The 'Wear and Tear' Myth

There have be recent advances in osteoarthritis (OA) and cartilage research that have changed what we know to be true about OA. In light of new evidence, clinicians should alter their interactions and protocols with regard to patients affected by OA. It has been widely believed for many year that people suffering with arthritis will need a joint replacement eventually and that that is the only option. It is also widely believed that cartilage will not regrow or become healthy again.

Patients are often told that reducing weight is the most effective way to decrease OA associated joint pain because it decreases the impact on the joint and the stress on the cartilage. However, recent research has shown that it is not so much the weight, but the percentage of body fat (1). A higher percentage of body fat has been shown to increase cartilage loss over time, while a higher percentage of lean muscle mass is associated with maintaining cartilage over time. Obesity has been shown to predict the progression of hand OA, which is not a weight bearing joint, so how does increased weight contribute to that? Further research found that obesity contributes to inflammatory responses in the joint which affects the cartilage and its ability to repair and thus can add to the progression of OA.

A commonly held belief is that once there is no cartilage left on a joint surface it will only get worse with more activity. Activities like bike riding, which don’t involve impact or loading of the joint, are preferred because they don’t wear the cartilage down more. As it turns out, cartilage loves loading. It has been found that astronauts after having spent substantial time in space have thinner cartilage upon returning to earth which is less healthy. In contrast, marathon runners have been shown to have thicker, more healthy cartilage than “normal” individuals (2). Cartilage doesn’t get its nutrients like other tissues of the body because cartilage doesn’t have a blood supply. Cartilage gets it nutrients through compression and load, by physically pushing the nutrients into the cartilage tissue. Furthermore, compression and load stimulates chondrocytes (the cells of cartilage) to make collagen and aggregan (parts of your cartilage) and loading also creates daughter cells that help repair cartilage. Instead of the “wear and tear” that we always think of, cartilage can “wear and repair”

Lastly, another part of this myth is the psychologic message that “wear and tear” sends. It casts the shadow that joint replacement is inevitable and there are no alternatives. It assumes that he joint will continue to wear out so you’d better get used to it. These ideas are, however, not evidence based. The body, even the cartilage, is “bioplastic”. That means that the body has the ability to change and adapt, even the bones and cartilage. Exercise and activity has been shown to improve cartilage health in people with OA and to decrease the system wide inflammation associated with OA (5, 6).

This isn’t to say that all joint replacements are unnecessary and ill-advised. Certainly many people need this procedure and have favorable outcomes. There are 10-34% who do have unfavorable long term outcomes, such as moderate to severe pain, two to five years after a total knee replacement (7).

1. van der Kraan PM. Osteoarthritis year 2012 in review: biology. Osteoarthritis Cartilage. 2012 Dec;20(12):1447-50. doi: 10.1016/j.joca.2012.07.010. Epub 2012 Aug 13. PMID: 22897882.

2. Smith, David & Gardiner, Bruce & Zhang, Lihai & Grodzinsky, Alan. (2019). Articular Cartilage Dynamics. 10.1007/978-981-13-1474-2.

3. Berthelot JM, Sellam J, Maugars Y, Berenbaum F. Cartilage-gut-microbiome axis: a new paradigm for novel therapeutic opportunities in osteoarthritis. RMD Open. 2019;5(2):e001037. Published 2019 Sep 20. doi:10.1136/rmdopen-2019-001037

4. Gwilym SE, Keltner JR, Warnaby CE, Carr AJ, Chizh B, Chessell I, Tracey I. Psychophysical and functional imaging evidence supporting the presence of central sensitization in a cohort of osteoarthritis patients. Arthritis Rheum. 2009 Sep 15;61(9):1226-34. doi: 10.1002/art.24837. PMID: 19714588.

5. Naugle KM, Ohlman T, Naugle KE, Riley ZA, Keith NR. Physical activity behavior predicts endogenous pain modulation in older adults. Pain. 2017 Mar;158(3):383-390. doi: 10.1097/j.pain.0000000000000769. PMID: 28187102.

6. Wallis JA, Taylor NF. Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery--a systematic review and meta-analysis. Osteoarthritis Cartilage. 2011 Dec;19(12):1381-95. doi: 10.1016/j.joca.2011.09.001. Epub 2011 Sep 10. PMID: 21959097.

7. Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open. 2012 Feb 22;2(1):e000435. doi: 10.1136/bmjopen-2011-000435. PMID: 22357571; PMCID: PMC3289991.

