A Comprehensive Review of Integrative Approaches for the Treatment of Osteoarthritis: Diagnosis, Differential Diagnosis, and Therapy Options

Osteoarthritis (OA) is a common form of joint deterioration and pain in older adults. It is also known as a degenerative joint disease because it involves the breakdown of cartilage in the joints where two bones meet. As the cartilage within the joints breaks down, it can result in swelling, pain, stiffness, and decreased function of the joints. Although osteoarthritis can damage any joint, especially those that have been repeatedly used or injured, it occurs most commonly in the joints of the hands, hips, knees, and spine.

Osteoarthritis is the most common joint disorder or arthritis in the body and one of the top causes of disability in the US. It affects around 242 million people worldwide, 30% of people ages 45 to 64 and 68% of those over age 65.

To prevent the pain, disability, and dysfunction accompanying osteoarthritis, an integrative medicine approach incorporates dietary and lifestyle interventions to help balance inflammation, reduce pain, and keep joints functioning well.

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What is Osteoarthritis?

Osteoarthritis is a degenerative disease that impacts the joints. It involves the disintegration of the cartilage that is found where two bones meet in joints. Cartilage is the type of tissue that cushions the ends of bones allowing joints to move freely and easily. It contains a high percentage (85%) of water in a matrix with specialized protein molecules called proteoglycans. These proteins make joints slippery, allowing for diminished friction with the movement of bone on bone.

With age, cartilage loses its ability to bind water. As this happens, it can become stiffer and more brittle, which contributes to the development of osteoarthritis and joint deterioration. Because cartilage does not contain blood vessels, it has a limited ability to heal and regenerate.

What Causes Osteoarthritis?

Osteoarthritis is more than just "wear and tear" from regular use of a joint alone.

While the causes of osteoarthritis are still being studied, the risk of developing this disease increases with age, although only some will develop the disease. Any factors that increase chronic inflammation may contribute to joint destruction, such as an imbalance in the microbiome of the gut (dysbiosis).

Research is emerging that shows that dysfunction and imbalances of the cartilage cells and the related matrix that makes up the joint are important factors in the development of osteoarthritis. The cartilage contains chondrocyte cells, which are cells that manufacture an extracellular matrix composed of collagen, glycoproteins, proteoglycans, and hyaluronic acid. These components are metabolically active and impacted by mechanical stress and the environment surrounding them within the joint. Under stressful conditions, substances in the extracellular matrix contribute to inflammation that causes a breakdown of the cartilage. Changes in the structure of these substances can make the joint less resilient when faced with mechanical loading. As the cartilage loses cushioning and elasticity, the synovial membrane surrounding the joint and secreting synovial fluid to lubricate the joint can become inflamed as well.

Some risk factors that make osteoarthritis more likely to develop include advancing age, repetitive stress on a joint from occupational overuse or sports, obesity or extra body weight, metabolic diseases like hemochromatosis (where the body has too much iron), and genetic factors involving the interaction of certain genes and risk factors that may contribute to the breakdown of cartilage.

These factors, like extra body weight, bone deformities, or injury, add stress to weight-bearing joints, which can contribute to the development of osteoarthritis. In addition, fat tissue produces cytokines that increase overall inflammation, including within the joints.

Osteoarthritis Symptoms

The most frequent symptoms of OA result from inflammation and destruction of the joints and include:

• Pain during or after movement
• Stiffness, often most prominent after waking or being inactive
• Loss of function, flexibility, or movement
• A grating sensation, popping, or cracking when using a joint
• Swelling due to soft tissue inflammation around the joints
• Difficulty with everyday activities

OA can occur throughout the body but is most commonly experienced in the following joints:

• Neck (cervical spine)
• Lower back (lumbar)
• Hips
• Knees
• The base of the big toes
• The base of the thumbs
• The most distal joints of the fingers (the joints closest to the fingertips)

Over time, osteoarthritis can generate bone spurs that grow around the joints. These are extra pieces of bone that feel like hard lumps around an affected joint.

How is Osteoarthritis Diagnosed?

Osteoarthritis is diagnosed using a physical examination to check the affected joint(s) for tenderness, swelling, redness, and flexibility. Imaging can help to further confirm joint degeneration by looking at the joint structure. While X-rays cannot show cartilage itself, they could indicate a narrowing of the space between the bones in the joint. This suggests a loss of the cartilage cushion. They can also show bone spurs around a joint that may occur with osteoarthritis. Magnetic Resonance Imaging (MRI) can be used to look more closely at cartilage and other soft tissues.

Ruling Out Differential Diagnosis of Osteoarthritis

When someone's joint pain and dysfunction are not clearly osteoarthritis based on physical examination and imaging, other diagnoses should be considered and ruled out. Physical examination findings and laboratory tests can help narrow down the proper diagnosis of joint pain.

For example, pain around the joint (periarticular pain) that is not reproduced by palpation of the joint or passive motion suggests an alternate diagnosis, such as bursitis, tendonitis, or periostitis.

Whereas prolonged stiffness (greater than one hour) and distribution of painful joints, including the metacarpophalangeal, wrist, elbow, ankle, or shoulder, make osteoarthritis unlikely and raise suspicion for a type of inflammatory arthritis such as rheumatoid arthritis.

