Makati Med's Symposium on the Treatment of Osteoarthritis

Last Saturday, I had another speaking engagement, this time at the Makati Medical Center- Department of Orthopedics’ Annual Orthopedic Symposium. The theme of the morning session was about the current trends in treatment of osteoarthritis, but not including joint replacement.  The focus was on the alternative management to joint replacement of patients with such conditions.  The theme was very relevant in my practice that’s why I readily agreed to be a speaker. 

As in the last Philippine Hip and Knee Society Convention, I was truly honored and privileged to have spoken before my esteemed colleagues because the audience was mostly orthopedic consultants, residents and medical students. I’d like to extend my gratitude to the Department for inviting me to be one of the speakers and share my knowledge. At the same time, it was also an opportunity for me to continuously update my knowledge by learning from other speakers’ experience. 

         Preparing lectures for orthopedic conferences is both stressful and energizing for me.  Stressful because there is so much pressure involved in researching and preparing a scholarly lecture before former mentors and colleagues in the profession.  I had to write and re-write my manuscript and think of all the possible post-lecture questions they will throw at me.  At the same time energizing, because it is an opportunity to shine and show your former mentors what you have learned during fellowship training. 

       The opening remarks were from the Makati Med Department of Orthopedics Chairman Dr. Liberato Leagogo who acknowledged the challenges of managing osteoarthritis, especially in the young and active patients. All the speakers, in my opinion, had well-prepared lectures that generated active participation among the audience. We even had the opportunity to learn from a foreign speaker from Singapore who was specializing in cartilage regeneration techniques.

      My lecture on the use of osteotomy (a surgical procedure that re-aligns a malaligned knee to prevent the progression of osteoarthritis, went well,  I thought. Thanks to my friend & colleague Dr. Marc Castro who provided me with some pictures I used in my presentation. The following are some of the pictures taken during the symposium.

Dr. Tony Rivera dishing out his usual fiery questions

         The afternoon session was devoted to presentation of researches in orthopedics which was personally sponsored by my mentor, Dr. Ramon Gustilo of Minnesota, USA. I wasn’t able to finish the afternoon sessions, though, due to clinic schedules. Dr. Gustilo himself gave a talk on the success and failures of total hip replacement patients.  Having done at least 10,000 hip and knee surgeries and has trained countless orthopedic surgeons, including me, throughout the world, his opinion and experience definitely are well-valued.

With my mentor, Dr. Ramon Gustilo

         There is so much more I want to talk about, but I just don't have the time right now. Hopefully, during the course of the next few days, I'll be able to share that with you.

           In the meantime, I just like to express this take home message:

     Doctors should invest in educating themselves, so that we remain up-to- date with the latest medical advances. This will help us provide state of the art medical care for our patients.  Attending conferences and actively participating is one way to do it.

        Orthopedic surgery is a very dynamic field.  Researches and studies are continuously being undertaken so what we might have learned a few years ago may not be the best option for our patients now.  However, I do acknowledge the fact that change does not mean improvement.  Long-term studies are usually needed to prove the effectiveness of  new procedures, especially if they are more expensive.

GMA's Pain in the Neck

Almost everyone in our orthopedic circle is talking about former President Gloria Macapagal-Arroyo's neck surgeries. We all know that GMA was diagnosed with cervical spondylosis and has undergone two neck surgeries so far and may have more surgeries in the future. 

"Was her neck surgery necessary, in the first place?" This question has been asked by my patients, family, friends and even colleagues in the profession, several times the past few weeks.

Although many people think that there may be some political reason for GMA undergoing this procedure at this particular time when evidences for her alleged corruption have piled up, I will leave that up to the political pundits to determine. As much as I’d like to remain apolitical in this blog though, I may have to touch politics a bit because an orthopedic problem is in the center of the discussions.

            I am not a spine surgeon (I am a hip and knee specialist), but as an orthopedic surgeon knowledgeable enough on this matter, please allow me to explain some things in order to give you some assurances that you most likely won’t face the same fate and to empower you to help explain these things to friends and family.

