Joint Degeneration and Arthritis

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

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Joint degeneration of the Lumbar vertebrae

While the subject of hip and knee prosthetics, failures of past surgical interventions with long-term outcomes, and the failure to integrate sensible conservative care and preventive medicine with hip and knee degeneration has been a concern in the last decade, Failed Back Syndrome and the need for a better approach to an even more prevalent degenerative joint pathology in the low back has been a concern for decades. Once again, the core of this failure in standard medicine has been a gradual diminishing of medical school education in musculoskeletal medicine and a focus purely on the more lucrative orthopedic surgery and palliative pain management.

A similar profile to the failures of hip and knee prosthetics and arthroscopic surgery outcomes with these degenerative joint conditions, and unnecessary surgeries, has been shown in large studies of lumbar spine pathologies, mirroring the problems with hip and knee orthopedics. The New York Times article quotes Dr. Michael Modic, chairman of the Neurological Institute at the Cleveland Clinic, who scanned hundreds of study participants with MRI and concluded that as many as 60 percent of healthy adults with no back pain have degenerative conditions in their spines, and that between 20 and 25 percent that receive MRI studies of the lumbar have herniated or bulging discs. Dr. Modic states that one-third of these herniated or bulging discs disappear in six weeks when repeat MRI studies were performed, and about two-thirds disappear in six months. His study found no definitive correlation between worsening disc bulging, resolving disc bulging, and symptoms. He recommended that a person with low back and leg pain should be treated conservatively for at least eight weeks before considering surgery, and that MRI scans should be used as a presurgical tool, and not as a definitive diagnosis suggesting surgical correction. Unfortunately, in 2013, the guidelines for conservative care are rest, pain medications, and a few trips to a Physical Therapist if you're lucky. By creating a scenario that ignores professional soft tissue therapies, and a holistic treatment, with myofascial release, neuromuscular reeducation, soft tissue mobilization, chiropractic manipulation, and acupuncture, as well as herbal and nutrient medicine, standard medicine is not doing all they can conservatively for the patient. Many patients wonder whether this new strategy is just keeping many of them in pain for a couple of months, so that those with persistent tissue injury or degeneration will finally emerge as candidates for surgery. Reports that a high percentage of these patients were prescribed synthetic narcotic pain relievers and drugs that affect the neurological system, and are generating an enormous problem of narcotic addiction, rather than simple NSAIDS, also raises suspicion in this regard. There is absolutely no reason to avoid direct conservative therapies in the treatment of low back and neck pain, which are safe and inexpensive.

Unfortunately, we live in a culture that wants a quick fix, and patients usually look at their situation as a choice between one type of therapeutic agent or regimen versus another. This black or white, or binary, attitude will result in failure in the majority of cases. The successful approach utilizes a variety of agents and therapies integrated to accomplish all 3 of the above goals, namely pain relief, elimination of the causes and contributors to tissue degeneration, and restoration of healthy tissues. By trying to choose a simplistic treatment approach, rather than a comprehensive treatment protocol, the patient is usually prolonging their suffering and at best will only slow the degenerative process. Surgery may be necessary, and may clean up some of the problems with unhealthy tissues, but without a comprehensive treatment plan, degenerative conditions will recur and continue to cause pain down the road.

In 2015, meta-reviews of all randomized controlled human clinical trials (RCTs) of epidural corticosteroid injections for low back pain and degeneration of lumbar joint tissues, conducted by the Oregon Health and Science University, and published in the Annals of Internal Medicine, concluded that these steroid injections provided no benefits over placebo for spinal stenosis, or degenerative disc disease, and provided only mild temporary pain relief for patients with herniated discs. This affirmed a 2010 meta-review of 45 RCTs of corticosteroid injections published in the British journal The Lancet, which found only mild temporary pain relief for about 63 percent of patients, but worse long-term outcomes after 6 months compared to those patients not receiving the steroid injections. The 2015 Oregon study also noted that evidence of study design bias was evident, with selective patient choices tilting the study in favor of the steroid injections, although even this did not help. A 2015 U.S. AHRQ meta-review of corticosteroid injection studies and randomized controlled human clinical trials also noted that for spinal stenosis that these injections were not effective compared to placebo, and that with radiculopathy that there appeared to be a short-term mild improvement in function, but the small benefits were not sustained. The review noted that no evidence existed to show that effectiveness varied with technique, dose or comparator. Such evident lack of benefit did not stop medical doctors from increasing the number of these corticosteroid injections 121 percent from 1997 to 2006, and using them to deny actual physiotherapy and acupuncture, which was proven effective. In 2014, a U.S. FDA panel of experts voted to issue stern warnings for these corticosteroid injections, noting that risks outweighed benefits, especially with injections near the arteries of the spine. All of this still has not slowed the prescription of 4-6 million corticosteroid injections per year in the U.S. with most of these administered in the pain clinics at a cost of $200 to $600 per shot. A full course of acupuncture and physiotherapy would cost about $600, but is rarely prescribed.

