yogabook / pathology / arthrosis / osteoarthritis

Arthrosis / osteoarthritis / degenerative arthropathy / arthropathia deformans / arthrosis deformans

Definition of

Terminology remark: The term osteoarthritis is misleading, as in the first two stages the bones themselves are not affected but only their cartilage coverings and, secondly, the ending -itis indicates an inflammation, which is not generally part of the picture of osteoarthritis but is only present in phases of activated arthrosis (osteoarthritis). Furthermore, the ending -osis describes the irreversible, chronically degenerative nature of the disease far better, while -itis usually refers to a reversable inflammation. For these reasons, the less common but much more correct term arthrosis is preferred.

Degenerative joint disease resulting from chronic wear and tear of cartilaginous joint coverings or intervertebral discs. 4 stages:

1. Roughness and thinning of the cartilage layer, tangential fissures
2. Replacement of hyaline cartilage by granulation tissue and inferior fibrocartilage; pseudocysts from necrotic cartilage and bone tissue (debris cyst)
3. Ulcerations; the connective tissue and chondrocytes proliferate
4. Flattening of the bone plate of a joint, formation of osteophytes (marginal bulges)

The Kellgren-Lawrence score is divided into grades 1 to 4 as follows:

1. 1-2 points: Minor subchondral sclerosis (compaction of the bone tissue under the cartilage layer, no joint space narrowing or osteophytes)
2. 3-4 points: Minor joint space narrowing and incipient osteophyte formation, indicated irregularities of the joint surface
3. 5-9 points: Extensive osteophyte formation, marked irregularities of the articular surface
4. 10 points: Pronounced narrowing of the joint space up to complete destruction, deformation/necrosis (tissue death) of the joint partners

A further classification distinguishes between

1. Pre-arthrosis: the joint is still healthy, damaging influencing factors are already present, but no damage is yet detectable
2. Arthritic changes that remain asymptomatic
3. Symptomatic stage. The transition from the last stage to this stage cannot be fully captured in parameters

An imbalance between load and resilience (including regeneration) causes cartilage to break down first. From the end of the growth phase, articular cartilage is no longer supplied with arterial blood and is then only passively supplied and removed by diffusion during pressure changes. Sufficient movement is essential for this. The ability to divide cells is also significantly restricted in adults. The cartilage already undergoes physiological changes over the course of a person’s life; it loses its ability to bind water and becomes more brittle, as a result of which it loses some of its cushioning properties. Women are slightly more frequently affected by osteoarthritis than men. Knee joints, hip joints and finger joints are the most common locations. 20% of the population show signs of coxarthrosis or gonarthrosis in the 6th decade of life. As a rule, the onset of osteoarthritis is gradual and the beginning is asymptomatic. Osteoarthritis is regarded as irreversible joint damage; only the progression can be delayed and the symptoms alleviated. A highly sensitive CRP analysis (only slightly, but statistically significant) shows that low-grade inflammation plays a greater role than previously assumed. Synovitis is also involved in 50% of cases. Affected joints are mainly:

1. Spinal column: facet joints and also the space between the vertebral bodies via spondylophyte formation
2. Shoulder (osteoarthritis of the shoulder)
3. Hip (coxarthrosis)
4. Finger arthrosis (Heberden arthrosis)
5. Osteoarthritis of the knee (gonarthrosis). Due to the great clinical relevance with its own entry cartilage damage knee joint
6. Arthrosis in the ankle joint (especially OSG)
7. Metatarsophalangeal joint of the big toe(hallux rigidus)
8. SIjoint arthrosis
9. Osteoarthritis of the jaw
10. Cubital arthrosis
11. Radiocarpal arthrosis
12. Rhizarthrosis (thumb saddle joint)
13. Bouchard arthrosis (middle finger joint)
14. Heberden arthrosis (finger end joint)
15. Hallux rigidus (metatarsophalangeal joint of the big toe)

As long as there is no indication for surgery, exercise therapy is one of the most important pillars. In the case of coxarthrosis, an adequate exercise program reduces the need for an endoprosthesis by 44%.