What is cervical spondylosis?

Also called arthritis of the neck, cervical spondylosis  is a broad term referring to the wear and tear (degeneration) of the cervical or neck spine, including the cushions between the neck vertebrae (cervical disks) and the joints between the bones of the cervical spine. "Spurs" on the bones of the spine (vertebrae) may develop as small, rough areas on their edges. These changes can, over time, reduce the size of the canal around the nerves, press down or impinge on the latter. Since these nerves travel from the spine to the arms, symptoms may radiate down to the arms. In advanced cases, the spinal cord may be involved and legs may be affected as well.

What are the symptoms of cervical spondylosis?

More common symptoms are:

• Neck pain (as mentioned may radiate to the arms or shoulder).  Neck pain is probably one of the most common problems that one encounters in day to day life. It is probably as common as the common cold.
• Neck stiffness
• Loss of sensation or abnormal sensations in the shoulders, arms
• Weakness of the arms or (rarely) legs
• Headaches, particularly in the back of the head

Aside from aging, are there other causes of cervical spondylosis?

The major risk factor is aging. By age 60, most women and men show signs of cervical spondylosis on x-ray. Other factors that can make a person more likely to develop spondylosis are:

• Past neck injury (often several years before)
• Severe arthritis
• Past spine surgery

Mrs. Arroyo’s doctors said her condition was triggered by her “continuing to work countless hours despite her stresses."  Well, in my opinion, it is difficult to say if this is true.  Although it may contribute to the perceived pain and muscle spasm, this is not the main reason. In general, mental or emotional stress DO NOT have any effect on spondylosis. Spondylosis is not normally caused by external factors; rather it is part of the normal aging process. Unless the stress that they are talking about is a physical stress associated with certain occupations which involve repeated bending and lifting heavy objects, which is, however, not the work of GMA.

I am not exactly sure what the symptoms of GMA were before the operation that made her doctors decide on the surgery, but let us give the benefit of the doubt to her doctors.  After all, I still believe that no doctor, in his or her right mind, would do something against the welfare of the patient.

How is cervical spondylosis treated?

Treatment is usually conservative in nature; the most commonly used treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, physical therapy, cortisone injections, cervical collars, and lifestyle modifications aimed at reducing the symptoms and preventing permanent spinal cord and nerve injury. Surgery is occasionally performed only. Many of the treatment modalities for cervical spondylosis have not been subjected to rigorous, controlled trials. Surgery is advocated for patients who have intractable pain, progressive symptoms, or weakness that fails to improve with conservative therapy. It should be the last resort because of the risks of the surgery.

So what are these risks of the surgery?

The usual complications of any surgery will be infection, accidental nicking of any blood vessel, nerve or surrounding vital structures.  Having trained in revision surgeries of the hip and knee, I know pretty well how difficult it is to treat infected orthopedic cases, especially if the infection has spread to osteoporotic bones. Arroyo, unfortunately, developed this infection and is now taking heavy doses of antibiotics. Her metal implants, which apparently loosened due to the infection, were removed and she was subsequently fitted with a metal contraption to immobilize her head and neck.

So, was GMA’s surgery necessary?

Surgery is used if other treatments fail and if pain or weakness gets worse. Apparently, GMAs symptoms were deteriorating (we are not sure). One study done abroad noted that 79% of patients with neck pain and/or referred pain syndromes and cervical spondylosis improved or became asymptomatic by the 15-year follow-up point.

Remember, the primary goal of surgery is to decompress the spinal cord, thus giving the nerves more breathing room. The orthopedic or neurosurgeon will remove bone spurs or a herniated disk, align neck bones and put in an implant where bones or disks were removed. These implants used will stabilize the neck so the neck spine will not move around and dislocate.

