Osteoarthritis (osteoarthritis) and back pain

Osteoarthrosis (syn: degenerative joint disease, osteoarthrosis, hypertrophic osteoarthritis, osteoarthritis) is directly related to pain in the neck and back. Osteoarthritis is a chronic joint pathology characterized by destruction and potential loss of articular cartilage in accordance with other joint changes including bone hypertrophy (osteophyte formation). Symptoms include gradual development of pain, aggravated or triggered activity, stiffness that decreases less than 30 minutes after the onset of activity, and rarely - swelling of the joint. The diagnosis is confirmed by radiography. Treatment includes physical measures (including rehabilitation), medications and surgery.

Osteoarthritis is the most common joint disease, the symptoms of which appear in the 4th-5th decade of life and are almost global at the age of 180 years. Only half of those who have osteoarthritis show symptoms of the disease. Until the age of 40, osteoarthritis occurs in men due to trauma. Women predominate between the ages of 40 and 70, after which the ratio of men and women is equalized.

[1], [2], [3], [4], [5]

Pathophysiology of osteoarthritis

Normal joints have little friction during movement and do not wear out under normal load, overload or injury. Hyaline cartilage does not have blood vessels, nerves and lymphatic vessels. On 95% it consists of water and extracellular matrix and only 5% of chondrocytes. Chondrocytes have the longest cell cycle (similar to CNS cells and muscle cells). The state of the cartilage and its function depend on the alternations of pressure and its decrease with load on the legs and use (pressure squeezes water from the cartilage into the joint cavity and into the capillaries and venules, while the release allows the cartilage to break, collect water and absorb the necessary nutrients).

Osteoarthritis begins with tissue damage due to mechanical trauma (for example, a break in the meniscus), mediators of inflammation from the synovial fluid into the cartilage, or disorders of the cartilage metabolism. Tissue damage stimulates the chondrospine to repair, which increases the synthesis of proteoglycans and collagen. However, the production of enzymes that cause cartilage damage, such as inflammatory cytokines, which are normally contained in small amounts, also increases. Mediators of inflammation trigger an inflammatory cycle, which subsequently stimulates chondrocytes and internal synovial cells, which ultimately leads to cartilage destruction. Chondrocytes are attacked by apoptosis. Since the cartilage is destroyed, the unprotected bone becomes compacted and sclerosed.

In osteoarthritis, all joint tissues are involved. The subchondral bone becomes denser, undergoes a heart attack, becomes osteoporotic, subchondral cysts arise. The tendency to restore bone causes subchondral sclerosis and the development of osteophytes along the edge of the joint. Synovia becomes inflamed, thickens, produces synovial fluid of lower viscosity and in greater volume. Periarticular tendons and ligaments become strained, tendonitis and contractures develop. As the joint becomes hypomobile, the surrounding muscles become weaker and perform a stabilizing function worse. Menisci crack and can be fragmented.

Osteoarthritis of the spine can, at the level of the disc, cause a pronounced compaction and proliferation of the posterior longitudinal ligament, resulting in a ventral compression of the spinal cord; hypertrophy and hyperplasia of the yellow ligament often causes posterior compression of the spinal cord. In contrast, the anterior and posterior spinal roots of the ganglion and the common spinal nerve are relatively well protected in the intervertebral foramen, where they occupy only 25% of a free and well-protected site.

Symptoms of osteoarthritis

Osteoarthritis begins gradually with one or more joints. Pain is an early symptom, sometimes described as a deep pain. Pain usually increases with body weight pressure (vertical position) and decreases at rest, but eventually becomes constant. Stiffness is felt on awakening or after motor rest, but lasts less than 30 minutes and decreases with movements. If osteoarthritis progresses, movements in the joint are limited and soreness and crepitation or creaking appear in the joint. Proliferation of cartilage, bone, ligaments, tendons, capsules, synovial membranes in combination with various degrees of joint effusion eventually leads to an increase in joint characteristic of osteoarthritis. As a result, flexion contracture may develop. Rarely can develop acute severe synovitis.

Most often, in generalized osteoarthritis, distal interphalangeal joints are affected, and proximal interphalangeal joints (the Heberden and Bushard nodules develop), the first carp-metacarpal substance, the intervertebral discs and the zygopharyngeal joints of the cervical and lumbar vertebrae, the first metacarpophalangeal joint, the thigh and the knee.

Osteoarthritis of the cervical and lumbar spine can lead to myelopathy or radiculopathy. Clinical symptoms of myelopathy are usually mild. Radiculopathy can be clinically pronounced, but it is infrequent, because the nerve roots and ganglia are well protected. Lack of vertebral arteries, spinal cord infarction and esophageal compression by osteophytes may occur, but infrequently. Symptoms of osteoarthritis can also occur from the subchondral bone, ligamentous structures, synovial membrane, periarticular bags, capsules, muscles, tendons, discs, periosteas, since they all have nociceptors. An increase in venous pressure under the subchondral bone in the bone marrow can cause pain (sometimes called "bone toad").

Osteoarthritis of the femur causes a gradual decrease in the volume of movements.

Pain can be felt in the groin, in the area of a large trochanter and reflected in the knee. With loss of cartilage of the knee joint (medial cartilage is lost in 70% of cases), the ligaments become weak, and the joint loses stability, local pain arises from ligaments and tendons.

Pain during palpation and pain in passive movements are relatively late symptoms. Muscle spasm and contractures support pain. Mechanical blockade due to the presence of free joints in the joint cavity or abnormally located meniscus can lead to blockage (locking) of the joint or instability of it. Also, sublaxation and deformation can develop.

