Joint Degeneration and Arthritis

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

A majority of Americans will experience degenerative changes to the knee, hip and/or lumbar joints and discs, many even starting in their early thirties. With aging, hip degeneration also affects at least a third of the population, and is a major factor in the decline of health with aging, as decreased mobility and increased inflammatory stress will be a major contributor to a variety of common health problems with age. Joint degeneration does not happen suddenly, and identifying a progressive problem and reversing this degeneration is very important to avoid a very stressful and debilitating outcome. A number of factors contribute to degenerative joint and vertebral disk conditions, and understanding these health problems and causative factors helps the patient and Complementary Medicine physician to devise the right individualized protocol to prevent, reverse, or treat the condition. Restoration of healthy joint and disc tissues is possible, and unless these underlying factors are addressed, large studies show that even surgery may not prevent the continuing degeneration, and prosthetic joints will also degenerate, and cannot be regrown like human tissue. Integrating Complementary Medicine into your health care may be the most important choice in your life to prevent the pain and debility that often accompanies these degenerative conditions.

By 2011, the strategies of modern medicine to treat degenerative joint and spine conditions were proving to be inadequate, and yet adopting a more sensible approach with early detection and prevention, and integration of Complementary Medicine has still been heavily resisted in standard medicine. There is no so-called "alternative" approach to this prevalent health problem, but there is much that can be accomplished with hard work and practical healthcare integrated into musculoskeletal medicine. The challenge is to find a system of early detection of this common problem and early intervention with conservative therapies designed to restore joint health. Large studies have shown that arthroscopic surgical repair will not prevent the recurrence of degeneration of the joint if underlying chronic inflammatory conditions are not corrected. The medical community responded to this finding by promoting a prosthetic replacement of joints, but by 2011 many of these prosthetics were failing in a short period of time and causing a problematic deposition of metal particles in the tissues, contributing to pathologies of the bone marrow, immune system, and the brain. The failures of metal-on-metal hip replacements will generate many billions of dollars in added healthcare costs, time off work, and future nursing care for invalid patients, adding stress to both the patients and their families, and the government, as rising healthcare costs add to government deficits and increased cost of insurance policies. While we have rejected metal-on-metal joint prostheses, we have not restored public trust. A more comprehensive and holistic approach to joint degeneration is urgently needed, and Complementary and Integrative Medicine (CIM) can supply what is needed to round out the treatment plan.

Scientific research is finally supporting Complementary and Integrative Medicine in this arena of Degenerative Joint Disease. A large randomized and placebo controlled human clinical trial in Finland, in 2013, showed that for a majority of patients with degenerative tissue in the knee, and small meniscus tears, that the outcomes with conservative physiotherapies alone were about equal to that of surgery and physiotherapy. Such studies may not even utilize the best combination of physiotherapies, though. Choosing the best course of conservative treatment that integrates Complementary Medicine, with Tui na soft tissue mobilization, acupuncture, herbal and nutrient medicine, as well as patient instruction in targeted stretch and exercise, and improved body mechanics, will result in an even better outcome, and one that is lasting. All of these may be combined in treatment from the right Licensed Acupuncturist, and the only side effects with such treatment are improved overall health and quality of life. Early intervention and persistence is the key to success, as regrowth of healthy joint tissues takes time.