Summary

Cervical spondylosis is a common cause of disability in older persons. It is important to note that bone degeneration process cannot be cured, nor can be entirely prevented.  To an extent, we all develop a degree of degeneration in the spine bones and discs as we become older.

The process can only be minimized through healthy diet and lifestyle, exercises and good structural posture. Because spondylosis is a universal finding as patients age, it is important to correlate clinical history and neurologic findings with the diagnostic studies. MRI is the most useful radiographic study for quantifying the degree of nerve impingement and excluding other pathologies.

Current treatment remains controversial with regard to surgical and nonsurgical management. It is a risky surgery, indeed, and has its complications, just like what happened to GMA. In the future, prospective randomized trials may be required to definitively establish treatment guidelines. Currently, surgical decompression is accepted for many symptomatic patients who are not responding to non-surgical measures.

Personal Message

I would like to wish Representative Arroyo well.  As a person of medicine and a compassionate Christian, I hope that you will eventually have a successful surgery. However, as a concerned Filipino citizen eager to know only the truth, I hope that the cases filed against you will prosper in court so that you can defend yourself in the proper forum. 

Our noble field of profession (medicine) should never be corrupted and used in derailing the administration of justice.

Have no Doubt, The Truth About Gout

“The best medicine I know for rheumatism is to thank the Lord that it ain't gout!” ' Josh Billings '

I recently ran into an old friend of mine. As we did the standard “Hi, hello, how are you?” exchange, he suddenly said, “Oh, I totally forgot you were a bone doctor! I should’ve called you last week because my Dad had terrible pain in his foot and he felt he was being haunted by the devil!” (Hmmm. Maybe they should have called an exorcist, I thought). Turns out they went to a hospital ER, were  seen by an ER physician who gave them a request for uric acid test. And then he popped the question: “Is gout the same as arthritis?”

 This is indeed,   a valid and logical question, especially if you’re not an orthopedic or joint specialist.  Even General Practitioners cannot differentiate the two.  In fact, it is not uncommon that patients come into my clinic with pain in their foot and has a uric acid test already with him (often times with normal results), as ordered by his GP.

What is gout and what causes it?

First it is important to note that there are different types of arthritis, hundreds in fact. Gout arthritis and osteoarthritis (most laymen call osteoarthritis simply as arthritis), are just 2 of the more common types, especially in Filipinos.  

To put it simply, gout is a version of arthritis caused by too much uric acid in the blood stream. Here, the body either makes too much uric acid or it cannot excrete it from the body through the kidneys in large enough quantities.  If you think about a tub and a water spout, if the drain on the tub is open, you can turn the water on full blast, and the tub won't overflow. Same thing with the body and gout. If your body gets rid of uric acid properly through your kidneys, you don't have to completely avoid those bad but yummy stuffs rich in uric acid (More on this later.)

What are the symptoms of gout?

The most common clinical feature of gout is a sudden, severe attack of throbbing pain, tenderness, redness, warmth, and swelling in some joints, with a feeling like the world hates me (or as the father of my friend mentioned, “The devil is haunting me!”). Even a light touch can elicit severe pain. Gout is more likely if arthritis first appears in the big toe but it can also affect other joints in the leg -- such as the knee, ankle, and foot -- and, less often, joints in the arm including the hand, wrist, fingers, and elbow.  Spine is very rarely involved.

The speed of the onset of pain and swelling is important for the diagnosis. Symptoms that take days or weeks (rather than hours) to develop probably indicate a disorder other than gout.

How does too much uric acid cause the painful arthritis attack?

Everyone has uric acid in the blood, and that comes from the daily turnover of cells in the body. However, it’s only when the levels reach too high proportions that uric acid crystallizes and may find their way into joints.  These uric acid deposits may initiate an inflammatory reaction (pain, swelling) due to the body producing white blood cells to combat the uric acid intruder. When this happens the inflamed area also produces heat and thus, becomes warm.

Over time, these uric acid crystals may also form into gritty nodules called "tophi." These nodules can appear as lumps under the skin near joints such as the elbows and fingers, at the rim of the ears, even in the kidneys.

