By Lori A. Burkhart
Osteoarthritis, or degenerative joint disease, affects the cartilage, which breaks down and eventually wears away. The end result is that instead of gliding naturally at the joints, bones rub against each other, causing pain, swelling and loss of motion.
It isn’t necessarily true that osteoarthritis (OA) affects only older people. According to Georgia Nab, DC, who left her own practice in Wichita, Kan., after 20 years to become a full-time staff doctor of chiropractic at Standard Process, the patients she sees with OA tend to be over 40, but the disease can occur in younger patients.
James Brantingham, DC, PhD, adjunct associate professor of health sciences at Murdoch University in Perth, WA Australia, and a lecturer in continuing education for Tong and Associates, agrees it is a misconception that OA occurs only in Medicare-age patients. “It is most common in people age 50 and up, but there are some with OA in the mid-30s because of the activities they have done,” he says. There can also be a genetic predisposition to OA. “The second-most common problem in the big toe behind bunions, especially for women, is OA,” Dr. Brantingham says. It is on the increase even in much younger people because of sports activities that require the toes to push off, such as football, volleyball, running and basketball. But those lead to OA of the knees and hips also.
Symptoms and Diagnosis
According to Dr. Nab, the symptoms of OA vary. She explains that while some patients in the early stages of OA will present with pain due to inflammation in the affected area, often OA is so slow to progress that patients don’t realize they have it. “A lot of times it is not picked up until X-rays are taken, and then you see the severity and the damage,” Dr. Nab says.
She says the patients don’t often comprehend how much range of motion they have lost until their DCs point it out. “What they will notice is ‘when I am driving I have to turn my whole body to look over my shoulder,’ and that is when it has been progressing for quite a while,” she says. For example, “you should be able to turn your head and go all the way over to your shoulder and take your ear and almost touch your shoulder and go through general ranges of motion, but patients with OA will only be able to turn maybe 15 to 20 degrees,” Dr. Nab says.
OA doesn’t necessarily have to do with age; it has to do with loss of motion in the joints and loss of normal curve within the spine. “If you are specifically talking about OA in the spine, then we look at where are the curves, because there are very specific curves that the spine should have,” Dr. Nab says. “If you lose those curves, then it puts abnormal stress on the joints and on the disks, and over time–by that I mean over ten or 15 years–all that extra stress will set in for OA.” She adds that is why corrective care is so essential for OA patients.
Dr. Brantingham says that to make an OA diagnosis in the extremities—for example, the knee—you have to check range of motion, do some common orthopedic tests and examine the knee for disorders that must be ruled out, especially if it is a meniscus problem. He doesn’t recommend that the average DC take on difficult meniscus problems. DCs have to rule out instability in the joint, such as an anterior cruciate tear, and must do Lachman's Test or Anterior Drawer Test. They must use all the tests that have been taught to them.
Treating OA
Patients do receive relief from OA treatment by DCs, but there are limits. For example, Dr. Brantingham recommends that DCs treat only mild to moderate knee or hip OA at this time. He recommends against treating OA that is Grade 4 on the Kellgren Lawrence grading scale for X-rays. “The worst degeneration you can see on an X-ray is Grade 4, and the joint would look almost destroyed,” he says. “Most DCs are comfortable treating Grade 0, 1 or 2, and some are comfortable treating Grade 3.” For great toe OA, he also recommends that DCs treat it only when mild to moderate: in this case Grades 0-1 and some Grade 2.
The degree of OA severity matters, Dr. Nab agrees. She says that if you are catching OA in the early stages, you can work with the patient on adjusting him or her properly and restoring some biomechanics; if the patient also will use nutrition to support those joints and ligaments, and will do home exercises, you can reverse some of the OA effects. “It makes sense. It goes back to Wolfe’s law, which talks about how abnormal stress on the bone will cause it to begin to deform,” Dr. Nab says. “Wolfe’s law would also state that if you take that stress off that bone or that disk, then it will begin to heal.”
There is a lot of OA research of which DCs should be aware. Dr. Brantingham says DCs need to do some added reading or training to know what not to do and what to do with adding manipulative therapy to an exercise protocol (see Sidebars 1 and 2). He believes the best RCTs for knee OA—and to learn this—are two by Deyle et al. from 2000 and 2005.1,2 In the first Deyle RCT, there was a 58 percent change in the WOMAC osteoarthritis index. Brantingham explains this is a very large change that reaches beyond the minimally clinically important difference, or MCID, for WOMAC, which is normally greater than 20 percent. The second RCT produced a 52 percent change in WOMAC with the addition of manipulative therapy to exercise.