Erosive osteoarthritis of the hand can cause synovitis and cyst formation.

Primarily, it affects the distal and proximal interphalangeal joints. The first carp-metacarpal joint is involved in 20% of cases of brush osteoarthritis, but metacarpophalangeal joints and wrist joint are usually not affected.

How is osteoarthritis classified?

Osteoarthritis is classified into primary (idiopathic) and secondary for known reasons. Primary osteoarthritis can be localized in a specific joint (for example, patellar chondromalation is a mild form of osteoarthritis that occurs in young people). If primary osteoarthritis involves several joints, it is classified as primary generalized osteoarthritis. Primary osteoarthritis is usually subdivided depending on the localization of the lesion (for example, the hand, foot, knee, hip). Secondary osteoarthritis develops as a result of conditions that alter the microenvironment of the cartilage. These are significant injuries, congenital cartilage anomalies, metabolic defects (eg hemochromatosis, Wilson's disease), post-infection arthritis, endocrinopathies, neuropathic changes, diseases that damage the normal structure and function of hyaline cartilage (eg rheumatoid arthritis, gout, chondrocalcinosis).

Diagnosis of osteoarthritis

Osteoarthritis should be suspected in patients with a gradual development of symptoms and signs, especially in adults. If there is a suspicion of osteoarthritis, a radiograph of the most symptomatic joints should be performed. Radiography usually detects marginal osteophytes, narrowing of the joint gap, increased subchondral bone density, subchondral cysts, bone remodeling and an increase in the joint fluid. Radiography of the knee in the standing position is most sensitive to detecting narrowing of the joint space.

Laboratory tests for osteoarthritis are normal, but may be necessary to exclude other diseases (eg, rheumatoid arthritis), or to diagnose diseases that cause secondary osteoarthritis. If there is an increase in the amount of synovial fluid in osteoarthritis, its investigation can help differentiate osteoarthritis from inflammatory arthritis; in osteoarthritis, the synovial fluid is pure, viscous and contains no more than 2,000 leukocytes per 1 μl. Osteoarthritis, affecting the joints of unusual localization, should cause suspicion of its secondary, studies in this situation, should be aimed at identifying the primary disease (eg, endocrine, metabolic, neoplastic, biomechanical).

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Treatment of osteoarthritis

Osteoarthritis usually progresses periodically, but occasionally, it stops or regresses for no apparent reason. The goal of the treatment is to reduce pain, maintain a compound mobility and optimize the joint and general function. Primary treatment of osteoarthritis includes physical measures of felicity), supporting devices, strength exercises, flexibility, endurance; modification of daily activity. Adjuvant treatment of osteoarthritis includes NSAIDs (eg, diclofenac, lornoxicam), tizanidine and surgery.

Rehabilitation treatment of osteoarthritis is advisable to begin before the appearance of signs of disability. Exercises (various movements, isometric, isotonic, isokinetic, postural, power) support cartilage health and increase the resistance of the tendons and muscles to motor loads. Exercises can sometimes stop or even promote the reverse development of osteoarthritis of the hip and knee. Tension exercises should be performed daily. Immobilization for a more or less long period of time can contribute to contractures and weighting of the clinical course. However, some rest time (4-6 hours per day) can be useful for maintaining a balance of activity and relaxation.

It may be useful to modify the daily activity. For example, a patient with osteoarthritis of the lumbar spine, hip, or knee should avoid deep soft seats and positions associated with postural overloads and with difficulties in getting up. Regular use of the popliteal pillow promotes the development of contractures and should be excluded. The patient should sit with a straight back without slipping on a chair, sleeping on a hard bed and using devices to comfortably adjust the driver's seat with a forward tilt, do postural exercises, wear comfortable leg-supporting shoes or athletic shoes, continue working and physical activity.

Pharmacotherapy is in addition to the physical program. Acetaminophen in a dose of more than 1 g per day can reduce pain and be safe. But more powerful analgesic treatment may be required.

NSAIDs may be considered if the patient has refractory pain or signs of inflammation (hyperemia, local hyperthermia). NSAIDs can be used concomitantly with other analgesics (eg, tizanidine, tramadol, opioids) to achieve better control of pain and symptoms.

Muscle relaxants (usually in low doses) rarely help reduce pain from spasms that support joints with osteoarthritis. In the elderly, however, they may tend to have more side effects than to benefit.

Oral corticosteroids do not play a role. However, intra-articular injection of depot corticosteroids helps to reduce pain and increase the amount of movement in the joint, in the presence of synovial effusion or inflammation. These drugs should not be used more than 4 times a year in any affected joint.

Synthetic hyaluronidase (an analog of hyaluronic acid, the normal component of the joint) can be injected into the knee joint to reduce pain for a long time (over a year). Treatment of osteoarthritis is carried out in a series of 3 to 5 weekly injections.

In osteoarthritis of the spine, knee joint or first carp-metacarpal joint, various options for reducing pain and restoring function can be used, but retaining mobility should include specific exercise programs. With erosive osteoarthritis, exercises to increase the volume of movements can be carried out in warm water, which helps to avoid contractures. Other ways to reduce pain include acupuncture, percutaneous electrostimulation of the nerve, local therapy with capsaicin. Laminectomy, osteotomy and total joint replacement should be considered only in the absence of the effect of non-surgical treatment.

Glucosamine sulfate 1500 mg per day, probably reduces pain and joint wear, chondroitin sulfate 1200 mg per day, it is also possible to reduce pain. Their effectiveness has yet to be proved. In experimental studies, the possibility of chondrocyte transplantation is assessed.