Early OA - Any suggestions?

[Teddy1]

Hi Folks, I have been having some trouble walking down stairs or hills and went for a knee x-ray (46 year old male kitesurfer). Sadly they show some arthritis in both knees as per “There is mild degenerative change in the medial compartment of both knees with very early joint space narrowing. There is some new bone formation around the lateral femoral condyle and inferior surface of the patella bilaterally. "

Any thoughts on further investigation or treatment? Should I give up kitesurfing?

Thanks,

Ted

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[Canuck Physio]

Hi Folks, I have been having some trouble walking down stairs or hills and went for a knee x-ray (46 year old male kitesurfer). Sadly they show some arthritis in both knees as per “There is mild degenerative change in the medial compartment of both knees with very early joint space narrowing. There is some new bone formation around the lateral femoral condyle and inferior surface of the patella bilaterally. "

Any thoughts on further investigation or treatment? Should I give up kitesurfing?

Thanks,

Ted

I would be inclined to mention that it may be useful to look into nutritional supplements. Although there is much debate about this, glucosamine sulfate and chondroitin appear to at the very least delay the onset of OA. Additionally synergy may be created when MSM, and cetyl myristoleate are added.

However, I believe that you may want to look at your general nutritional status. There are many factors related to proper nutritional status and certain nutritional compounds that may aid in delaying the progression of OA. Examples include low levels of Vitamin D.

Additionally I believe it is necessary to adopt an appropriately tailored physiotherapy based exercise resistance program. Mal-alignment is known to contribute to medial or lateral progression of the disease. JAMA 2001 Aug 15;286(7):792.

I believe that these 2 key aspects (nutrition & muscular balance and strength) are interventions that you can consult about with appropriately qualified professionals in your area so that you can manage your problem, and continue doing what you love to do.

Regards

[Teddy1]

Dear Canuck Physio & Friends, Thank you for the reply. I'm from Ont but live in the UK so it sounds that we might have a similar history? I've got a few questions regarding your reply.

*I'm trying glucosamine sulfate. Is there any evidence that chondroitin is impt? Hard to see how such a large molecule like chondroitin would work? Similarly is there any evidence/reference for MSM, and cetyl myristoleate?

*Can you recommend book or type of professional for nutritional aspects of OA?

Thank you. Happy to hear from others too.

Ted

I would be inclined to mention that it may be useful to look into nutritional supplements. Although there is much debate about this, glucosamine sulfate and chondroitin appear to at the very least delay the onset of OA. Additionally synergy may be created when MSM, and cetyl myristoleate are added.

However, I believe that you may want to look at your general nutritional status. There are many factors related to proper nutritional status and certain nutritional compounds that may aid in delaying the progression of OA. Examples include low levels of Vitamin D.

Additionally I believe it is necessary to adopt an appropriately tailored physiotherapy based exercise resistance program. Mal-alignment is known to contribute to medial or lateral progression of the disease. JAMA 2001 Aug 15;286(7):792.

I believe that these 2 key aspects (nutrition & muscular balance and strength) are interventions that you can consult about with appropriately qualified professionals in your area so that you can manage your problem, and continue doing what you love to do.

Regards

[Canuck Physio]

Hello again,

Eyap, hows those Sens eh?

Like I mentioned there appears to be some debate about the supplements mentioned. The problem stems from our current capacity to measure the microscopic changes that occur with chronic degenerative diseases. Outcome measures use to analyse the effects of such supplements usually involve subjective pain scales, not entirely accurate for a clinical decision to be made. However, there appears to be clinical results that suggest certain therapies, or supplements do work for people.

Here is a summary of some recent studies into the supplements mentioned:
1. Glucosamine: Glucosamine Sulfate as opposed to Glucosamine HCL appears to be effective. Overall there is still much ongoing debate in regards to this.
Arthritis Rheum. 2007 Jul;56(7):2267-77.
Glucosamine for pain in osteoarthritis: why do trial results differ?

2. Same idea for Chondroitin: for Dr's their thinking is if some patients believe it works for them (placebo?) they don't see constant prescription as a faux pas.

3. MSM:MSM (3g twice a day) improved symptoms of pain and physical function during the short intervention without major adverse events.