To restore degenerative spinal discs, a number of considerations must be considered, such as relief of mechanical impingement from contracted muscles, stimulation of new growth, relief of chronic inflammatory dysfunction, and delivery of the nutrients to rehydrate and restore the disc tissues. Blood circulation does not directly reach the disc tissue, and so both blood supply around that disc and the movement of nutrients from the blood to the endplates of the discs is important. It is important to provide a holistic set of therapies to accomplish these goals.

A variety of health problems are associated with the disease of spinal degeneration, and contribute to this state. In many patients, the same vascular pathology that worries them about risk of future cardiovascular problems also contributes to the spinal degenerative condition. In the medical text, Myelopathy, Radiculopathy, and Peripheral Entrapment Syndromes by David Durrant, and Jerome True, the authors state: "Many of the patients that develop degenerative stenosis (narrowing of the spinal discs) fall into the same age group at risk for acquiring cardiac and peripheral vascular disease. Some of these individuals may also have a coagulation disorder from disease or from therapeutic intervention (blood thinners). Clinicians who identify cardiac, vertebral, and/or aortic disease should pay attention to the possibility of a history (that is) suggestive of an undiagnosed intermittent myelopathic (spinal cord) presentation." The arteries run alongside the nerve roots, spinal cord, and supply the needed nutrients to maintain the vertebral discs and lamina. When there is a problem with the health of the blood vessels, or the blood quality, this could obviously contribute to the ill health of the vertebral discs and spinal tissues.

Attention to vascular health should be part of the therapeutic protocol for degenerative lumbar conditions, especially as this is important to establishing a rehydrating of the discs via the disc endplate. An interesting area of research that links coagulation problems with fibrin buildup and hardening of both blood vessels and surrounding tissues, especially in the tight capillary beds of joints, is the subject of proteolytic enzymes. Nattokinase and serratiopeptidase are two especially potent proteolytic enzymes now studied to reduce microclotting and fibrous tissue formation. These supplements could significantly benefit the protocol in degenerative lumbar conditions, and perhaps improve vascular health and decrease atherosclerosis. Hyaluronic acid (HLA) is a molecule that the cells utilize to attract and story water, and may also help with disc hydration. Attempts to inject large dosages into joint material has been tried now for a decade or two, with limited success. This may be due to the limitations of HLA to be accepted into these cells all at once. A better route of delivery of HLA may be to introduce a small amount daily into circulation and have it enter cells that need it. Cells that lack HLA grow more HLA receptors, but these receptors may only accept a small number of HLA molecules at one time. Pure HLA serum may be taken orally, held under the tongue, and enter the bloodstream, or may also be applied to the skin locally near the joint, or near nearby arteries. Incorporating these various therapeutic protocols into a more complex individualized treatment plan is difficult without support in standard medicine, and without payment from insurance companies or government sponsored healthcare. Patients are understandably reluctant to pay out of pocket for an array of herbal and nutrient medicines, even though this could greatly improve outcomes.

Much scientific research is devoted to understanding the underlying health problems leading to secondary osteoarthritis, or degenerative joint disease caused by another underlying health problem or disease. The National Institutes of Health (NIH) estimates that 18.2% of the U.S. population will have some form of arthritis or rheumatic condition by 2020. Osteoarthritis is the most common form of arthritis, affecting at least 12.1% of all U.S. adults in 1998, and was the second most common diagnosis in the population. It is estimated that 80% of the aging population will experience secondary osteoarthritis. Research reveals that this slowly developing degenerative condition is likely related to a syndrome of anabolic dominance leading to an eventual catabolic excess. Anabolism is the metabolic construction of complex molecules in our tissue which is balanced with catabolism, the breaking down of complex molecules in the tissues to resupply energy and the building blocks of larger molecules. This process is stimulated and regulated mainly by hormones and the endocrine feedback system. In TCM terminology, this would be referred to as a balance of Yin and Yang, with anabolism being a yang process balanced by the bioavailability of catabolic yin nutrients and energy. When this balance is dysfunctional, a gradual disease process occurs leading eventually to Osteoarthritis. Preventing this underlying cause of secondary osteoarthritis in aging demands a more intelligent holistic approach in healthcare.