Nutrition and Active Lifestyles
Dr. Nab also prefers to use nutritional products to help support patients with OA, and she used Standard Process products in her Wichita practice for 20 years. She recommends glucosamine synergy, especially because it contains Boswellia. “Not only are we helping to support the disks and the joints, but we’re adding Boswellia to help decrease the inflammation,” Dr. Nab says. “Inflammation plays a part in OA, because if you think about the “itis” in OA, it means inflammation.”
Dr. Nab uses a three-pronged attack on OA because the patient also has to be active. “The patient needs to be proactive in doing specific spinal exercises depending on whether the OA is in the neck or low back, and those are the best patients who get results,” she says.
References
ACA News Extra...
The Evidence
A comprehensive review of the literature in 2012 was made to update a systematic review on manipulative therapy (MT) for lower extremity conditions.
The conclusions are that regarding MT for common lower extremity disorders, there is a level of B (fair evidence) for short-term and C (limited evidence) for long-term treatment of hip osteoarthritis. There is a level of B for short-term and C for long-term treatment of knee osteoarthritis, patellofemoral pain syndrome and ankle inversion sprain. There is a level of B for short-term treatment of plantar fasciitis but C for short-term treatment of metatarsalgia and hallux limitus/rigidus and for loss of foot and/or ankle proprioception and balance. Finally, there is a level of I (insufficient evidence) for treatment of hallux abducto valgus. Further research is needed on MT as a treatment of lower extremity conditions, specifically larger trials with improved methodology.
Brantingham JW, Bonnefin D, Perle S, Cassa TK, Globe G, Pribcevic M, Hicks M, Korporaal C. Manipulative therapy for lower extremity conditions: update of a literature review. J Manipulative Physiol Ther. Feb 2012;35(2):127-66.(2):127-166.
Systematic reviews supporting the addition of manual or manipulative therapy with exercise in the treatment of knee osteoarthritis:
Bennell KL, Hunter DJ, Hinman RS. - found: 12 RCTs - the addition of passive manual mobilizations to an exercise program produced superior significant pain relief (see page 3 regarding manual therapy). Management of osteoarthritis of the knee. BMJ. 2012;345:e4934.
Bronfort G, Haas M, Evans R, Leiniger B, Triano J.- found: moderate and positive level of evidence. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. Feb 25 2010;18(1):1-112.
RCTs investigating manipulative therapy for hip osteoarthritis:
Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum. Oct 15 2004;51(5):722-729.
Brantingham JW, Parkin Smith, Cassa T, Pollard H, de Luca K, Globe G, Globe D, Jensen M, Mayer SN, Korporaal C. Full kinetic chain manual and manipulative therapy plus exercise compared with targeted manual and manipulative therapy plus exercise for symptomatic osteoarthritis of the hip - a randomized controlled trial. Arch Phys Med Rehabil. 2012 93(2):259-267.
Benefits of chiropractic for treating OA low-back and cervical pain.
Yu H, Hou S, Wu W, He X. Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases. Chiropractic management of atlantoaxial osteoarthritis yielded favorable outcomes for these 10 patients. J. Manipulative Physiol Ther. 2011 Feb;34(2):131-7.
Beyerman KL, Palmerino MB, Zohn LE, Kane GM, Foster KA. Efficacy of Treating Low Back Pain and Dysfunction Secondary to Osteoarthritis: Chiropractic Care Compared With Moist Heat Alone. Chiropractic care combined with heat is more effective than heat alone for treating OA-based lower back pain. J. Manipulative Physiol. Ther. 2006 Feb;29(2):107-14.
Knee Osteoarthritis Treatment
James Brantingham, DC, PhD, spearheaded a three-part series for ACA News setting forth a protocol to help chiropractic physicians safely treat mild to moderate knee OA. You can find the series in the June, July and August 2010 editions of ACA News:
Brantingham JW, Globe G, Cassa TK, Bonnefin D. Managing patients with knee osteoarthritis. Part I. ACA News. June 2010, pages 24-27.
Managing patients with knee osteoarthritis. Part II. Chiropractic manipulative therapy. ACA News. July 2010, pages 24-27.
Managing patients with knee osteoarthritis. Part III. Rehabilitation and medical treatment. ACA News. Aug. 2010, pages 22-25.
Published in the April 2013 ACA News.
Osteoarthritis, or degenerative joint disease, affects the cartilage, which breaks down and eventually wears away. The end result is that instead of gliding naturally at the joints, bones rub against each other, causing pain, swelling and loss of motion.