Are there certain foods to avoid in gout?

There are certain diet restrictions to follow if the individual has gout, or is predisposed to this disease.

1.     Alcohol, especially beer

2.     Bacon

3.     Organ meats such as liver and kidney

4.     Sardines and anchovies

5.     Mushrooms

6.     In the bean family, avoid lima beans and kidney beans

7.     Spinach

8.     Anchovies

So how do we differentiate gout from osteoarthritis?

To make things simple, below is a link to a table showing the difference between the common clinical features of gout and osteoarthritis

Gout versus osteoarthritis

What is the best way to diagnose gout arthritis?

Blood levels of uric acid will give you an idea if you have gout or not. But a synovial fluid examination is the most accurate method for diagnosing gout. Your doctor will use a needle attached to a syringe to draw out fluid from the affected joint. This is called aspiration. The procedure is usually only mildly uncomfortable. (Parang kagat lang. Kagat ng buwaya!) Afterwards, there can be some minor discomfort in the area where the needle was inserted, but it usually goes away in no time.

The fluid sample is sent to a laboratory for analysis. Presence of monosodium urate (MSU) crystals, nearly always confirm a diagnosis of gout. The laboratory can also test the sample for infection.

So, dear readers, just to clarify. If your foot is not suddenly red, very swollen and/or exquisitely painful, it’s probably not gout.  If your pain is vague and generalized, it’s probably not gout.  If you don’t have accompanying general feeling of malaise, weakness or mild fever, it’s probably not gout. 

If, however, you think it may in fact be gout, be sure to see your bone doctor and immediately discuss treatment options so the best course of treatment for you can be decided. 

P.S.  There is a condition known as pseudogout.  Its presentation is very much like gout but the underlying cause is different.  More on this on the next blog post…

Food supplements for Osteoarthritis

Hi. 

For this post, I decided to do away with the emotional tone.  Instead, just plain orthopedic information in the meantime.   (Is that good or bad?) Anyway, I will be discussing one issue pertaining to osteoarthritis, my field of specialization. Just as a reminder to my readers, though, that the contents of this post are all still based on my personal experience and point of view, and I don’t work or am NOT connected with any pharmaceutical company.  

So, you may have probably seen a lot of commercial advertisements that promote glucosamine and chondroitin.  (Aling Dionisia is in one of these advertisements). 

Recently, this question from a patient has again cropped up. “ Doc, do food supplements like glucosamine and chondroitin sulfate really help people with osteoarthritis?”  Patients of mine who have relatives in the US have asked me this question several times since their supplements are apparently given by their relatives for free.  

My honest answer?  

Some will pretend to know.

But me? I don’t know.  And I say that with a smile on my face.

Let me tell you a little bit more about these food supplements.  First, osteoarthritis, the most common form of arthritis which is mainly due to “wear and tear” as we age, can be in the form of mild, moderate or severe.  The severe form is very crippling and painful. Surgery in the form of joint replacement is the treatment of choice for the severe type.  The mild and moderate forms have several treatment options, one of them is the use of these food supplements, mainly in the form glucosamine and chondroitin sulfate. 

In the US, glucosamine and chondroitin, either alone or in combination, are probably two of the most common food supplements used by adults. 

Chondroitin and glucosamine have been found in the normal cartilage (the material in between bones that act as “shock absorbers”) of joints.  So, it makes sense that if you take them as food supplements, they can “replenish” the worn out cartilage.  But one question is, how do they get to the joints when you take them orally?  Cartilage doesn’t have blood vessels where these substances can be delivered to the intended tissues.

As with any vitamins, there are different ways that you can take it, depending on the brand. Most branded forms are large tablets but here in the Philippines, there is a powder form of glucosamine which is mixed with water.  This may be especially suited for you if you don’t take pills well.

But are there studies that support the use of these food supplements?  