Efficacy of methylsulfonylmethane (MSM) in osteoarthritis pain of the knee: a pilot clinical trial
L.S. Kim , L.J. Axelrod , P. Howard , N. Buratovich , R.F. Waters
Osteoarthritis and Cartilage- 2006 March (Vol. 14, Issue 3, Pages 286-294,

4. Cetyl Myristoleate appears to help certain patients, however, research which has previously been done has not been followed up on this compound.

The key here is, if you can afford it, it may be beneficial for you to try these and see if they are effective for you. The problem is there is in fact conflicting evidence in regards to their effectiveness because studies almost always examine the subjective pain experience of the individual. Scientific equipment is not yet available for measuring and tracking the changes within the joint surfaces, although this may change in the future with recent advances in tracer technology.

The point of me mentioning these is that if you do go see a local nutritionist, you can at least be informed about the key compounds that are being touted as beneficial. If someone tries to hard line you on a certain compound, at least you are now aware. That is not to say a nutritionist probably will have an awareness of what compounds can improve bone health. Some of these include calcium, vitamins, and more recently evidence into creatine.

Most importantly, and I'd be amiss if I didn't mention this, Physical Therapy is probably your very best bet for maintaining joint integrity for years to come:

Deyle, Gail D, Allison, Stephen C, Matekel, Robert L, Ryder, Michael G, Stang, John M, Gohdes, David D, Hutton, Jeremy P, Henderson, Nancy E, Garber, Matthew B
Physical Therapy Treatment Effectiveness for Osteoarthritis of the Knee: A Randomized Comparison of Supervised Clinical Exercise and Manual Therapy Procedures Versus a Home Exercise Program
PHYS THER 2005 85: 1301-1317

Physical therapy, including strength and muscle balance exercises as well as education about biomechanics of joint movement and ergonomics will probably be your best preventive course of action.

Best thing is too probably find yourself a Physiotherapist, and as well a Nutritionist who can sort out some preventative treatment program.

[Teddy1]

Dear Canuck, Thank you very much for the detailed reply. It's given me much to follow up. I've got a physio to give me a programme which I'm excited about and will start the hunt for a nutritionist. I'm excited about the potential to improve things or at least get healthy trying. Best wishes for Christmas to you. I hear there is lots of snow back home. Cheers! Ted

[physiobob]

Any thoughts on further investigation or treatment? Should I give up kitesurfing?

Definitely NOT! A bit of OA in the knees is probably there in most people from 40 upwards. This is a normal finding.

Think of your issue as a knee joint problem with eccentric loading of the joint when going down hills. This is a typical presentation and matches the x-ray findings or a person who is overloading their knee and has been doing so for a long, long time. Trouble is that finally is became painful so now you have taken notice.

Kite surfing is fairly low impact compared to say jogging so this is not a sport to give up. What you need to do is have someone take a look at your mechanics and give you some specific exercises to work on what's missing. This is very important to arrest the degeneration that it is currently causing. Nutritional supplements are perhaps useful and some Aussie studies specific to OA (I think in the knee) have shown a statically significant with dosage also being important. I think they look at doubling the standard recommended does and this did have a better effect than the normal dose (around 1500mg per day for memory). Not sure of the actual study but perhaps someone else can shed some light on that.

Get in and see a dedicated sports PT in your local area. A few dollars investment now will pay year of dividend in terms of a worsening knee issue.

[Teddy1]

Dear Physiobob, Thank you so much for your helpful advice. It's been very useful as its changed my mindset. Thinking about, the kitesurfing is low impact and good knee exercise so I'm going to continue with that. I will also take your advice on seeing he physio and report back on my progress. Can you take a stab at the title of that Aussie journal so I can look it up. Thank you very much. Ted

Definitely NOT! A bit of OA in the knees is probably there in most people from 40 upwards. This is a normal finding.

Think of your issue as a knee joint problem with eccentric loading of the joint when going down hills. This is a typical presentation and matches the x-ray findings or a person who is overloading their knee and has been doing so for a long, long time. Trouble is that finally is became painful so now you have taken notice.