It isn’t necessarily true that osteoarthritis (OA) affects only older people. According to Georgia Nab, DC, who left her own practice in Wichita, Kan., after 20 years to become a full-time staff doctor of chiropractic at Standard Process, the patients she sees with OA tend to be over 40, but the disease can occur in younger patients.
James Brantingham, DC, PhD, adjunct associate professor of health sciences at Murdoch University in Perth, WA Australia, and a lecturer in continuing education for Tong and Associates, agrees it is a misconception that OA occurs only in Medicare-age patients. “It is most common in people age 50 and up, but there are some with OA in the mid-30s because of the activities they have done,” he says. There can also be a genetic predisposition to OA. “The second-most common problem in the big toe behind bunions, especially for women, is OA,” Dr. Brantingham says. It is on the increase even in much younger people because of sports activities that require the toes to push off, such as football, volleyball, running and basketball. But those lead to OA of the knees and hips also.
Symptoms and Diagnosis
According to Dr. Nab, the symptoms of OA vary. She explains that while some patients in the early stages of OA will present with pain due to inflammation in the affected area, often OA is so slow to progress that patients don’t realize they have it. “A lot of times it is not picked up until X-rays are taken, and then you see the severity and the damage,” Dr. Nab says.
She says the patients don’t often comprehend how much range of motion they have lost until their DCs point it out. “What they will notice is ‘when I am driving I have to turn my whole body to look over my shoulder,’ and that is when it has been progressing for quite a while,” she says. For example, “you should be able to turn your head and go all the way over to your shoulder and take your ear and almost touch your shoulder and go through general ranges of motion, but patients with OA will only be able to turn maybe 15 to 20 degrees,” Dr. Nab says.
OA doesn’t necessarily have to do with age; it has to do with loss of motion in the joints and loss of normal curve within the spine. “If you are specifically talking about OA in the spine, then we look at where are the curves, because there are very specific curves that the spine should have,” Dr. Nab says. “If you lose those curves, then it puts abnormal stress on the joints and on the disks, and over time–by that I mean over ten or 15 years–all that extra stress will set in for OA.” She adds that is why corrective care is so essential for OA patients.
Dr. Brantingham says that to make an OA diagnosis in the extremities—for example, the knee—you have to check range of motion, do some common orthopedic tests and examine the knee for disorders that must be ruled out, especially if it is a meniscus problem. He doesn’t recommend that the average DC take on difficult meniscus problems. DCs have to rule out instability in the joint, such as an anterior cruciate tear, and must do Lachman's Test or Anterior Drawer Test. They must use all the tests that have been taught to them.
Treating OA
Patients do receive relief from OA treatment by DCs, but there are limits. For example, Dr. Brantingham recommends that DCs treat only mild to moderate knee or hip OA at this time. He recommends against treating OA that is Grade 4 on the Kellgren Lawrence grading scale for X-rays. “The worst degeneration you can see on an X-ray is Grade 4, and the joint would look almost destroyed,” he says. “Most DCs are comfortable treating Grade 0, 1 or 2, and some are comfortable treating Grade 3.” For great toe OA, he also recommends that DCs treat it only when mild to moderate: in this case Grades 0-1 and some Grade 2.
The degree of OA severity matters, Dr. Nab agrees. She says that if you are catching OA in the early stages, you can work with the patient on adjusting him or her properly and restoring some biomechanics; if the patient also will use nutrition to support those joints and ligaments, and will do home exercises, you can reverse some of the OA effects. “It makes sense. It goes back to Wolfe’s law, which talks about how abnormal stress on the bone will cause it to begin to deform,” Dr. Nab says. “Wolfe’s law would also state that if you take that stress off that bone or that disk, then it will begin to heal.”
There is a lot of OA research of which DCs should be aware. Dr. Brantingham says DCs need to do some added reading or training to know what not to do and what to do with adding manipulative therapy to an exercise protocol (see Sidebars 1 and 2). He believes the best RCTs for knee OA—and to learn this—are two by Deyle et al. from 2000 and 2005.1,2 In the first Deyle RCT, there was a 58 percent change in the WOMAC osteoarthritis index. Brantingham explains this is a very large change that reaches beyond the minimally clinically important difference, or MCID, for WOMAC, which is normally greater than 20 percent. The second RCT produced a 52 percent change in WOMAC with the addition of manipulative therapy to exercise.
Nutrition and Active Lifestyles
Dr. Nab also prefers to use nutritional products to help support patients with OA, and she used Standard Process products in her Wichita practice for 20 years. She recommends glucosamine synergy, especially because it contains Boswellia. “Not only are we helping to support the disks and the joints, but we’re adding Boswellia to help decrease the inflammation,” Dr. Nab says. “Inflammation plays a part in OA, because if you think about the “itis” in OA, it means inflammation.”