Yes, there are. And you know what, there are also studies that do not recommend it.  One of my colleagues in the profession told me that you can always find a study that supports what you want to hear.  And you can always find a study that will not support what you want to hear.  Confusing, huh.  

The American Academy of Orthopedic Surgeons (AAOS) came out with a guideline released in 2009 for knee osteoarthritis.  As a consequence of inconclusive evidence, the guideline does not recommend the use of these food supplements.  I am not aware of any local study that dwells on the topic.  But there have been several reports that showed that the results of studies in Caucasians are very different from Asians like us.  And so further studies, I think, are needed, especially on Filipinos.

In my practice, I personally see patients who claim they improve with the intake of these food supplements.  And you cannot take that away from them.  Placebo effect? Maybe yes. Maybe not. My mentor, who is a world-renowned Filipino-American orthopedic surgeon, takes them every day. And is still very strong, at 80 years old. There are others who are big fans of food supplements.

So, when a patient asks me if they can take these food supplements, I tell them that they can take them if they want, as long as they don’t experience any side effect (There have been no major side effects that have been reported anyway).   But they have to realize also that osteoarthritis is a degenerative process that comes with age. It cannot be totally prevented, but at least we can delay the process. 

Until valid and definitive clinical trials have been undertaken in a Filipino population regarding the effectiveness of taking food supplements like glucosamine and chondroitin, I cannot recommend for or against the use of them. The problem is, no company in the Philippines will spend millions of pesos/dollars to conduct such clinical trials.

So, do you still want to take those food supplements?  The decision is yours.

If you have taken or know someone who have taken these food supplements before, do tell us about your experience!

More non-surgical treatment of osteoarthritis on the next blog…

5 Exercise Tips for Patients with Arthritis

       “Can you believe it, Doc? The reason I went to aerobics class is for me to lose weight and decrease my joint pain. And now, I injured my ankle from doing this. I feel so hopeless."

        I’ve heard this complaint from my patients a few times already.  Some people never run out problems,  huh?

 

       The typical patient who tells me this can be described as: a middle-aged woman, gifted, endowed, and abundant. She has cellulite deposits and “ruffles” around the waist. The common question people ask her is “Hi, Ma’am. When are you giving birth?”
 

       Ok, ok, not all of you like that description. I’m just kidding.
 

       But I want to congratulate these patients. They made a heroic attempt at exercising and ended up martyred along the way.

       Seriously, you may think that exercise and arthritis don’t go hand in hand. But that’s certainly not the case. Exercise is important for people with arthritis. Keeping your weight down and your muscles strong can help to delay surgery and improve your surgical result from joint-replacement surgery.
 

       Here are some exercises I recommend if you are suffering from early signs of osteoarthritis.  They are generally low-impact exercises and thus occurrence of injury is somewhat minimized.

1. Walking:

       This is my favorite recommendation. You can do this inside the mall, in the parks, inside your subdivision. Whenever you’re parked in a huge parking lot, try choosing the farthest spot available. No kidding. You also save yourself from the stress of competing with the other drivers who want the nearest parking spots! And why don’t you try walking with your loved one, hand in hand, eye to eye, shoulder to shoulder, bad breath to bad breath.  

2. Swimming or water exercise:




       Warm water swimming, is a way to perform normal activities without the impact of working out on land. In the water your body's buoyancy reduces stress on your joints while building strength and increasing range of motion. Water exercises can involve aerobics, walking, jogging or just about anything else. Even sports can be played in the water (e.g. water polo) for added excitement. I recently went to a hot spring in Pansol, Laguna and found the warm water just right for arthritis.

3. Cycling:



       Cycling is also one of my favorite recommendations, because not only is this a low-impact way to exercise, but the cyclic motion of cycling is stimulating for the cartilage within a joint. Cycling gives a good muscular and cardiovascular workout and loosens up stiff joints by circulating the remaining lubricants. It’s like warming up a cold vehicle. Start off with stationary cycling, and move outdoors as you get stronger.

