that have a direct relation with the development of osteoarthritis. The most important are:
1. Obesity: Overweight and development of osteoarthritis have a well-established in the knees. In addition, it is always a negative factor in the evolution of the disease since it affects the joints of support or weight-bearing, as is the case of the lumbar spine, hips or feet.
Obesity is a major risk factor for developing osteoarthritis.
2. Physical activity in sports: the activity is not normal because of osteoarthritis, but the continued use, persistent and repetitive of a joint (overuse) can lead to injuries focal osteoarthritis, as the case may be of some athletes who practice too much.
3. Work: if an anatomical region is subject to continuous action or forced over a long period, this may be the origin of a disease artrósica, such as miners, mechanical hammers handlers, loaders, among others.
4. Bone density: it has been observed that in people with a lower bone density, which are the bones more fragile, the risk of developing osteoarthritis decreases. Osteoporosis (bone mass shortages due to a decalcification of the bones) "protects" some form of this disease.
However, osteoporosis is a disease that can cause severe bone fractures, so it is essential to prevent it through exercise and adequate intake of calcium (present in dairy products).
5. Nutritional factors: it has been said that certain micronutrients, such as antioxidants, involved in the control of free radicals, which are capable of damaging some macromolecules such as the cell membrane lipoproteins, proteins and DNA.
Etiopathogenesis
Cartilage is composed of specialized cells (chondrocytes) and an intercellular matrix produced by those cells, which in turn are made up of collagen fibers embedded in hyaluronic acid. They depend on the biomechanical characteristics of the cartilage. Hyaluronic acid confers the same elasticity and ability to withstand heavy weights.
The cause of osteoarthritis is the primary change in the normal function of chondrocytes and its degeneration causes the release of enzymes that cause inflammation. In osteoarthritis secondary when it starts the degeneration of cartilage destruction and the cause is usually a disease, injury, trauma or abuse of any joint.

Clinical features
Typical is the absence of general or systemic manifestations, as well as the involvement of a few joints (pauciarticular) that appears in a slow, gradual, preferably in the knees, hips, cervical and lumbar spine, hands (interfalángicas joints, and the first trapeziometacarpal metatarsofalángica) , And except in cases of osteoarthritis secondary respects shoulders, wrists, ankles and elbows.
Pain is the initial symptom and more important. At the top is a mechanic (insidious onset, improves with rest and worsens with exercise), distinct type of inflammatory pain (steady, persistent sleep, wake up the patient arrives in the evening) that appears in other joint diseases kind of inflammatory (various types of arthritis), but in the end stages can also be persistent and occur even at rest or during sleep.
Stiffness, morning or after prolonged inactivity: generally less than 30 minutes, which generally improves with the mobilization and exercise.
Decrease in the arc of movement.
Secondary muscle contracture.
Muscular atrophy secondary to the detention proof.
In addition, one must consider the inconvenience of each affected region: the knee, hip, wrist or column expressing their own alterations.

Laboratory data
Analysis data revealing the presence of osteoarthritis are minimal (unless there is an intercurrent disease): high sedimentation rate; hematic biometrics, blood chemistry and general urine within normal; synovial fluid with high viscosity with low cellularity less than 1000 cells per mm3; this test is useful in other inflammatory diseases or microcrystals.

Radiology
In the early stages, the alterations are minimal or non-detectable, but with developments appear injuries characteristics:
1) Decrease in joint space by thinning of the articular cartilage.
2) Sclerosis subcondral, which manifests as an increase in bone density of the portion of the underlying bone and cartilage that is the response of bone to the alteration of the mechanical joint.
3) Osteófitos, are the specific features of osteoarthritis and bone which are condensation on the banks Osteoarticular in response to repetitive stress on bone joints.
4) Cysts subcondrales or GEODAS, spaces that are formed in the bone due to the change of the sites load it.
5) dislocations, disturbances in the normal alignment of the joint, which indicate the severity of the condition.

