One of my favourite pastimes as a child was leafing through photo albums. I used to find it immensely intruiging to look at the pictures while comparing the images of that time with the actual present day people and places. It never ceased to amaze me how time changes the appearance of a human being, the freshness of his countenance, the colour of his hair, his posture, the look in his eyes marked by years of different experiences both happy and tragic. As I grew older, this amazement was mixed with my ever increasing interest in science which made me view aging with a da Vinci eye, beyond the realms of the outer skin cover and into the intricate wonders of the inside of the human body.
Our internal organs age in the same way as our external features do. Our heart gets progressively less efficient, our blood vessels narrower with accumulated debris and our brains less sharp and focused, even if mercifully for some of us the change is almost unnoticeable due to the lower threshold at start-off. Our joints are not spared the onslaught of Father Time either, rendering us progressively less flexible, reaching a point of Swiss Guard stiffness by the time we are in our twilight years where even the simplest of tasks like tying a shoelace, fastening a shirt button or getting out of bed is accompanied by a cacophony of heartfelt groans and bodily creaks.
A joint is basically a location where two or more bones make contact. Most of us are the proud owners of about 350 joints, but the number is debatable considering that most bones, like our skull bones, fuse on the way from birth to adulthood. Whatever the count, the main fuction of joints is to allow movement and provide mechanical support to our skeleton, thus helping us stay in the upright position unique to homo sapiens and providing us with the flexibility to carry out all the functions we enjoy in our daily lives which when coupled with our supposedly supreme mental capabilities puts us at the helm of the animal hierarchy.
When classified according to their structure, three types of joints emerge. Fibrous joints, like those found in the skull, are held together by fibrous tissue which allows no movement. The cartilaginous joint found in between the vertebrae, is characterised by the presence of cartilage in between the joint which allows only a limited amount of movement. The synovial joint, like the knee and shoulder joints, on the other hand is joined by a fibrous articular capsule which is continuous with the bones of the joint and thus has a greater degree of movement in different planes. The bony surfaces in this type of joint are covered by a layer of cartilage which provides protection against load and shock.
Contrary to popular belief, aging of our joints does not come about as a result of wear and tear from daily use. Rather, as we age, the water content of the cartilage gradually decreases thus rendering it less resilient and more prone to degradation. This resultant degeneration of the joint surface triggers a natural regeneration response in the joint cavity which usually causes inflammation of the surrounding capsule and the formation of bony outgrowths or “osteophytes” at the margins of the joint, probably an attempt of the bone cells to remodel the incongruence of the articular cartilage. This combination of chronic inflammation and degeneration of joints and the resultant repair process is called osteoarthritis. All these changes take place progressively over the years which explain the fact that osteoarthritis is hardly ever found, if at all, in young individuals.
According to the NICE guidelines, osteoarthritis is defined as a complex disorder with multiple risk factors. Genetic factors score high in the list, estimated as being between 40 and 60 per cent for osteoarthritis of the hip, knee and hands, which are the most common sites afflicted by this condition. Environmental factors such as aging, female sex and obesity also play a role as do biomechanical risk factors. These include all the genetic causes of joint malalignment and laxity and many environmental/lifestyle risk factors such as recreational or occupational joint trauma and reduced muscle strength. The guidelines also stress the importance of the reversibility and avoidability of most of the environmental risk factors most notably obesity, reduced muscle strength and joint injury. The importance of individual risk factors varies between joint sites and these risk factors may also differ from risk factors for clinical progression and poor clinical outcome; where high bone density is a risk factor for development, low bone density may be a risk factor for progression of osteoarthritis of the hip and knee.
The hallmark symptoms of osteoarthritis are joint pain and stiffness which is most marked in the morning but which gradually wears off with the movement associated with our daily chores. The only signs seen at the affected joint area are usually a bony swelling and deformity which does not directly correlate to the severity of the disease; an afflicted person could have the most severe of symptoms and yet have no signs whatsoever. In severe cases, the pain and stiffness are very debilitating and can cause severe limitations to the person’s lifestyle, with the affected person becoming totally dependent on the care of a third party. It is no wonder that depression ranks high in such individuals.
The management of osteoarthritis is as multifold as the risk factors that expose us to it. Conservative treatment such as weight loss, regular exercise, ideally walking and swimming, alternating with sufficient rest provide the basis for control of this condition and for the optimal effect of other treatments when used. Pain relief in the form of the many pharamaceutical panaceas available and steroid injections in refractory cases are still the medical gold standard. Surgery in the form of fragment removal, repositioning or fusing bones to increase stability and reduce pain or joint replacement is resorted to in very severe cases. Despite the many therapies available, none is the proverbial manna which tilts the scale heavily in favour of prevention as a means of controlling this condition as much as possible. Let us not find out that we have let our joints down when they opt to do the same to us.