4. Light to moderate weight-lifting:




       Training with weights can help strengthen muscles, and is also an excellent way to stimulate bone health. It must be done safely, with proper instruction. Just about anyone can learn a few good strength-training exercises. Even with a few dumbbells and some basic knowledge, a weight workout can be perfect for arthritis.

5.Low-impact dancing while doing house chores.




       Not the hip-hop or rap music to go. Mild dancing can be done as tolerated, while letting you finish your house chores. The important thing is you have to keep moving your joints.
 

       So now, get out and exercise! Exercise controls not only your weight but also your blood pressure, and other vital signs. It reduces joint pain and stiffness, builds strong muscle around the joints, and increases flexibility and endurance. It also helps promote overall health and fitness by giving you more energy, helping you sleep better, decreasing depression, and improved sense of well-being.

       As you can see, there are many options for exercise, even for those with joint pain from arthritis. Again, exercise has been shown to be useful for patients with arthritis both before and after joint-replacement surgery. So now you have no excuses ... get out and get physical!
 

       Can you think of other ways you can include exercise in the daily routines of your life?

Rev Up Your Joints

         Unless it’s the Holy Week, I think the average speed for vehicles in Metro Manila is disastrously slow, due to the absurd traffic jams we have.  Like a snail on steroids or Extra Joss, would be a good comparison. 

     Unfortunately, driving in traffic, with its frequent stopping and going, produces some of the hardest miles you’ll ever put on your engine, eventually damaging your vehicle.  It also has been shown to consume more fuel than straight, continuous driving. 
 

Aside from traffic, other Metro Manila road conditions that tend to damage your vehicles are humps, potholes, reckless drivers and swerving vehicles.  Our highways, like EDSA and Commonwealth Avenue (thank God, they placed a speed limit on the latter), are choked with rushing death machines such as buses, jeepneys and motorcycles.    

So what do these motoring issues have to do with an orthopedic surgeon like me?

Like vehicles, our joints are subjected to a fair amount of stress everyday.  In our youth, we have a good lubrication system in our joints that allow it to move smoothly and efficiently, like a brand new car.  Brand new engines have smooth, slick surfaces that enable friction-free movement between parts. 

But as we age, the inevitable happens, the joints are slowly stripped off their cartilage, joint fluid, which serves as the lubricant, decreases and bones begin to rub against each other during movement.  The friction between bones creates pain and inflammation.  Such as in engines, when the lubricants are used up, the friction between engine parts causes heat and wear and tear of surfaces.  Eventually, vehicle performance is diminished if these problems are not properly addressed by proper maintenance.

So, like engines, our joints have to be properly maintained to combat the stresses applied to it.  Regular low-impact exercise are to joints what regular oil change and fluid replacement are to vehicles, by promoting production of joint fluid.  Whereas, irregular high-impact movement is very stressful to the joints and accelerate damage.  Like the stop-and-go movement of cars in traffic situations.    

Loading is also a very important issue in joint maintenance.  When joints have to bear a lot of load, such as in people who are overweight, much stress is applied on it.  Maintaining an ideal weight, can delay damage to the joints.

In my medical practice, I am often asked about how to prevent arthritis, or inflammation of the joints.  I find that this analogy with cars and car maintenance, helps patients visualize what needs to be done. 

A vehicle, once used, will never run as smoothly as a brand new one again.  But regular maintenance and reduction of stress, can help delay the wear-and-tear for a longer time.  Arthritis cannot be totally prevented, but it can be delayed.  Prevention means maintaining a fine balance between use and disuse.  It also means avoiding as much stress on the joints as we can.

Cars represent a huge investment for us because it conveniently and efficiently takes us where we want to go, and so we feel the need to maintain that investment.   But our joints are more important than that, as we use them daily and helps us in our every movement and task.  If you love your car enough to regularly maintain it, shouldn’t you be loving your joints more?

More ways to show joint-love in the next article…