The anabolic hormones include insulin and insulin-like growth factors, testosterone, estradiol, and growth hormone. When we have problems with hormonal balance and insulin resistance, or relative excess of estrogen from progesterone deficiency, we may develop anabolic dominance. Excess adrenal stress that is chronic may not only stimulate high blood pressure, but excess androgens and testosterone. Testosterone may aromatize to estradiol in our tissues, or to dehydroepiandosterone (DHEA), and stimulate breast tumors, prostate hypertrophy, and other tissue abnormalities. In a similar way, these hormones play a significant role in tissue repair and maintenance, and imbalances may lead to degenerative arthritic conditions. Insulin resistance and anabolic dominance may lead to Metabolic Syndrome and inability to lose weight from the midsection, high cholesterol and poor cardiovascular maintenance. Such syndromes of imbalance lead to poor inflammatory regulation and tissue remodeling, and eventually degenerative joint disease is discovered, often too late to fully correct. The smart patient will seek help to prevent these problems be utilizing preventive medicine and CIM/TCM. The knowledgeable TCM physician can test for your hormonal profile, look at the circadian rhythms of cortisol imbalance, and gradually correct the Yin and Yang of hormonal imbalances that lead to degenerative disease. TCM may thus be a valuable Complementary Medicine in prevention of osteoarthritis as well as a comprehensive treatment strategy.

Hormonal health and the healthy production of anabolic growth factors appears to play an important role in all aspects of joint repair and regeneration. A 2012 study at the Department of Biomedical Engineering at Johns Hopkins University Medical Center, in Baltimore, Maryland (Li H, Feng F et al), found that a new type of drug, the matrix metalloproteinase (MMP) inhibitor, failed in early human clinical trials because the patients with osteoarthritis studied benefited from the drug only in the presence of significant anabolic growth factors. Matrix metalloproteinase is enzyme that is zinc-dependent and plays an important role in tissue remodeling, with certain types of MMP in excess associated with both osteoarthritis and rheumatoid arthritis. Matrix metalloproteinases are linked to excessive cartilage degeneration. Currently, drugs that inhibit MMP work by chelating zinc to decrease the enzyme activity. Since there are 28 known types of MMPs, many of which play important beneficial roles in the body, allopathic drugs to inhibit MMPs may be problematic concerning adverse effects. From such study, though, we may determine that an array of therapeutic protocols could potentially aid this aspect of joint tissue regeneration, such as hormonal balance, adrenal stimulation, chelation therapy, and improved regulation of inflammatory mediators, which are linked to excess MMP production, such as TNF-alpha and IL-1. This holistic approach holds much promise. As research proceeds, we see proof that an array of herbal chemicals act as inhibitors of matrix metalloproteinase, such as the phytoestrogen Bavachinin, a component of the Chinese herb Psoralea cordyfolia fruit, or Bu gu zhi (PMID: 26235583), or the herbal compound called Cpd 861, found to inhibit fibrin collagen type 4 excess in diabetic patients by a modulating effect on the metalloproteinase types (PMID: 24615213). The array of effects seen in study of herbal extracts usually shows a synergistic and modulatory effect that is restorative of natural homeostatic functions and processes.

Another aspect of lumbar degeneration that has been well studied, but still stymies standard medical practice, is the degeneration of the lumbar discs. This type of degeneration is seen in a significant portion of the population even in the 30-40 year old range, and is expected in 60% of the aging population. Degenerative discs may range from mildly bulging to severe disc bulging with extrusions that are relatively large, and include stenosed, or flattened discs. Disc degeneration is not only reversible, but is proven in large studies, cited above, to reverse on its own in a high percentage of patients. MRI studies of degenerative discs can look quite alarming, with extrusions and bulges pressing into the surrounding joint tissues and even against the nerve roots and spinal cord. What is not seen in MRI studies is the fluid nature of many of these bulges and extrusions. Discs that are degenerated may bulge in different directions when body position changes the pressure on the disc, and extrusion may recede with change of body position. On the other hand, spinal disc herniations will usually stay stable no matter what the body position. The exact cause or causes of spinal disc degeneration still eludes science, although many studies do explain the array of factors seen with this pathology. The challenge for the physician and patient is to understand what course of therapeutic protocols will help reverese the disc degeneration and restore healthy disc material.