Joint degeneration is usually referred to as osteoarthritis, but this term does not apply to all degenerative joint conditions. Arthritis means inflammation of the joint, and there are over 100 medical classifications, or types, of arthritis. Osteo- is a term referring to bone, and is used also to refer to the bone covering at the joint, or cartilage, as well. Many cases of joint degeneration are more correctly called osteoarthroses, though, as inflammation is not the primary concern. Degeneration of the cartilage may also be due to metabolic concerns, and this would be classified as chondromalacia, sometimes called "softening of the cartilage", but referring to inadequate metabolic nutrition delivered to the cartilage, or dystrophy, in many cases. Areas of cartilage degeneration that are attributed to repeated trauma or hard exercise also occur in Osteochondritis Dissecans, and usually involves small loose bodies of cartilage or bone that move in the joint and cause an inflammatory and mechanical wearing on small areas of bone covering, which are referred to as lesions. Often, there is an array of causes for joint degeneration, though, and these diagnostic terms that fit everyone into a neat box may be outdated. For many patients, osteoarthritic changes, often driven by failure of anabolic hormones and poor delivery of blood nutrients, improper body mechanics contributing to imbalanced wear and tear, poor tissue repair after injury or surgery, and underlying health problems all contribute to the joint degeneration. The exact causative explanations of joint degeneration are still being debated, though, and an overview of the scientific understanding on this subject helps the patient and physician to formulate the right individualized treatment protocols to stop tissue degeneration and promote healthy regrowth. As hard as it is to believe, modern science still has many questions regarding the pathophysiology of joint degeneration, and has focused too heavily on surgery, steroidal and non-steroidal anti-inflammatory drugs, and now joint replacement, rather than a more sensible and holistic approach with early intervention with conservative and restorative treatments. We must applaud the technological advances in recent years with less invasive surgeries, platelet-rich plasma and prolotherapies, and attempts with stem cell technology, but none of these has yet been proven effective in the long-term. Conservative joint tissue restoration utilizes the body itself to maintain lasting health.

Because of the lack of understanding of the etiopathology of joint degeneration, even the incidence of this problem is not clearly reported, and various medical sources give varying reports of incidence. This is mainly due to the problems with classification of the disease. The Centers for Disease Control in the U.S. report that osteoarthritis is characterized by degeneration of the cartilage and underlying bone within a joint, and is seen in about 14% of the population, and close to 34% of the aging population, but specifies that this is believed to be a very conservative estimate. Females experience osteoarthritic joint degeneration at about a 2-3 to 1 ration over males, due to both anatomic differences and hormonal cycles. Steroid hormones are now found to be integral to tissue maintenance. The incidence of lumbar disc degeneration is often reported to exceed 50% in the aging population, and even exceeds 20% in the young population. This high incidence of degenerative joint pathologies has led to a competitive attitude concerning treatment protocol, with much discouragement of more conservative treatments in Complementary Medicine, and a push for new surgical technologies and prostheses. Many patients who are developing conditions of joint degeneration, though, are placing their hope in a more integrated approach, and not waiting until the condition is severe and a joint replacement prosthetic seems the only option. Too many patients have been talked into a joint replacement prosthetic too soon, not realizing the future ramifications of this decision.

Diagnostic Considerations and Early Detection of Degenerative Joint Disease

Obviously, early diagnosis of a gradually progressive joint degeneration is very important in the total scheme of reducing disability and expense in this realm of medicine. Unfortunately, patients do not usually receive this elucidation of the problem, and when they do, the treatment plan has been only palliative, with NSAIDs, corticosteroid injections, and arthroscopic surgery to clear necrotic tissues. In the last decade, the patient was told that there was nothing that could be done, and to just wait until they needed a prosthetic joint replacement or spinal fusion. They were not adequately informed of the long-term outcomes with joint prostheses, though, as there is a relatively short warranty on these devices (3-12 years), leaving the patient with an eventual need for a second prosthetic, and then no recourse except a wheelchair. While we may expect prosthetic technology to continue to advance, the overall expense of this approach, in both money and rehabilitative time and debility, is enormous, raising the cost of healthcare for us all. On the other hand, Complementary and Integrative Medicine is inexpensive and practical, supplying an array of therapies that help the proactive patient achieve restoration and maintenance of healthy joints. What we need to demand from standard medicine is sound early diagnosis and integration of these Complementary therapies to decrease the dependency on drugs and surgeries with risks and adverse outcomes.