ICD M15 – M19. M47: Spondylosis

Cause

– Behavior

1. Overuse: Overloading
2. Underuse: Quantitative lack of exercise
3. Narrowuse: Qualitative lack of exercise
4. Incorrect loads
5. physically demanding occupations such as tiler, footballer, construction worker
6. Immobilization
7. Inadequate footwear (causes osteoarthritis of the metatarsophalangeal joint)
8. Alcohol consumption of 20 glasses of beer or more per week favors coxarthrosis and gonarthrosis. On the other hand, the risk is reduced with 4 – 6 glasses of wine per week
9. Smoking
10. Competitive sport

– Musculoskeletal system

1. Arthritides
2. Chronic, inflammatory and non-inflammatory arthropathies
3. Post-traumatic (after joint trauma or injury, dislocation)
4. Varus exhibitionsor valgus exhibitions
5. Axial misalignments
6. Operations
7. Subluxations
8. Growth disorders in the epiphyseal region
9. Coxa valga luxans: flat acetabulum
10. Meniscus removal after meniscus damage increases the risk by a factor of 20

– Disposition factors/diseases relating to health and medication

1. Biological inferiority of the cartilage tissue (only this form is considered „primary“)
2. degenerative (age)
3. Osteoporosis
4. Osteonecrosis
5. Congenital or acquired malfunctions and malpositions of the musculoskeletal system, including dislocations, nutritional and circulatory disorders, toxins and inflammation
6. after recidiv. arthritides
7. Endocrine changes: Hyper-PTH, Cushing’s disease, diabetes mellitus
8. Metabolic disorders: Gout, diabetes mellitus, hemochromatosis
9. Ochronosis Deposition of homogentisic acid in tissues
10. Acromegaly
11. Hyper-PTH
12. Chondrocalcinosis (synonym: „pseudogout“)
13. Rickets
14. female sex, the reason is assumed to be the menopause
15. Vitamin D receptor (VDR) gene polymorphisms
16. intra-arterial bleeding
17. Deposition of homogentisic acid in the joint
18. Traumatic cartilage damage
19. neuropathic: diabetes mellitus, enervation disorders
20. Medication: antibiotics from the gyrase inhibitor class lead to the breakdown of the hyaline cartilage by complexing Mg; Macrumar (impairs bone density)
21. Disturbed joint stability of the same joint or disturbances of static and kinetic neighboring joints
22. Chronic arthropathies
23. RA
24. Inflammatory joint diseases

Diagnosis

1. X-ray: joint space narrowing (eccentric, DD: arthritis: concentric)
2. subchondral sclerosis (compaction of the bone tissue under the cartilage)
3. Cerebral cysts(synovia-filledcysts in bone niches)

Symptoms

The symptoms in brief without exact classification to the stages:

1. Initially joint stiffness, pain on start-up and exertion, tension pain
2. later: pain at rest, instability of the joint, joint stiffness, recurrent arthritic attacks, creaking and rubbing in the joint, contractures
3. Early triad: start-up, fatigue and exertion pain
4. Late triad: constant pain, night pain and muscle pain
5. Pain and objective findings do not correlate
6. Joint effusion (activated osteoarthritis)
7. Deformation (distortion)
8. muscular changes: Imbalances, tension, contractures
9. Increased sensitivity to cold and wet conditions
10. Synovitis due to cell residues and metabolic products
11. possibly muscle atrophy due to avoidance of exercise
12. possibly increased tone of some muscles
13. possibly crepitations: Rubbing, crunching, creaking
14. Changed joint play, emergence of translation possibilities
15. In the late stage: local hypomobile joints lead to hypermobile neighboring joints

Stage 1 is usually asymptomatic, but the MRI already shows pathological changes

Stage 2:

1. Joint instability due to narrowed joint space
2. Pain on exertion, especially on fatigue due to instability and reflex hypertonicity
3. Painful due to muscle tension
4. Changed movement behavior due to pain avoidance
5. Radiographically, a narrowing of the joint space can be seen

Stage 3:

1. Pain on movement due to capsule irritation, changes in the insertions
2. Painful muscle contractures due to pain avoidance behavior
3. Perceived lack of strength due to painful movement restrictions
4. Deterioration in the cold due to cross-linking of the synovium
5. Start-up pain: pain mainly at the beginning of an activity due to cross-linking of the synovium at rest
6. X-rays show cracks in the cartilage and a thickening of the bone underneath (subchondral sclerosis)

Stage 4:

1. Bone changes are visible radiographically: flattening and calculus cysts (bone cavities) as well as osteophytes or spondylophytes, the formation of which is also promoted by increased osteoblast activity
2. Arthritis: inflammatory reactions due to abrasion of the bone; signs of inflammation
3. Joint effusion
4. Morning stiffness
5. Pain at rest, permanent pain and night pain
6. Hypertension in the bone veins due to bone marrow fibrosis

The movement restrictions in the late stage can usually be estimated as follows:

1. Gonarthrosis: flexion more than extension
2. Coxarthrosis: endorotation more than extension more than abduction more than flexion
3. Omarthrosis: exorotation more than lateral abduction, frontal abduction_shoulder more than endorotation
4. Lumbar spondylarthrosis: extension and lateral flexion more than flexion
5. Spondylarthrosis of the thoracic spine: predominantly rotation
6. Cervical spondylarthrosis: extension more than rotation and lateral flexion more than flexion

Complications

1. Soft tissue and nerve root compression due to osteophytes in stage 4
2. Activated osteoarthritis with more or less pronounced arthritis symptoms
3. Movement restrictions
4. Joint misalignments
5. contralateral arthrosis of the lower extremity due to evasive behavior: Coxarthrosis predisposes to contralateral coxarthrosis and contralateral gonarthrosis
6. Contractures, static changes, muscular imbalances and their consequential damage
7. Insomnia
8. Chronic pain

Therapy

1. Avoid stress factors: Obesity (increases joint stress), cold and wetness (make it more difficult to lubricate the joint due to cross-linking in the synovium)
2. Therapy of any known causative or predisposing factors
3. Physiotherapy
4. Heat therapy
5. Nicotine cessation
6. Avoidance of overloading, competitive sports, prolonged physical demands
7. Avoid sports that put a strain on the joints, especially those with quick changes of direction, contact with opponents, high pressure loads, racket sports, indoor sports
8. Avoidance of lack of exercise (cartilage nutrition)
9. Avoid inadequate footwear (negative impact on posture and movement)
10. if necessary: weight reduction
11. if necessary: orthoses, walking stick, special footwear
12. Limitation of alcohol consumption: men under 25 mg/d, women under 12 g / d
13. For activated osteoarthritis: NSAIDs, application of cold, intra-articular glucocorticoid injections, immobilization
14. Intra-articular cortisone injections only for synovitis
15. Injection of local anesthetics if necessary
16. Exercise therapy: endurance training, strength training, flexibility training, especially for the muscles that move the joint in question. In the area of endurance sports, sports that are easy on the joints such as cycling, swimming, aqua gymnastics and Nordic walking
17. Postures that are easy on the joints when standing and sitting: upright posture puts the least strain on the joints
18. oral or intra-articular chondroprotectants (effect partly controversial): Chondroitin, glucosamine, MSM (methylsulfonylmethane), SAMe (adenosylmethionine), collagen
19. Orthopaedic aids, if necessary: orthoses, insoles, walking aids
20. Surgical options: Endoprosthesis, Pridie drilling, removal of the destroyed articular cartilage, synovectomy, osteotomy for repositioning
21. If necessary, muscle relaxants against muscle pain (tension, hypertonus)
22. Training under venous blood flow restriction (BFR) to 40-80% of arterial pressure

Asana practice and movement therapy

The complete healing of osteoarthritis is currently not considered possible. This is also underpinned by the renewal time (also known as turn over) of the affected tissue: cartilage. This has a theoretical turn over of 200 to 400 years, whereby this applies to optimal conditions. In practice, however, the conditions of our civilized way of life are anything but optimal, as the frequency of osteoarthritis diagnoses shows. At present, we can only guess what future healing methods will look like. Implanted reproductions from stem cells may be able to solve the problem of osteoarthritis in its early stages in the future. What can the practice of yoga currently achieve? A significant, if not the majority of osteoarthritis is probably due to overuse and narrowuse, i.e. specific overloading or insufficiently wide-ranging use of the joint. The latter can certainly be understood spatially and combinatorially.

