In this excerpt from a recent issue of the Johns Hopkins Arthritis Bulletin, Associate Professor Lynne C. Jones, Ph.D. talks about the importance of cartilage in the development of osteoarthritis.
In my experience here at Johns Hopkins, most patients have little awareness of cartilage until something goes wrong with it. And even then, they often have a limited understanding of what cartilage is and does, what can be done to protect joints from further damage, and what treatment options are available to help reduce pain and restore mobility. In many ways, that’s perfectly understandable. </>
Compared with most other body tissues and organs, cartilage is "out of sight and out of mind." Like a shock absorber in a car, it doesn't announce its presence until it becomes damaged and affects your ability to navigate the highways of everyday life.
Cartilage is an essential component of healthy joints. You may have experienced the pain and loss of mobility that occur when cartilage is damaged, either by a traumatic injury or by diseases such as osteoarthritis and rheumatoid arthritis.
Here are my answers to some the most common cartilage-related questions asked by patients.
Q. What is cartilage?
Dr. Jones: Cartilage is a translucent, connective soft tissue that's found in many areas of the body, including the joints, rib cage, spine, ear, nose, voice box, and bronchial tubes. This semitransparent substance is called hyaline cartilage, a name that derives from the Greek word hyalos, which means glass.
In normal joints, hyaline cartilage is a firm, rubbery material that covers and protects the ends of bones. Its primary components are water and two types of proteins—type II collagen and proteoglycans -- that together form a gel-like matrix that allows it to change shape when compressed. Cartilage also contains specialized cells called chondrocytes, which produce collagen, proteoglycans, and enzymes that help maintain healthy cartilage.
Q. Is aging inevitably associated with cartilage degeneration?
Dr. Jones: There are age-related cartilage changes. And yes, it seems that osteoarthritis is an age-related disease. That said, it still doesn’t mean that the changes due to aging are necessarily the changes that automatically lead to osteoarthritis. After age 60, a majority of men and women show some evidence of joint-space narrowing on X-rays (a sign of cartilage loss), but most of them have no osteoarthritis symptoms. Their cartilage is still fully functional.
Is there any credible evidence that cherry juice or a drink mixture of honey, vinegar, and water relieves symptoms of osteoarthritis? Johns Hopkins specialists answer readers’ questions in this excerpt from a recent issue of the Arthritis Bulletin.
- Arthritis question 1
Q. My cousin, who has osteoarthritis in her hip, swears that drinking a daily mixture of equal parts honey, vinegar, and water has alleviated her arthritis pain. Though I have never been one for folk remedies, I’m assuming that there is some logic operating behind this one. As for the honey and water, I suspect that they are simply a delivery system that makes vinegar palatable. Is my cousin’s honey-vinegar-water concoction just a homemade placebo? Kansas City, MO
A. Human physiology is quite complex, so it’s difficult to ascertain and analyze which properties of a given food or drug actually have a desired effect in a given target tissue. The body cannot be viewed as a container in which everything we ingest is evenly distributed to all tissues. The trip from mouth to joint involves many modifications, and few substances ever get to the joint in the same form as they entered the mouth. Moreover, pain modification in osteoarthritis is just as likely to happen at the level of pain perception (in other words, in the brain) as in the joint itself. To my knowledge, there have never been any studies evaluating the use of this honey, vinegar, and water mixture for the treatment of osteoarthritis or rheumatoid arthritis.
- Arthritis question 2
Q. My wife reads the popular health literature religiously and is now on a cherry juice kick. We start every day not with orange juice (our breakfast drink for the past thirty years) but with a cherry juice concentrate that she buys at the local health food store.
We both have arthritis. I have arthritis my left knee and both hips. Harriet has arthritis in her neck and upper back. She insists that we drink the juice to fight off the arthritis pain. I happen to like the taste of it, but I have my doubts about its pain-relieving effects. Have you heard of any studies of cherry juice, or do you know of people who have benefited from it? Princeton, NJ
A. The pigments in the skins of cherries, blackberries, grapes, and other dark-colored fruits contain compounds known as anthocyanins. Some studies have demonstrated in vitro (test-tube) activity of these compounds as antioxidants and weak anti-inflammatories, with some studies suggesting that they may inhibit prostaglandins in animals. To our knowledge, no controlled clinical trials of these compounds in humans with arthritis have been published in the peer-reviewed medical literature. Still, I’d encourage you to include a variety of dark-colored fruits (and vegetables) in your diet simply because they offer other, proven health benefits in the form of vitamins, minerals, and fiber.