Dr. Nab uses a three-pronged attack on OA because the patient also has to be active. “The patient needs to be proactive in doing specific spinal exercises depending on whether the OA is in the neck or low back, and those are the best patients who get results,” she says.
References
- Deyle G, Henderson N, Matekel R, Ryder M, Barber M, Allison S. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. Ann Intern Med. 2000;132(1):173-180.
- Deyle GD, Allison SC, Matekel RL, et al. Physical therapy treatment effectiveness for osteoarthritis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther. Dec 2005;85(12):1301-1317.
ACA News Extra...
The Evidence
A comprehensive review of the literature in 2012 was made to update a systematic review on manipulative therapy (MT) for lower extremity conditions.
The conclusions are that regarding MT for common lower extremity disorders, there is a level of B (fair evidence) for short-term and C (limited evidence) for long-term treatment of hip osteoarthritis. There is a level of B for short-term and C for long-term treatment of knee osteoarthritis, patellofemoral pain syndrome and ankle inversion sprain. There is a level of B for short-term treatment of plantar fasciitis but C for short-term treatment of metatarsalgia and hallux limitus/rigidus and for loss of foot and/or ankle proprioception and balance. Finally, there is a level of I (insufficient evidence) for treatment of hallux abducto valgus. Further research is needed on MT as a treatment of lower extremity conditions, specifically larger trials with improved methodology.
Brantingham JW, Bonnefin D, Perle S, Cassa TK, Globe G, Pribcevic M, Hicks M, Korporaal C. Manipulative therapy for lower extremity conditions: update of a literature review. J Manipulative Physiol Ther. Feb 2012;35(2):127-66.(2):127-166.
Systematic reviews supporting the addition of manual or manipulative therapy with exercise in the treatment of knee osteoarthritis:
Bennell KL, Hunter DJ, Hinman RS. - found: 12 RCTs - the addition of passive manual mobilizations to an exercise program produced superior significant pain relief (see page 3 regarding manual therapy). Management of osteoarthritis of the knee. BMJ. 2012;345:e4934.
Bronfort G, Haas M, Evans R, Leiniger B, Triano J.- found: moderate and positive level of evidence. Effectiveness of manual therapies: the UK evidence report. Chiropr Osteopat. Feb 25 2010;18(1):1-112.
RCTs investigating manipulative therapy for hip osteoarthritis:
Hoeksma HL, Dekker J, Ronday HK, et al. Comparison of manual therapy and exercise therapy in osteoarthritis of the hip: a randomized clinical trial. Arthritis Rheum. Oct 15 2004;51(5):722-729.
Brantingham JW, Parkin Smith, Cassa T, Pollard H, de Luca K, Globe G, Globe D, Jensen M, Mayer SN, Korporaal C. Full kinetic chain manual and manipulative therapy plus exercise compared with targeted manual and manipulative therapy plus exercise for symptomatic osteoarthritis of the hip - a randomized controlled trial. Arch Phys Med Rehabil. 2012 93(2):259-267.
Benefits of chiropractic for treating OA low-back and cervical pain.
Yu H, Hou S, Wu W, He X. Upper cervical manipulation combined with mobilization for the treatment of atlantoaxial osteoarthritis: a report of 10 cases. Chiropractic management of atlantoaxial osteoarthritis yielded favorable outcomes for these 10 patients. J. Manipulative Physiol Ther. 2011 Feb;34(2):131-7.
Beyerman KL, Palmerino MB, Zohn LE, Kane GM, Foster KA. Efficacy of Treating Low Back Pain and Dysfunction Secondary to Osteoarthritis: Chiropractic Care Compared With Moist Heat Alone. Chiropractic care combined with heat is more effective than heat alone for treating OA-based lower back pain. J. Manipulative Physiol. Ther. 2006 Feb;29(2):107-14.
Knee Osteoarthritis Treatment
James Brantingham, DC, PhD, spearheaded a three-part series for ACA News setting forth a protocol to help chiropractic physicians safely treat mild to moderate knee OA. You can find the series in the June, July and August 2010 editions of ACA News:
Brantingham JW, Globe G, Cassa TK, Bonnefin D. Managing patients with knee osteoarthritis. Part I. ACA News. June 2010, pages 24-27.
Managing patients with knee osteoarthritis. Part II. Chiropractic manipulative therapy. ACA News. July 2010, pages 24-27.
Managing patients with knee osteoarthritis. Part III. Rehabilitation and medical treatment. ACA News. Aug. 2010, pages 22-25.
Published in the April 2013 ACA News.
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