Kite surfing is fairly low impact compared to say jogging so this is not a sport to give up. What you need to do is have someone take a look at your mechanics and give you some specific exercises to work on what's missing. This is very important to arrest the degeneration that it is currently causing. Nutritional supplements are perhaps useful and some Aussie studies specific to OA (I think in the knee) have shown a statically significant with dosage also being important. I think they look at doubling the standard recommended does and this did have a better effect than the normal dose (around 1500mg per day for memory). Not sure of the actual study but perhaps someone else can shed some light on that.

Get in and see a dedicated sports PT in your local area. A few dollars investment now will pay year of dividend in terms of a worsening knee issue.

[physiobob]

There's a few links here:

The Role of Glucosamine in Fighting Osteoarthritis

Cochrane et al suggest glucosamine plus chondroitin is best supplement for OA knee; do you agree? What is effective dose of each ingredient? How can you tell if what you are being sold is genuine? : NLH Question Answering Service

I'll also copy and paste the contents of the first link below in case this page becomes out of date in the future:

The Role of Glucosamine in Fighting Osteoarthritis
06/12/03 J.R. Rogers

Glucosamine Sulphate Working Against Osteoarthritis

Osteoarthritis (OA) is the most common type of arthritis and typically damages the weight-bearing joints such as the hips, knees and spine.

Although primarily considered a disease of aging, OA can also result from sports-related injuries. In fact, about 10% of OA sufferers are in their 20’s. Figures from the Australian Bureau of Statistics reveal that more than 1.1 million Australians suffer from OA.

Ideally, treatment of the disease involves relief of the symptoms, and controls the progressive degeneration of the articular joints. Modern drug therapy has concentrated on symptomatic relief of pain using simple analgesics such as aspirin, or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen. These drugs do not stop joint degeneration, and many are associated with side effects such as the production of potentially fatal stomach ulcers.

Glucosamine sulphate is a natural substance, termed a "chondroprotective agent", which relieves the symptoms of OA without serious side effects, and also appears to slow the progression of the disease.

The Role Of Glucosamine

OA is caused by a degenerative process which affects the cartilage of the articular joints, resulting in symptoms of inflammation, pain and restricted movement. The degeneration appears to be caused by a disruption in the synthesis of important compounds (such as proteoglycans) from amino sugars within the chondrocytes (cartilage-producing cells).

Glucosamine is one of these amino sugars, and it is produced in the body from the sugar glucose and the amino acid glutamine through the action of the enzyme glucosamine synthetase.

Glucosamine stimulates the synthesis of proteoglycans, glycosaminoglycans (more commonly referred to as mucopolysaccharides), and collagen.

It therefore plays a role in the formation of cartilage and the cushioning synovial fluid between the joints, hence its "chondroprotective" classification.

The chondrocytes can either synthesize glucosamine themselves, or obtain it from circulating pre-formed glucosamine. Supplementary glucosamine can be an important source of this vital amino sugar for those with reduced capacity to produce glucosamine, such as the elderly.

Glucosamine Sulphate

Compared with other potential chondroprotective compounds such as chondroitin and animal cartilage, glucosamine is a much smaller molecule that is more readily absorbed and incorporated into cartilage and ligaments.

Glucosamine is available commercially as N-acetyl glucosamine, and the salts, glucosamine hydrochloride and glucosamine sulphate. Glucosamine sulphate is the form used in the majority of clinical studies - probably due to the stabilization of glucosamine with the sulphate ion.

Sulphur occurs throughout the body in amino acids, and occurs as sulfate in connective tissue as a binder and stabilizer. Sulphate is found in sulphated glycosaminoglycans and proteoglycans. Inorganic sulphate compounds have formed an important basis for Blackmores Celloid® Mineral therapy for over 60 years, with sulfate salts being used to help regulate body fluids and to stabilize intercellular connective tissue.

More recently, researchers at the World Health Organization’s Center for Rheumatology have discovered that sulphur inhibits the various enzymes which lead to cartilage destruction in joints.

The stabilization of glucosamine with sulphate appears to enhance the bio availability of glucosamine and potentiate its therapeutic effect.