Chinese researchers believe that acupuncture can reduce joint tenderness in people with rheumatoid arthritis. Should you try it? Johns Hopkins offers bottom-line advice.
Rheumatoid arthritis, the most common form of inflammatory arthritis, dramatically limits movement and function as well as causing damage to cartilage and bone. For the estimated 1.3 million Americans with rheumatoid arthritis, the inflammation causes pain, stiffness, swelling, and damage to a variety of joints.
Even though researchers have questioned the utility of acupuncture over the years, acupuncture is a potentially viable adjunctive therapy for arthritis pain, and it is rapidly gaining favor in the western world.
When an acupuncturist inserts thin needles into a person’s skin at any of 2,000 carefully defined pressure points, Qi (pronounced chi, it means "life force”) is restored throughout the various meridians, or channels, within the human body. If Qi is at optimum flow, the body is harmonized with the universal forces of yin and yang (emblematic of balance), and the patient is pain-free and physically healthy.
What’s the evidence? At a meeting of the Association of Rheumatology Health Professionals, Lai-Shan Tam, M.D., Associate Professor, The Chinese University of Hong Kong, presented his randomized, placebo-controlled acupuncture study (the best kind of medical trial).
Dr. Tam and his colleagues randomly assigned 7 male and 29 female patients (58 years old, on average) with rheumatoid arthritis that was unresponsive to other therapies to one of three acupuncture/placebo groups. The first group of 12 subjects received electro-acupuncture, in which pulsating electrical currents are sent through the acupuncture needles to stimulate target areas. The second group of test subjects was given traditional acupuncture, while the remaining 12 patients received placebo needles.
At the end of the acupuncture sessions, the researchers noted that:
- Those receiving electro-acupuncture had experienced a significant reduction in the number of tender joints and a measurable decrease in pain, stiffness, and swelling.
- The traditional acupuncture group experienced benefits but at a diminished rate.
- Those in the placebo group saw no change.
"The patient’s comfort is as important as relieving the disease itself,” says Dr. Tam, "so, while the results were not as positive as had been hoped, this does show that acupuncture, either electro- or traditional, when used in conjunction with disease modifying agents, may still provide beneficial pain relief for those with otherwise intractable rheumatoid arthritis.”
The bottom line: If you have rheumatoid arthritis, do not stop taking medications that actually treat the underlying causes of rheumatoid arthritis in favor of acupuncture. If you have rheumatoid arthritis (or osteoarthritis) and are thinking about acupuncture for pain relief, here are some important tips:
- Make sure that your physician and acupuncturist is involved in planning the duration and specifics of your treatment.
- Use acupuncture as an adjunctive therapy in addition to standard arthritis treatments -- not in lieu of them.
- Be certain that your acupuncturist uses disposable needles as required by law.
To find a licensed practitioner in your area, visit the website of the American Association of Acupuncture and Oriental Medicine at http://www.aaaomonline.org.
Dr. Kevin R. Fontaine, Assistant Professor of Medicine in the Division of Rheumatology at Johns Hopkins University talks about non-pharmacological treatments for fibromyalgia.
Although fibromyalgia syndrome is not curable and has no blood tests to detect it, there are a variety of non-pharmacological treatments that can help relieve symptoms. Following are several questions I am frequently asked about complementary fibromyalgia treatments, and my answers.
Q. How important is it for a person with fibromyalgia to take a majority stake in their improvement?
A. People with fibromyalgia have to understand that, in most cases, they're not going to be able to take a pill that’s going to give them tremendous relief. Rather, it’s up to them to stretch, to exercise, to walk, to try to reduce stress in their lives, to seek counsel for anything that’s going to relieve stress or family issues. A willingness to be proactive and to learn ways to take better control over their symptoms is a critical factor in managing fibromyalgia.