If the joint has significant warmth and redness, a crystalline type of arthritis like gout or pseudogout is more likely, and an infected joint may also need to be considered. Aspiration of some fluid from the joint (arthrocentesis) can be used to help distinguish between these types of arthritis by looking for crystals and/or culturing the fluid for microbes.

Functional Medicine Labs to Test for Root Cause of Osteoarthritis

There are no laboratory tests that are specifically diagnostic for osteoarthritis, but functional medicine laboratory testing can assess for markers in the blood reflecting elevated inflammation or antibodies that are linked to other causes of arthritis, for example, rheumatoid arthritis, to narrow down a diagnosis. They can also help uncover factors like vitamin D deficiency or dysbiosis that can contribute to inflammation and cartilage destruction.

Inflammatory Testing

Imbalanced inflammation is a primary contributor to osteoarthritis, so markers like High Sensitivity C-reactive protein (hs-CRP) and erythrocyte sedimentation rate (ESR) can help evaluate inflammation throughout the body that's often associated with altered immune function.

Gut Health Testing

Imbalanced bacteria within the gut microbiome, toxicity, unaddressed food sensitivities, or a leaky gut barrier allowing food or other substances to enter the bloodstream can all increase inflammation that can contribute to the cartilage and joint damage that occurs with osteoarthritis. A Comprehensive Stool Test like the GI-MAP measures gut bacteria, leaky gut, inflammatory markers, and pathogens to evaluate the state of the gut and guide treatment aimed at restoring balance.

Vitamin D Testing

Higher serum 25-(OH) vitamin D levels are linked to reduced knee cartilage loss and a lesser risk of developing osteoarthritis. Vitamin D levels can be detected in the blood via serum or a blood spot test.

Iron Testing

Research suggests that iron overload, which can occur in some genetic conditions like hereditary hemochromatosis, hemophilia, thalassemia, and sickle cell disease, is associated with osteoarthritis. Laboratory testing can elucidate the balance of iron metabolism and storage in the body, such as a complete iron panel measuring iron, total iron binding capacity (TIBC), transferrin, transferrin saturation, and ferritin.

A high ratio of iron to transferrin in the blood could suggest that a person has hemochromatosis, which is a genetic condition where the body does not process iron normally. This can be confirmed with genetic testing.

Ruling Out Other Forms of Arthritis

If the specific type of arthritis isn't clear from physical examination and imaging, some laboratory testing can help rule out other reasons for joint pain and inflammation, such as rheumatoid arthritis (RA). Blood markers like rheumatoid factor (RF) and antibodies to cyclic citrullinated peptides (anti-CCP) can help assess rheumatoid arthritis.

Conventional Treatment for Osteoarthritis

Conventional management of osteoarthritis includes managing pain and improving the function of the joints via the use of knee braces or walking aids, oral or topical nonsteroidal anti-inflammatory drugs (NSAIDs), duloxetine, joint injections, and surgical total joint replacement.

Standard treatment of osteoarthritis frequently involves using nonsteroidal anti-inflammatory drugs (NSAIDs) to manage pain and address inflammation. Other medications that are used for pain management in osteoarthritis include acetaminophen (Tylenol) and duloxetine (Cymbalta), an antidepressant that is also approved to treat chronic pain, including pain from osteoarthritis.

In addition to medications, consistent movement along with physical and/or occupational therapy may be prescribed to help maintain function without causing additional pain.

When more conservative treatments do not bring enough relief, more invasive techniques like cortisone or lubrication injections may be considered. Corticosteroid injections involve using a needle to inject a corticosteroid into the affected joint(s), which must be limited to a few times as steroids may worsen joint deterioration over time. Lubrication injections (viscosupplementation) involve injecting hyaluronic acid into the joint to help increase cushioning, although studies are inconclusive on the benefits of this procedure.

If the joint is heavily damaged with intense pain that does not respond to more conservative measures, total joint replacement surgery may be considered.

Functional Medicine Treatment Protocol for Osteoarthritis

To prevent the pain, disability, and dysfunction that accompanies osteoarthritis, an integrative medicine approach incorporates dietary and lifestyle interventions such as an anti-inflammatory diet, acupuncture, massage, tai chi, and nutritional supplements to help balance inflammation, reduce pain, and keep joints functioning well. This functional medicine approach to osteoarthritis aims to balance inflammation, manage pain and other symptoms, and prevent further damage and injury to the joints.

Therapeutic Diet and Nutrition Considerations for Osteoarthritis

In people with osteoarthritis, an individualized diet that emphasizes anti-inflammatory foods and minimizes inflammatory processed foods and additives can help balance overall inflammation and maintain a proper weight. For example, studies suggest that eating a Mediterranean-style diet rich in fresh vegetables and fruits, legumes, whole grains, seeds, nuts, and olive oil with moderate consumption of fish, shellfish, white meat, eggs, and fermented dairy products can lessen the risk of developing osteoarthritis and result in a higher quality of life for people living with it.