Treatment
In patients with functional limitations should be minimal handling or non-pharmacological treatment, patient education, weight control, physical therapy, occupational therapy, orthotic use, identification of risk factors. If necessary, drug treatment should begin with simple analgesics, failing to achieve improvement will be used opioid analgesics such as propoxyphene, codeine or oxicodeína for a few days.
After the evaluation of risk factors for gastric and renal toxicity (age over 65 years, comorbidities, ulceropéptica history of illness, history of digestive tract bleeding, use of anticoagulants) may be used NSAIDs, naproxen, diclofenac and piroxicam; if necessary, by the existence of some gastric disturbance, may be used drugs COX-2 inhibitors, always taking care with the type of cardiovascular comorbidities, especially in patients older than 65 years.
The use of steroids intrarticulares can give good results in the process, when the indication and technique are correct, the slow release compounds prolong the effectiveness of these products. The steroid infiltration is a clear indication in cases of acute or in combination with other techniques, such as the onset of physical or complement to other drugs. In these cases it is important that the patient keep a sleep period of 24 to 48 hours to avoid excessive use of the joint after the analgesia produced.
The type of drugs, nutrients or dietary supplements such as Glucosamine, Chondroitin Sulfate, which are derived from soy and avocado, have not shown a great difference in the results of profit that mentions the industry.
Viscosupplementation has submitted regular results, controversial, and that can be used in the early stages of the disease.
Orthopedic surgery is a remedy more in the treatment of osteoarthritis and in recent decades has decisively improved the living conditions of many patients artrósicos. His statement is more frequent than in the lower extremities above. The surgical techniques used include the use of arthroplasties, osteotomies, arthrodesis, prosthetic implants or partial debridement articulate, and so on.
Prevention
Definitely the best prevention is the element that has to avoid the extensive damage of osteoarthritis, especially with the modifiable factors of the disease, such as controlling weight, exercising appropriate and well-managed, to avoid excessive use of certain joints and, in the aspect of work, maintain proper posture. First of all, go to the doctor since the onset of symptoms and adhere to lincamientos management and care that he recommends.

Questions and answers

1. What is it?
Osteoarthritis is the result of wear and tear on the joint surface, which occurs at a slow but progressive. Overall, it begins to be felt in middle age and affects mainly the joints that support more work, such as the hips, knees and spine, causing pain and progressive disability. It also presents most often in the hands, which is the cause of diminished capacity for movement.
In the knee, we can enjoy the same alterations:
In the x-ray of the left edges are sharp and healthy joints, while in the image on the right shows that over the years has developed an arthritis patient who already deformed joints edges.

2. What are the changes?
The cartilage of the affected joint is then softens and tears; it was revealed that the bone was found underneath, which hardens by rubbing it must endure and begins to grow in the form of spurs in and around the joint . In Progressively hinders the free movement of the joint, which increasingly will become disabled.

3. In addition to the wear, what other causes contributing to the onset of osteoarthritis?
Osteoarthritis always is exacerbated by the excessive body weight, the positions of the defective spine and body, as well as strokes or repeated efforts. Also the muscle contractions caused by mental states of tension, played a decisive role in the emergence of this disease.

4. Does the spine is affected often?
Yes, especially the cervical spine (the neck) and lumbar spine (the waist). In these cases, the pain and disability may be due to neuritis, a muscle spasm or at the premature aging of the spine, which is why over the years, almost all people show signs of physical and radiographic osteoarthritis in the column.
The red line shows the sites worn by osteoarthritis in the lumbar spine.
In the next image colors are highlighted with the sites of pain that the patient has indicated to the doctor. The blue zone covers the long arm and forearm. The doctor found that pain originates in the small area marked as blue C7.

5. What forms of pain that can cause osteoarthritis?
This depends on the area of the body is affected. For example, in the case of the cervical spine (the neck), the pain usually part of the base of the neck and runs to the shoulder, arm and the hand goes up on that side. In case you hit the lumbar spine (the waist), the pain from the waist, it affects the buttock, thigh, leg and foot or the heel of the hand, whether in the form of pain, contracture or cramp.
In any of the above cases, the pain may be accompanied by a tingling, burning or numbness in arms and hands or legs and feet.
Using the same example, in the picture we see how the patient said that his pain spreads from the waist through the buttock, thigh, leg and even reaches the big toe.
Such pain is satisfactorily resolved by the specialist, who will apply the medication only where it originates, ie in the lumbar spine that is indicated by the red arrow.
The following example shows how the pain is projected to several areas of the shoulder and arm, resulting in different sites of the cervical spine.

6. In what circumstances is the pain?
It has been found that the pain is associated with the increased movement of the affected joint and to surges in the weight it supports. Another important and frequent cause of pain is uncomfortable or improper posture, which forces the joints for several hours, such as bad posture or sleeping in a bed inappropriate. The same is true for the positions during the vicious and prolonged labor. This is associated with stress and muscle contracture, which aggravate the pain.

7. The pain can go alone?
The pain is usually the result of which a nerve is compressed or irritated, as in the case of osteoarthritis of the spine, or the wear is due to inflammation or irritation of the nerve endings of any another articulation, so once it has occurred, the pain will increase along with the progress of the disease and always will be within the range of nerve or nerve compromised by the process of osteoarthritis.
In the picture we see two variants of compression of the nervous system.
These two vertebrae with the same kind of affection but in a different place in the vertebrae disc 1 (light gray) that normally exists between one and a vertebra, is planning a hernia right in the center as they mark the arrow, and to move in that direction encountered with the spinal cord (in blue), which compresses.
In the 2 vertebra hernia is projected on a nerve root (red), as we mark the arrow.
In either case, there is an intense pain (the famous low-back pain and sciatic) that can be eliminated in the most simple and direct in full, that is, placing the medicines directly from the discs sick. That is called local treatment and the result is amazing.