Q. How is fibromyalgia treated?
A. Despite the lack of a definitive cause, fibromyalgia symptoms can be significantly improved with a multifaceted approach. There are two major goals:
- Lessen pain and fatigue
- Improve sleep
Much of the success of fibromyalgia treatment lies with the patient, and many people report feeling better simply because a diagnosis has been made. It is reassuring for people to know that the disorder is not deforming or life threatening, and that they will be able to take steps to help better control their symptoms.
Q. What role does physical activity play in fibromyalgia treatment?
A. Getting up and moving is the key to improving fibromyalgia. A lack of physical activity worsens fibromyalgia symptoms because unconditioned muscles are more sensitive to pain. Although activity and exercise may be the last thing people with fibromyalgia want to do when they feel achy and tired, studies have shown that fibromyalgia symptoms improve after six to eight weeks of moderate aerobic exercise. It’s thought that aerobic activities such as walking, swimming, and bicycling raise the pain threshold and increase pain tolerance, along with physical stamina.
At Johns Hopkins, we encourage our fibromyalgia patients to explore different ways to become active and find what works best for them. It is important not to overdo activity, however. Start slowly, with perhaps 5 to 10 minutes of brisk walking a day, for example. As you begin to feel better, gradually increase the time of the exercise session until you are up to 30 to 40 minutes of aerobic activity at least three times a week. People whose pain is exacerbated by the jarring movements of weight-bearing exercise (such as walking or jogging) may try swimming or riding a stationary bicycle instead.
Many researchers now believe that the "sunshine vitamin" may one day play a key role in preventing the development and progression of arthritis. Researchers, including scientists at Johns Hopkins under the direction of Uzma Haque, M.D., Assistant Professor of Medicine in the Department of Medicine, Division of Rheumatology at Johns Hopkins, have been looking at the effect of vitamin D on rheumatoid arthritis and osteoarthritis and the data are quite suggestive. Vitamin D is proving to be a most promising area for arthritis research.
Vitamin D is a fat-soluble vitamin that's essential for human health. Vitamin D levels are assessed with a simple blood test that measures levels of 25-hydroxy vitamin D, or 25(OH)D, the metabolite that reflects vitamin D stores; results are expressed in terms of nanograms per milliliter (ng/mL).
Although there is continuing debate over what constitutes an optimal level, most experts now agree that the level should be 30 ng/mL or higher. Yet most Americans -- up to 60% by some estimates -- have suboptimal blood levels of vitamin D. In part, that's because we spend less time outdoors and absorb less vitamin D from sunlight. However, it also may be because we don't get enough vitamin D from our diet. Only a few foods contain significant amounts of vitamin D.
It has long been recognized that vitamin D is essential to bone health because it promotes calcium absorption. Vitamin D regulates as many as 1,000 different genes, including those that weed out precancerous cells and slow the runaway reproduction of cancer cells. Vitamin D also helps maintain a healthy immune system and activates cells that fight infection, including the bacterium that causes tuberculosis.
During the past decade, there's been an explosion of research suggesting that vitamin D plays a significant role in joint health and that low levels may be a risk factor for rheumatologic conditions such as rheumatoid arthritis and osteoarthritis.
Unlike other vitamins, vitamin D is not just a simple nutrient. It's also an active steroid hormone that binds to receptors in a host of vulnerable tissues -- including the joints affected by arthritis -- and works to keep these tissues healthy. Arthritis patients may be even more likely than the general population to have low levels of vitamin D. According to a study presented at the 2008 European Union League Against Rheumatism (EULAR) meeting in Paris, nearly 75% of patients who presented at a rheumatology clinic -- including those who were subsequently diagnosed with inflammatory joint diseases, soft-tissue rheumatism, uncomplicated musculoskeletal backache, or osteoporosis -- were deficient in vitamin D.
If your D level is lower than 30 ng/mL, the parathyroid gland becomes overactive and sets in motion a process that depletes calcium from bones in order to maintain normal blood levels of calcium. This currently accepted optimal level of vitamin D is based solely on vitamin D's calcium function. However, it ignores other important functions. As we learn more about vitamin D, Dr. Haque anticipates that the optimal level will be pushed considerably higher, with an ideal range between 50 and 70 ng/mL.