by Dr. Iain Corness
More on “Arthur”
Last week I wrote about arthritis, and in particular
osteo-arthritis, the wear and tear type of joint degeneration. For these
sufferers, surgery is the treatment of last resort. Since around 90 percent
of patients, show lessening of pain, improvement in functional status and
overall quality of life, I think we should be looking at operation sooner,
rather than later. In particular, with minimally invasive surgery which can
now be done at the better centers, that means the recovery time after a knee
replacement, for example, is very much reduced.
Arthritis is a widespread problem. Another letter went, and I quote, “Dear
Dr Corness, I am especially interested in your thoughts about knee joints.
In 1994 (I was 49 years old) I developed pains in my knee joints, which were
so severe that even walking up a slight incline was agony. I also developed
severe pains in my wrists, so much so that picking up a bunch of keys was
agony. My hairdresser told me he had similar problems but now used a tablet
containing 1500 mg Glucosamine and 1200 mg of Chondroitin (marine
Chondroitin) and had no problems. I started taking this and within two weeks
my pains had completely vanished and they only returned once, when I ran out
of tablets. I took this supplement until 2001, when I came to Thailand and
hoped that the warmer climate here would do the job of the tablets. I have
since had no problems. Should you be looking at this supplement as an
alternative to injections or surgery?”
This brings up an immediate couple of points that should be examined. The
first is, from the description, I am not convinced that he was suffering
from ‘osteo’ arthritis, but rather ‘Rheumatoid’ arthritis. This is another
form of arthritis and is noted for spontaneously settling and then flaring
up again, and many factors seem to be involved with this. In simple terms,
look upon rheumatoid arthritis as a form of inflammation in the joint,
whilst osteo-arthritis is more of a ‘degeneration’ in the joint.
The other point is that whilst it is undoubtedly possible for all kinds of
compounds to affect arthritis (rheumatoid in particular), it is incorrect to
then generalize and suggest that this form of medication is good for
We are now in the era of EBM, otherwise known as Evidence Based Medicine. To
prove the efficacy (or otherwise) of prescription drugs or various treatment
modalities, it takes more than one sufferer and a hairdresser. Yours is what
is called ‘anecdotal’ evidence. True ‘hard’ evidence needs enormous studies,
following rigid protocols where the results produced by active substances
are compared to those from non-active (placebo) substances.
For example, a research group in Norway began with a literature search from
1966 to April 2004. They crosschecked reference lists in systematic reviews,
searched conference abstracts, and talked to clinical experts. The studies
included scientific papers in English, German, and Scandinavian.
The trials only included patients with osteo-arthritis of the knee that had
been verified by clinical examination according to the American College of
Rheumatology criteria and by X-ray. All trials had to be randomised, double
blinded (this is where neither the patient or the treating doctor were to
know which were the ‘active’ tablets), placebo controlled, and of parallel
design. Pain intensity had to be scored on a universal pain scale. The
number of patients exceeded 10,000, and only after that could they come up
with some ‘hard’ data.
The results of studies like the one above, and others from around the world,
would indicate that the first line of treatment for osteo-arthritis is still
the simple painkiller paracetamol. A “safe” NSAID (if there is one) can be
added for acute flare-ups.
However, I am not saying that non-medical treatment does not work for
certain individuals, but I myself do have to follow current medical
protocols in my writings. In the meantime, if swallowing chondroitin or
glucosamine, green lipped mussels or muttering mantras work for you, then
keep doing it! It has also been shown quite categorically, that if the
sufferer ‘believes’ in some type of treatment, there are definite advantages
from this and good clinical responses that can occur.
A date with Arthur
I received a letter asking about arthritis (Arthur to his
friends), which I have published below as it has some very salient points:
He wrote, “One of the main problems that affect the elderly as you know, is
arthritis. Sometimes that includes bone alteration on feet and hands that
In the years I noticed a dramatic improvement of new therapies and drugs on
many diseases, rarely I read on updated treatment on the above infirmity.
It should be interesting for your readers affected by arthritis to read some
comments on the last advanced cure, if any, in your column.”
Thank you for your letter, so let’s get straight into the nitty-gritty. As
you get older, you will get to meet ‘Arthur’. Unfortunately, there are many
types of arthritis, and descriptions of these go back into antiquity.
Perhaps the oldest known type of arthritis, called ‘gout’ or gouty
arthritis, has been described since Hippocrates in the 5th century B.C. Then
it was known as the “Disease of Kings” due to its association with rich
foods and alcohol consumption, something in which the commoners were not
able to indulge.
However, today one of the most common forms of arthritis is
‘osteo-arthritis’, and rather than being of a biochemical nature,
osteo-arthritis is much more of a mechanical wear and tear situation. And
arthritis is very common. In America, the estimated incidence is that 37
million adults are suffering from it.
Unfortunately, we all wear out. Joints in particular are mechanical devices,
with one bone sliding on another with a slippery bit (called cartilage) in
between as the bearing surface, cum-shock absorber.
Most joints, especially knee joints, are designed to last our three score
years and ten, and that’s about it. Medical science has helped us so we now
live longer, but we have not worked out how to make the joints last longer!
We do know why they wear out, especially knee joints. Since they are
mechanical, increase the loading on the joint and it wears out quicker.
Imagine that your knee has been designed to hold up 80 kg for 70 years, and
now increase that loading to 120 kg. That same knee now has to support 50
percent more than it was ‘designed’ for, so you can expect it to wear out 50
percent sooner. Simple and painful.
So they hobble down to the doctor and ask for something for the pain. The
doctor flips mentally through the latest medical drugs for this condition,
and most probably will hand over some Non Steroidal Anti Inflammatory drugs
(NSAID’s) and tell the patient to lose weight.
Now I am not saying that this is totally wrong - but - when the NSAID’s
first came out (hands up all those who remember Indocid) they were heralded
as being the answer to these problems. Some were even supposed to ‘grow’ new
cartilage. The answer to a maiden’s prayer, or the osteo-arthritic’s prayers
Unfortunately, we very quickly found that Indocid and its ilk drilled holes
in the lining of the stomach and were more than slightly dangerous. So we
developed newer and better and more stomach-sparing NSAID’s. Unfortunately,
these too produced problems.
Nothing daunted, we came up with even newer and more wonderful NSAID’s,
which came with even newer and more wonderful array of side effects. So
wonderful that one called Vioxx had to be withdrawn by the manufacturers.
Really, we have been chasing our tails here, and not winning.
So what can the poor patient do? The doctor is not offering help, only
tablets with abominable (read “abdominal”) side effects. Most patients have
already tried paracetamol, hot water bottles, someone else’s great new
tablets, NZ green lipped mussels, a cabbage leaf (which does work for
mastitis, or so the ladies tell me), various herbal or homoeopathic
medications, yoga, meditation, copper bracelets, muttering mantras and
goodness knows what else.
So what can the “osteo” sufferer do? Exercise does help to improve the
mobility in the knee joint, and by strengthening the muscles and ligaments
around the knee, give it more stability. But it will not re-grow cartilage.
There is another avenue in the treatment, and that is direct injections into
the affected joints. This produces spectacular results, which unfortunately
are very short lived. Back to square one.
This is such an interesting subject, I will continue with Part 2 next week.