In recent years, advances in MRI technology have given us the chance to obtain relatively inexpensive images of our joints in weight-bearing positions, with greater clarity and better assessment of specific problems that need to be addressed. The older MRI technology requires long periods in a claustrophobic machine and images are obscured with patient movement, while the newer technologies utilize software developed by the U.S. military in the field to deliver much better images not obscured by body movement. These MRI images are also free from the harmful accumulative radiation that comes with X-ray and CAT scans. Unfortunately, standard medicine in the United States has been very slow to adopt this new technology, in fact fighting its introduction, while racking up enormous charges for the old MRI images, and providing only an assessment to justify more surgeries, not help the individual patients find early conservative interventions that are customized to the individual case. This has to be changed, and only patient demand may achieve this goal.

Diagnostic biomarkers of osteoarthritic changes in blood and urine tests, and greater use of kinesthetics and functional movement assessments, need to be adopted as well, as well as a return to actual physical exam techniques in orthopedics and musculoskeletal medicine. Applied kinesiology, or the science of body kinetics (proper human movement and ergonomics), has long been ignored in standard medicine despite the now well-known work of Frederick Matthias Alexander (1869-1955) and Moshe Feldenkrais (1904-1984), and in fact was legally fought in standard medicine because it threatened the profitability and advance of surgical and pharmaceutical orthopedics, yet it still persists and is highly touted by patients. Once again, this specialty of kinesiology was considered "alternative" and derided, instead of being integrated into preventive care. Over time, University medical schools all but phased out the teaching of standard musculoskeletal medicine and physical assessment, until a 2003 council on orthopedics called for a reintroduction of the subject into standard medical texts and teaching (Project 100). In 2011, experts at the University of Michigan Medical School (Seetha U. Monrad, John L. Zeller, Clifford L. Craig, and Lisa A. DiPonio) published an assessment of this return of actual practical musculoskeletal medicine, stating: "Musculoskeletal disorders and diseases are a leading cause of pain, physical disability, and doctor visits throughout the world. Despite this phenomenon, a large body of evidence demonstrates that graduating students and practicing physicians receive inadequate education in musculoskeletal medicine throughout their training, starting with medical school". Patients have been given the impression that their medical doctors are well trained in musculoskeletal medicine, but this is not the case, and finding the knowledgeable Complementary Medicine physician, such as an experienced and well-trained Licensed Acupuncturist and herbalist with training in Tui na (soft tissue mobilization), an Osteopathic Doctor, a Chiropractic Doctor and/or a good Physical Therapist will complete the patient need in this area of medicine.

Markers in testing for the progression of osteoarthritic joint degeneration include C-reactive protein (CRP), interleukin 6 (IL-6), eosinophilic cationic protein (ECP), bone sialoprotein, carboxypropeptide of type II procollagen (CP2), cartilage oligomeric matrix protein (COMP), transforming growth factor beta (TGF-beta), keratan sulfate (KS-5D4), C-terminal teleopeptides of collagen type II (CTX-II), hyaluron, and others. At present, these are rarely tested, though, and the hope is that when they are introduced, they are used not only to sell pharmaceuticals, but to integrate conservative care in a timely manner. In 2014, a clinical trial of HLA (hyaluronic acid) in circulation as a marker of disease was evaluated at Era's Lucknow Medical College, in Lucknow, India, and the conclusion was that with improved data these circulating HLA, or HA, levels could help differentiate between normal asymptomatic and symptomatic cases, and distinguish various severities of osteoarthritis at earlier stages (PMID: 25653977). Hyaluronic acid is an essential component of the cells, especially in the joint tissues, creating the capacity to hold water and lubricate soft tissues with little direct blood supply, such as tendons, ligament, joint tissues, meniscus, and cartilage. HLA is now available as a serum or pill as well, and both topical and oral supplementation is found effective to aid diry and hardened tissues. Of course, opening up the circulation to these tissues is important to deliver such nutrients as HLA, glucosamine, chondroitin, L-phenylalanine, L-arginine etc. and concurrent physiotherapies would be important in this protocol.