Almost without exception, cartilage needs movements that exert pressure on it so that it can release metabolic waste products and absorb new nutrients from the synovium when the pressure is released. One exception to this rule is the meniscus of the knee joint, which is an intermediate cartilage and not a bone covering. Based on the above, if healing is not currently possible, it should at least be possible to slow down progression. In very favorable cases, the cartilage may regenerate to a certain extent, but it will not become as good as new during the patient’s lifetime.

To improve the situation, it is therefore necessary to start moving the affected joint – and preferably not just this one, because if the cause was narrowuse, it usually affects many joints – in all directions again. If the cause of the osteoarthritis is actually not overloading but narrowuse, the muscles covering the joint will most likely be stiff. It is therefore important to gradually regain the natural range of motion in order to be able to use it. It cannot always be completely ruled out that osteoarthritis-related pain will occur in the short term, but by far the majority of the discomfort that occurs should be stretching pain or exertion. Of course, movements must be performed slowly and consciously and excessive static loads in certain positions must be avoided for the time being. More frequent changes between different positions of the joint are indicated so that the cartilage is subsequently loaded and unloaded. Any co-factors such as obesity naturally play a reinforcing role; more varied exercise also addresses this co-factor, although the diet may also need to be adjusted.

For the practice of asana, this means that on the one hand stretching postures are needed to help regain the natural range of movement, while on the other hand movement, i.e. versatile dynamic sequences, do the actual work.

The case of overuse is slightly different. In this case, the range of motion of the affected joint and all other joints is not necessarily restricted, so that stretching postures will play a lesser part in the program unless it is established that the muscles covering the affected joint are highly toned and thus chronically exert too much pressure in the joint. This could have contributed to the development of osteoarthritis and must be remedied. Muscular imbalances canalso lead to certain joint positions and less variation in the load, so these must also be eliminated as far as possible.

Another factor that must be considered is all forms of anomalies, weak points of the musculoskeletal system, which may be directly or indirectly causally related to the disorder. In addition to the orthopaedist and the classical physiotherapist, the osteopath is certainly a good point of contact here. Disorders in one area should never be considered in isolation but will have an effect on other, particularly neighboring areas. In principle, however, almost any distant effects are conceivable and a large number of these have also occurred and been documented. Not only distal to the diagnosed osteoarthritis, but also promimally, the muscles and joints that are connected in muscle chains and complex movements must be checked.

Incidentally, in the case of osteoarthritis, the clinic, i.e. the perceived symptoms, are initially the yardstick for action. As with meniscus damage, the correlation between the clinic and radiology, i.e. perceived symptoms and imaging findings, is rather loose. Significant damage visible on MRI does not necessarily lead to symptoms. On the other hand, some symptom descriptions have no radiological correlates. Patients should therefore listen to the advice of an orthopaedic surgeon who is also interested in conservative treatment and obtain at least a second opinion before agreeing to a joint replacement and irreversibly changing their body. In all of this, it must be borne in mind that long-term use of painkillers can never be free of side effects and that the effects of the disorder on the rest of the body, especially the musculoskeletal system, must also be taken into account.

If profound joint discomfort occurs, clarification should be sought at an early stage so that, if it is indeed osteoarthritis, the progression can be treated conservatively from as early a stage as possible and, clinically speaking, an improvement can usually be achieved, which would certainly not happen without movement therapy intervention, the progression would take its course and the symptoms would become increasingly obvious.

Asanas

As described above, depending on the case(overuse or narrowuse) and joint: promotion of flexibility with stretching postures in all movement dimensions and utilization of the range of motion, especially with repeated movements, i.e. dynamic exercise