8. What is the most common clinical symptoms of osteoarthritis ÁE a patient?
The disorder is presented with a gradual introduction of pain that, as we said, it may be in the hip in the groin area, in the buttock, thigh or at the knees, which are the most disabling, but remains in frequency and importance in the neck, back and waist.
The pain when climbing stairs is characteristic, especially when the body's weight is shifted toward the affected side, plus you can see a sense of friction or crepitation of the bones.
The patients reported that their discomfort increases when, trying to relieve by rest, but find they are compounded if spend much time sitting or lying down. Finally, there is a gradual and painful limitation of movement.
When examining the parties concerned is that they are hard to the touch and hurt at pressuring. The patient was referred to note increased friction within the joint, as if you missing lubrication. In the case of the hip and waist, the pain occurs limitations of movement and a progressive inability to extend or lift the legs: it stems later in drag their feet when walking and in a progressive shortening of the leg of the affected side.
The red line that runs from knee to the chest of the patient lying down is the normal distance of bending in a healthy person. But those who suffer from osteoarthritis of the knee or hip have difficulty in bending his leg.
The red line shows the sites worn by one of osteoarthritis in the hips.

9. What other symptoms can occur?
The stiffness almost always accompanies osteoarthritis. Also, the muscle spasm is common. When there is pain in a joint, the body defends itself trying to immobilize the area through the con-tractura of the muscles surrounding the affected area, but that, far from calming the pain, as it aggravates the patient tries to put in motion. Thus, over time patients are increasingly mobilized by the fear of pain, what is going to provoke them, almost without notice, progressive deformities and disability.
Here we can see how they relate muscles of the back with the bones of the back of the head, with shoulder blades and vertebra of the neck and the very back. Therefore, the contraction of these muscles (for nervousness, tension, bad positions or efforts) próaúce intense pain.

10. Doctor, doctor you like, why symptoms consult?
In the typical course of events the patient first consulting your doctor usual because feels pain in the groin, the buttock, in the leg or in the column.
He refers, for example, that the affected area is very stiff in the morning and sometimes it costs to get shoes or socks. He said the pain was aggravated by the efforts or the uncomfortable positions.
Therefore, the doctor tells studies and analysis of X-rays, which are of great help, and prescribes salicylates, analgesics or anti-inflammatory drugs until after a while, the patient's body becomes accustomed to the remedies and no longer responds to painkillers such as at the beginning.
The patient says to the doctor where you feel more pain before starting treatment.

11. What is your overall approach to the treatment?
After examining the patient and meticulous with all who suffer from osteoarthritis establish, explain how you benefit with the treatments, initially in a continuum with specific medication, control of risk factors mentioned, such as exercise, weight control, caring posture.
When they were done, the next step is to instruct on how to strengthen or affected joints and how to recover the function of all the muscles that have atrophied with the decline or lack of use of diseased joints.
It is possible therefore that we see the patient for various reasons, among them, because they're worried about the future of their disease, which increasingly responds to the least-oral medication or injections, or by fear of failure that interferes with their work or their life in general, and wondered about the seriousness that it can achieve its case and at what pace.
The local treatments do so with all its power and without damaging the overall health of the patient, causing an effective delay in the progression of disease and marked improvement in pain, with a beneficial impact on the patient's emotional sphere, which is provided to them same future as an invalid.

12. How the patient learns to do all these things?
We need instructions on how to make the right training in their own homes and on how to plan their activities. A mechanic, for example, can sit on a bench high for four or five hours, instead of standing all day, and a letter from your doctor can help a police officer to get a desk job, not to mortify their diseased joints on standing for long hours.
The life of a patient can be directed to save as much as possible, the load on your joints. This can be extended further until the indication of what should not eat, to reduce the overhead means the excess weight.

13. What else relieves the pain?
Overall, the therapies physiatrists, applications of dry heat with bags of sand or rubber and hot gel pad or electric.
Following the implementation of these forms of heat, massage indicated with a gel or ointment; this would supplement the excellent and long-term profit achieved by medication, which previously has been introduced into the patient directly into the affected areas.
Often, success in relieving pain and restore and maintain the role of the parties with ar-trosis, will be the result of the continued cooperation of the patient, who must find in the medical advisor and a true friend concerned about getting their welfare.
14. What are the cases are candidates for surgery?
There are two indisputable indications: 1) the almost total loss of ability to perform daily activities such as sitting down and getting up from a chair, for example, or 2) the pain is so constant and so unbearable that the patient and is unwilling or unable to live with it.

Among the therapies that help relieve pain are:
1) manual massage.
2) sand bag hot pad or electric.
3) Application of clay or wax hot.
15. Does this mean that the patient is no longer "forced" to suffer more?
Indeed, the process can not be stopped in full, but you can greatly reduce the speed of its evolution over very long periods, which undoubtedly will be adding victories in other forms of treatment, which supplement the excellent results until now, which allows patients to return to live as normal beings, without pain and without fear of disability, threats that up before such treatments are always hinting.