Trust and Confidence: the need for the patient to take a realistic and objective assessment of the health care industry and influence on government when deciding the course of treatment

There is a history of enormous monetary intervention by the health care industry in both influencing government, and influencing the health care provider and public with treatment recommendations and data. The current health care debate has revealed that the health care industry accounts for over 15% of the entire economy, and could potentially account for up to 30% in the future. Of course, with this amount of profit as a motive, common business sense requires the industry to try to control how this enormous sum of money is spent. Lobbying and political contribution by the health, insurance and pharmaceutical industry accounts for over half the direct campaign donation to congress in 2008, and analysts report that a similar figure might be applied to lobbying money spent. Advertising budgets have soared, and the finance committee in the U.S. Senate, leg by Republican Charles Grassley, has uncovered massive amounts of money spent on fraudulent ghost-written scientific studies and payments to researchers and those who control university health research.

As published studies of efficacy in knee surgery emerged, there was a large decrease in the number of surgeries to repair degenerative knee joints. New devices, promising a more natural and "biologic' approach to surgery, have emerged. In 2009, the FDA admitted that its own former commissioner unduly influenced the fast-track approval of such a device, a biologic meniscus patch, because of intense pressure from three Congressman and one Senator, all whom received significant campaign donations from the company manufacturing this device. The FDA agency director overrode the advice of its science advisers to approve and endorse this surgical device. The story can be read by clicking on the site in additional information at the end of this article. Only a miniscule percentage of manual therapies, including surgical interventions, are proven to work in randomized controlled human clinical trials (RCTs), yet the manual therapy of acupuncture has been held to this high standard, and decades of clinical trial design have been used to make it difficult to show clinical benefit over so-called acupuncture placebo, which is of course impossible in any real sense, especially blinded to both the patient and administering physician, as blinded placebo sticking with needles is ridiculous. Consequently, acupuncture has been consistently shown to work, but not significantly better than this so-called placebo in many cases. Why acupuncture was held to these standards and no other manual medicine has yet to be explained, but intelligent patients can figure this out.

Both the patient and the surgeon must not be unduly swayed by data and recommendations pushed by the industry, but must make a decision based on the realistic, safest and best course of therapy by analyzing objectively what could realistically work. Hopefully, this article helps the patient and their doctor decide to look into, and try conservative therapies. The course of therapy presented in Complementary and Integrative Medicine is not simpler, and requires a proactive approach by the patient, but may produce the best long-term outcome for many patients.

Another consideration affecting the public trust and confidence in the standard treatment of the degenerated joint, and the widely pushed protocol of total prosthetic joint replacement, in the United States, is the enormous profit in this procedure. An article in the August 4, 2013 New York Times reported on the experience of a patient in 2009, who at age 60 needed a total hip replacement. Unfortunately, his insurer claimed that this was a preexisting condition and failed to cover the procedure. The out-of-pocket cost totalled nearly $170,000, which the patient was reluctant to pay for. Ultimately, he was helped and advised to go to Belgium for the total hip replacement and rehabilitation, and the total cost out-of-pocket, including the air fare and rehabilitation, which the patient said was all excellent, was just $16,500. When he looked into reduced prices for the procedure in the United States, a friend helped him obtain a reduced price for the prosthetic device itself that was about one-tenth the standard fee. Obviously, the system in the United States involved an enormous profit margin, unlike the medical procedure in most other countries. Patients are beginning to wonder whether this profit margin is fair, and whether these considerations play a significant role in the advice to get the prosthetic. Hopefully, such issues will be resolved in the future, especially with the implementation of the Healthcare Affordability Act. Patients need to feel that their medical system is primarily focused on their health, not profit margins that may go as high as ten-fold. A number of investigative reports have also addressed this issue, such as the reporting by Dr. Sanjay Gupta, who has taken the TV viewer into the hospital and clinic to show the outrageous fees and prices attached to almost all medical devices and procedures. Such a system undermines patient trust.