Improving the delicate balance of beneficial bacteria in the gut microbiome can help balance inflammation that contributes to osteoarthritis. Eating a variety of real whole foods while incorporating probiotic-rich foods, such as kimchi and sauerkraut that contain naturally-occurring probiotics, and prebiotic-rich foods like artichokes, garlic, and beans that nourish healthy bacteria is critical for helping to bring the microbiome back into balance and rebalancing excess inflammation.

Supplements Protocol for Osteoarthritis

Numerous botanical and nutritional supplements can help improve inflammation that contributes to joint deterioration in osteoarthritis and reduce pain. Some of the most extensively studied supplements for osteoarthritis include glucosamine, chondroitin, curcumin, and Boswellia serrata.

Glucosamine and Chondroitin Sulfate

Glucosamine and chondroitin are substances that your body makes that are important components of cartilage. Studies show that glucosamine supplementation leads to significant improvements in pain and function over time in patients with osteoarthritis and results in less deterioration and narrowing of joints. Glucosamine sulfate combined with omega-3 fatty acids has also been shown to help with pain and stiffness associated with knee and hip osteoarthritis.

Similarly, chondroitin sulfate is a naturally occurring component of the cartilage of joints and can be taken in a capsule as a supplement. It appears to help prevent further joint deterioration in osteoarthritis with minimal side effects. Research shows that chondroitin supplementation alleviates pain and improves joint function compared to a placebo.

Some research suggests that glucosamine and chondroitin are more effective at helping osteoarthritis when combined. Both supplements protect and stimulate joint cartilage while also suppressing inflammation. For example, glucosamine and chondroitin, alone and in combination, can reduce markers of inflammation like CRP. Further, glucosamine and chondroitin can improve the microbiome and reduce inflammation via this effect since they both have limited intestinal absorption and are predominantly utilized by gut microbiota to protect the gut barrier.

Caution should be taken since glucosamine and chondroitin supplements may interact with the blood-thinning (anticoagulant) drug warfarin (Coumadin).

Dose: Glucosamine Sulfate 375 mg with Chondroitin Sulfate 300 mg, three to four capsules daily

Duration: 6+ months

Turmeric (Curcuma longa)

Turmeric (Curcumin) is used extensively as a culinary spice and has traditionally been used in Ayurvedic medicine. Curcumin has powerful antioxidant properties and has been shown to benefit osteoarthritis in several ways. Studies show that curcumin inhibits the matrix degradation of chondrocytes, decreases inflammatory cytokines, and restores type II collagen and glycosaminoglycan synthesis. A randomized, double-blind study showed that curcumin had similar effectiveness in reducing inflammation as the NSAID diclofenac in patients with OA of the knee.

Meriva® is a proprietary curcumin-phosphatidylcholine phytosome complex that has been shown to improve the quality of life and decrease the use of NSAIDs in patients with osteoarthritis. It has significantly increased bioavailability compared with unformulated curcumin.

Dose: 180mg per day

Duration: 8+ months

Boswellia

Boswellia serrata has traditionally been used in Ayurvedic medicine for its antirheumatic (antiarthritis) activity and has been shown to inhibit the synthesis of pro-inflammatory cytokines that promote free-radical damage and inflammation. The most active component of Boswellia extract is 3-O-acetyl-11-keto-beta-boswellic acid (AKBA) which has potent anti-inflammatory activity that derives from its potent inhibition of 5-lipoxygenase (5-LOX), a major enzyme in the biosynthesis of leukotrienes coming from arachidonic acid in the cellular inflammatory cascade.

A double-blind, randomized trial showed that 5-Loxin®, an extract of Boswellia serrata enriched with 30% AKBA, improved pain and stiffness scores. Similarly, Aflapin® is another synergistic composition derived from Boswellia serrata gum resin which has even more potent inhibition of 5-LOX and reduction of MMP-3 secretion, a matrix metalloproteinase that contributes to the degradation of the joint in osteoarthritis.

Dose: 50mg 5-Loxin® or Aflapin® twice per day

Duration: 1-3 months

When to Retest Labs

To monitor treatment, it is important to review clinical symptoms and/or repeat laboratory testing after 6-8 weeks. This can determine whether the treatment has been sufficient or needs to be continued or modified.

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Summary

Osteoarthritis is the most common form of arthritis and results in progressive deterioration of the joints. This process involves subchondral bone sclerosis, cartilage matrix degradation, and osteophyte formation, most often in the joints of the hands, knees, hips, and spine. This is due to increased chronic inflammation, biological aging, and the loss of structural components, including type II collagen and glycosaminoglycans (e.g., chondroitin sulfate and hyaluronic acid).

To prevent the resulting pain, disability, and dysfunction of OA, a functional medicine approach consists of dietary and lifestyle interventions that help balance inflammation, reduce pain, and keep joints functioning well. An individualized anti-inflammatory diet focused on plant-based foods, like the Mediterranean Diet, that emphasizes vegetables, whole grains, seeds, and nuts, can help lower inflammation throughout the body, including the joints, and contribute to maintaining a balanced weight. Supplements like glucosamine, chondroitin, curcumin, and boswellia can be part of an individualized approach to reducing pain and preventing further joint damage.