Clinical Trials With Glucosamine Sulphate

Glucosamine sulphate is the most clinically studied glucosamine compound. It has been used in more than 20 double-blind, placebo-controlled studies involving over 6,000 people, together with hundreds of scientific investigations into its mode of action.

Several important studies have compared glucosamine sulphate with the drug ibuprofen in their effects on osteoarthritis. In one study of the knee OA, 200 patients were divided into two groups, one group taking 500mg glucosamine sulphate three times daily (1500mg daily dosage), the other ibuprofen 400mg three times daily. The study lasted four weeks and patients were assessed weekly according to a standard rating index of relief of symptoms of pain and improvement in mobility.

While improvement appeared sooner in the drug-treated groups in the first week, there was no difference in scores from the end of the second week onward. At the end of the treatment, there was a success rate of 52% in the ibuprofen group and 48% in the group taking 500mg glucosamine sulphate three times daily.

Significantly 35% of patients taking ibuprofen suffered side effects, mainly gastrointestinal, compared with only 6% in the glucosamine sulphate group. The researchers concluded that "glucosamine sulphate was therefore as effective as ibuprofen on symptoms of knee OA".

Several other similar studies compared the relative benefits and drawbacks of glucosamine versus ibuprofen for those suffering from OA. Those studies resulted in findings that while ibuprofen sometimes acted more quickly in the short term in reducing pain from OA, those taking glucosamine ultimately obtained greater and longer lasting pain relief from glucosamine. In addition, far more of the persons taking ibuprofen reported suffering negative side effects than did those persons taking glucosamine.

Summary
# Glucosamine sulphate plays an important biological role in the formation of cartilage and synovial fluid.
# Glucosamine sulphate appears to be more biologically active than other chondroprotective agents.
# Glucosamine sulphate has been studied in many randomized, double-blind clinical studies of osteoarthritis.
# In the case of OA, glucosamine sulphate appears to be as effective as a leading NSAID treatment, but with far fewer side effects.
# Glucosamine sulphate is non-toxic, and is safe for long-term administration.
# Scientific studies of human subjects have shown that glucosamine sulphate is often effective in reducing joint tenderness, swelling, and pain associated with OA when taken in daily doses ranging from 500mg to 2000mg per day. The studies used a variety of glucosamine forms, methods of delivery, and amounts. The most common amount, form, and method of delivery used in the studies was glucosamine sulfate pills several times per day in a daily amount totaling 1500 mg.

References

1. Safe, M Joint Account, The Australian Magazine, March 20-21. (1999) p27.

2. Myers S & Callinan P, Celloid® Prescribers’ Reference. Sydney: Blackmores Ltd; 1992.

3. Adinfinitum Agency: Glucosamine sulfate proven superior to other forms of glucosamine and chondroitin sulfate. Press release 1998.

4. Werbach, M. Nutritional Influences on Illness 2nd Edition, Third Line Press, Ca. U.S.A. 1993, page 468, referring to paper by D’Ambrosio L et al. Glucosamine sulphate: A controlled clinical investigation in Arthrosis. Pharmatherapeutica 2(8): 504-8; 1981.

5. Mueller-FassbenderH. et al: Glucosamine sulfate compared to ibuprofen in osteoarthritis of the knee. Osteoarthritis and Cartilage (1994)2; 61-69.

6. Noack W etal Glucosamine sulfate in osteoarthritis of the knee. Osteoarthritis and Cartilage (1994)2; 51-59.

7. Qiu G, Gao S, Giacovelli G, Rovati L., and Setnikar I: Efficacy and Safety of Glucosamine Sulfate Versus Ibuprofen in Patients with Knee Ostoarthritis. Arzneimittel-Forschung, 48(5): 469-74, May 1998.

8. Vaz, A: Double-blind clinical evaluation of the relative efficacy of ibuprofen and glucosamine sulphate in the management of osteoarthrosis of the knee in out-patients. Curr.Med.Res.Opin., Vol.8, No.3, 1982.

9. Thie N., Prasad N., Major P.: Evaluation of Glucosamine Sulfate Compared to Ibuprofen for the Treatment of TMJ Osteoarthritis: A Randomized Double Blind Controlled 3 Month Clinical Trial. Journal of Rheumatology, 28(6): 1347-55, June 2001.