The spinal disc is composed of hard annular rings surrounding a soft fluid center, with the endplates of the disc, on the top and bottom, composed of a type of cartilage, and pressed against the vertebral joint cartilage, or bone covering. Most of the nutrients that pass into the inner layers of the annular rings, and the inner gel-like pulposa, comes from the vertebral bone cartilage, and this cartilage, which is the bone covering, gets its nutrient chemicals largely from the blood vessels in the vertebral bones. When the cartilage of the vertebrae degenerates, the supply of nutrient chemicals to the disc endplates, and thus to the inner disc, is greatly diminished. Therapy that restores vertebral cartilage, decreases mechanical pressure on the vertebrae and discs, increases circulation, and decreases chronic inflammation, will help restore the vertebral discs. This process is similar to the restoration of the degenerative knee joint.

Much study has identified the complex chronic pro-inflammatory imbalance that contributes to the degeneration of the vertebral discs, but unfortunately, this pathophysiology is complex, and has so far been difficult to treat with a simple allopathic anti-inflammatory drug. A combination of various immune cytokines and growth factors, controlled by a complex tissue and cellular environment, is involved. In 2014, a randomized controlled study of electroacupuncture stimulation, to see if this treatment protocol could play a significant role in modulating this complex chronic inflammation and disc degeneration could play a role in a broader therapy, was conducted in China. The researchers found that a short course of 8 frequent treatments at just one point on the spine, DU14. The laboratory animals were analyzed after this treatment, compared to randomly selected animals that received surgical intervention or no treatment. The tissue analysis showed that the electroacupuncture treatment inhibited the disc annulus fibrosis (outer ring) programmed cell death (apoptosis), accomplished by inhibition of the pro-inflammatory cytokines TNF-alpha and its receptors (TNFR-1) by decreasing the receptor enzyme caspase-8 pathway. The electroacupuncture also increased the expression of healthy integrin-beta1 and Akt (adhesion proteins and kinase enzymes that regulate metabolism, cell proliferation and apoptosis). To see this remarkable study, click here: http://www.ncbi.nlm.nih.gov/pubmed/25618973 . Of course, actual clinical treatment includes much more than 8 acupuncture treatments at just one point, but this shows that remarkable proven benefits from just this part of the therapy. This in not an 'alternative' approach, but another treatment tool to integrate into care. Obviously, such acupuncture treatment could prevent disc degeneration as well. Another study in China, in 2014, using a randomized controlled study in the laboratory, also demonstrated that electroacupuncture stimulation at the Jiaji points along the lumber vertebral processes can effectively suppress disc degeneration by inducing up-regulation of MMP-13 (matrix metalloproteinase enzymes involved in tissue regeneration regulation) and down-regulating TIMP-1 in vertebral discs. To see this study, click here: http://www.ncbi.nlm.nih.gov/pubmed/25069194 . TIMP-1 is a tissue inhibitor of matrix metalloproteinasees. Such study shows that acupuncture stimulation is modulatory and supports healthy homeostatic mechanisms. These same mechanisms are studied and expensive drugs to perform these same tasks are developed, but come with pages of adverse health effects, called 'side effects', that the acupuncture stimulation does not produce.

In the majority of cases of lumbar and cervical spine-related pain, 8 weeks of conservative care should be tried before considering surgery. Obtaining the best course of conservative care is essential. When the injury of degeneration truly demands spinal surgery, though, this needs to be done with the least chance of tissue damage, and then rehabilitated in the best manner possible. By ignoring this post-surgical rehabilitation, the patient is looking at the all too familiar pattern called "Failed Back Syndrome". Utilizing Complementary Medicine in this regard is also sensible. For the patient needing surgery, new techniques in Minimally Invasive Spinal Surgery, or MISS, present opportunities for better outcomes. While many companies are suddenly promoting laser spinal surgery heavily, with enormous profits for a few companies, the great majority of neurosurgeons have dismissed laser tools for decades, citing the advantages of delicate scalpels over the sometimes uncertain consequences of the variable laser. Scalpels may not involve the smallest entry scar, but do allow the surgeon the most control, able to see the tissues better with a microscope or endoscope directly, utilize tools that curve around structures, allow for more precise depth of cutting, and do not involve heating tissues to cut them, which may damage the surrounding nerves. A serious and honest talk with a couple of experienced spinal surgeons will reveal the truth about laser surgery. Relying purely on the advertising angles will not.