5 Tips for Staying Active at Work

Don’t Let Your Job Stand in the Way of Physical Fitness

Sitting for hours every day at work can take its toll on your health and fitness. Taking stretch breaks at your desk is one way to help stay active and improve your physical fitness at the office.
We all know the importance of physical fitness, and many of us would love to spend more time at the gym, or workout and play more in the beautiful summer weather. But for so many of us, our jobs get in the way, especially when home demands and commuting time are added to the hours spent actually making a living.
For those whose jobs require long hours sitting at a desk or workbench, fitness is a particular concern, especially in light of recent studies showing the dangers of being sedentary for too many hours a day.
A research review by the University Health Network in Canada that appeared in the Annals of Internal Medicine found that sitting for long periods every day increases your risk for heart disease, cancer, diabetes and death.
Sitting with bad posture can do a number on your health, too. Slouching, slumping the shoulders, and tipping the neck forward place excess weight on the spine, causing joint pain and disc injuries that can lead to chronic back pain.
If we can’t just quit our jobs to get more active, what can we do during work hours to get moving and improve our physical fitness?

1) Don’t Sit Still

Limit sitting as much as you can. Consider getting a standing desk. If you must sit at your desk, take breaks every 20 - 30 minutes. Stand when you can stand instead of sitting, for instance when taking phone calls. Walk when you can walk instead of standing — instead of sending an email, walk to a colleague’s office to deliver a message.

2) Exercise at the Office

Beyond these changes, there are workouts you can integrate into your workday that include stretching, aerobics, resistance, and isometric exercise. Here are a few examples of exercises you can do at the office:

• Stretch at your desk. Try stretching your arms above your head, tilting your ears to your shoulders, and putting your hand on the back of your chair and twisting your torso.

• Find an open office or step outside for a quick cardio workout. Jogging in place, taking a lap around the parking lot, jumping jacks, lunges and squats are just a few ideas for quick exercises that won’t get you too sweaty and in need of a change of clothes.

• For increasing muscular strength, you can use dumbbells, resistance bands or tubes at your desk or body weight exercises. They tone muscles by using the resistance of gravity, as well as isometric, or squeezing, exercises.

3) Walk or Bike to Work

If you live close enough to your office, try walking or biking to work instead of driving or taking public transportation. In addition, the physical fitness benefits, walking to work can also help get you in the right mindset for a productive work day. If walking or biking to work isn’t feasible, force yourself to walk more by parking farther away or taking the stairs rather than the elevator.

4) Get Active During Lunch

With a busy work schedule, it’s very easy to fall into the trap of dropping into a nearby restaurant or fast food joint or ordering delivery. This usually means an unhealthy meal and a lunch break without any extra time for yourself. Bringing lunch to work will not only make for a more nutritious meal, but it will also save you the time of waiting in line and ordering food. Use that time to go for a walk or even to the gym.

5) Challenge Yourself

Last but not least, don’t forget to set goals, whether that means walking a specific number of steps a day, doing desk exercises for a set number of minutes, or even bringing your lunch a certain number of days a week. It’s easy to get lost in the status quo of your work day. Challenge yourself to be active as much as possible, and set realistic goals to hold yourself accountable.
You’ll be glad you did.

The Brain and Pain

I found a couple studies that I wanted to share with you. I often discuss the brains role in pain processing and changes that occur in the brain as a result of pain. The psychological effect pain has on us is immense and is just starting to be recognized and understood. Here are the studies that, I think, help shed some light on how we, as health care providers and manual therapists, can help our patients.

• Bunzli, S., Smith, A., Schutze, R., Lind, I., & O’Sullivan, P. (2017). Making sense of low back pain and pain related fear. Journal of Orthopaedic & Sports Physical Therapy.

This narrative (not a study per se) is especially interesting to me because I deal with it all the time. The authors conclude that the Common Sense Model (CSM) can be used to cope with “fear-avoidance behaviors”. In the “Fear Avoidance Model”, patients foresee extremely negative outcomes of their pain and so they avoid any and all activity that might exacerbate the pain, which leads to disuse atrophy, depression and chronic pain. By using the CSM patients can 1.) identify the pain, 2.) know what causes the pain, 3.) understand the consequences of the pain, 4.) learn how to control it, and 5.) know how long it will last. With this knowledge the patient is able to better cope with and treat their pain.

• Kregel, J., Coppieters, I., De Pauw, R., Malfliet, A., Danneels, L., Nijs, J. & Meeus, M. (2017) Does Conservative Treatment Change the Brain in Patients with Chronic Musculoskeletal Pain? ASystematic Review. Pain Physician, 20(3), 139-154

This study reviewed 9 different studies which used MRI to determine if functional and/or structural changes occurred in the brain of patients suffering with chronic musculoskeletal pain after a course of conservative care. They found that conservative care seemed to produce both functional and structural changes in the brain and also that these changes were associated with positive clinical outcomes (decreased pain, increased function).