The knee bone's connected to... the intestines!?! A holistic approach to the treatment of Osteoarthritis

by Dr. Joseph Debé

Modern science is continually making discoveries that validate a holistic approach to healthcare. This is certainly the case with arthritis. Although "arthritis" means inflammation of the joint, the cause of the condition may emanate, in part, from such remote sites as the intestines, the liver, and the mind.

The most common form of arthritis is osteoarthritis, which is also known as degenerative joint disease. Osteoarthritis is basically a degenerative process involving the degradation of the cartilage that caps bones where they meet to form joints. Cartilage is a tissue that allows for shock absorption and smooth movement of one bone on another. Along with cartilage breakdown eventually comes overgrowth of bony spurs, which are apparently an attempt by the body to stabilize the damaged joint. 

The knees, hips, fingers, lumbar and cervical spines (lower back and neck) are the most common areas that develop osteoarthritis, although it may occur in any joint. Joints may undergo degenerative changes for quite some time before any symptoms develop. Symptoms usually begin gradually and may first manifest as stiffness felt for a short period after getting up in the morning. More advanced symptoms can include more constant stiffness at rest, reduced range of motion, grating or other noises upon motion of the involved joint, muscle atrophy, joint pain and swelling, deformity and significant disability. People with osteoarthritis can often predict bad weather as their joint discomfort increases with drops in barometric pressure. 

Although osteoarthritis incidence increases with age, it is not caused by age. This is obvious, as most people develop osteoarthritis in only a few joints–yet, are not all their joints the same age? Osteoarthritis basically results from an acceleration of cartilage breakdown in relation to regeneration. Cartilage is continually recycled, albeit very slowly. As old cartilage is broken down, new cartilage is manufactured. As long as these processes are in balance everything is fine. However, when degradation exceeds regeneration, joint weakening and degeneration begin. 

The initial event in this process appears to involve the development of excessive loads within an area of the joint cartilage. This biomechanical stress produces structural and biochemical changes within the cartilage, which result in the formation of free radicals and a cascade of pro-inflammatory chemical reactions. This leads to destruction of cartilage and joint fluid. As cartilage and joint fluid break down, the joint loses its ability to absorb shock and more stress is applied to the adjacent bone. The surrounding bone degenerates and over-proliferates, forming spurs. 

Obviously, minimizing mechanical stress to the joints is essential for preventing and treating osteoarthritis. Restrictions in joint motion are a significant contributor to the degenerative process. Joints require smooth unimpeded movement in order to be healthy. Cartilage does not have a direct blood supply and therefore must obtain its nutrition and rid its waste products in a special way. Nutrients and oxygen diffuse through the joint fluid or across bone from nearby blood vessels to reach the cartilage. Waste products are removed in the opposite direction. For exchange of nutrients and waste products to take place requires motion of the joint. Cartilage functions like a sponge in soaking up nutrients and releasing waste products. As the joint is moved and pressure is applied, the cartilage is compressed and releases fluid and waste products, which are drained from the area. During rest the cartilage imbibes water and nutrients and expands. Individuals with osteoarthritis should take a couple of twenty-minute breaks during the day to lie down and remove the effects of gravity so that the cartilage can soak up nutrition. This is also a good opportunity to do some guided imagery and visualize the joints healing. Activity and rest are both necessary for health of cartilage. Published studies have found passive exercise to be the most effective for regenerating cartilage. "Passive" means that the patient relaxes while his/her joint is repetitively moved through a range of motion by another person or mechanical device. 

In addition to exercise and rest, joint manipulation is often critical to assure full-unrestricted joint range of motion. Almost every individual I have ever examined has had one or more joints that are restricted in their full normal range of motion. Joint manipulation is usually the only way these restrictions can be eliminated. A restricted joint does not undergo the alternate compression and expansion of cartilage, which is required for health. Studies have found that surgical fixation of a joint results in degenerative changes within two weeks. Joint restrictions can be thought of as milder versions of surgical fixation. Joint restrictions can result from mechanical stress (such as improper lifting, wearing high heels, sitting with a wallet in a back pocket, and bad posture), chemical stress (such as toxicity and nutrient inadequacy), and mental–emotional stress. What's more, joint restrictions produce pain, muscle tension, and blood vessel constriction, all of which can contribute to the arthritic process. In fact, blood vessel disease (atherosclerosis) probably contributes to osteoarthritis by impairing nutrient delivery to joint structures. Chiropractors are the healthcare professionals most qualified to treat joint restrictions. 

Muscle hypertonicity (tightness) can also contribute to osteoarthritis by causing excessive compression of joints. Moist heat therapy, ultrasound, electrotherapy, massage and stretching are some of the treatments that can help reduce muscle tension. What’s more, certain electrical frequencies have been found to stimulate cartilage regeneration. Ultrasound produces a number of beneficial physiological effects, including very deep heating, which increases blood flow and nutrient delivery to tissues surrounding the joint. Ultrasound also affects soft tissues by increasing new collagen formation and extensibility. 

An up–regulated immune system, or inflammation, can also contribute to osteoarthritis in susceptible joints. It is when inflammation becomes chronic that trouble begins. When the immune system comes in contact with a perceived foreign invader, there is an activation of proinflammatory cytokine production. Cytokines are immune system messenger molecules that are released from white blood cells and circulate throughout the body. Cytokines have multiple effects within the body. The proinflammatory cytokines stimulate joint tissues to produce nitric oxide. Nitric oxide plays vital roles in the body, but is harmful in high concentrations. Nitric oxide is a free radical and contributes to direct damage of tissues. It also inhibits collagen formation within cartilage. Collagen is a major connective tissue protein that forms part of the structure of cartilage. Nitric oxide also inhibits an enzyme that plays a role in the cross–linking of collagen fibers. The net effect of this is a breakdown of collagen and weakening of cartilage. Proinflammatory cytokines also activate an enzyme called cyclooxygenase which produces the damaging chemicals leukotriene B4 and leukotriene C4. The involved cytokines also down–regulate synthesis of other connective tissue proteins. 

Over half of the body's immune system is localized around the gastrointestinal tract. This means that anything that over–activates the intestinal immune system can result in contribution to the arthritic process via cytokine formation. Some of the things that can activate the intestinal immune system include parasites, bacteria, viruses, fungi, toxins, and food antigens. A food antigen is a particle of food that is recognized by the immune system as a foreign invader. Although an individual can react to any food, some of the most common problematic foods are wheat, dairy, citrus, yeast and shellfish. Many different factors are involved in producing an intestinal environment that will activate the immune system. These include: poor eating habits such as eating too quickly and eating while stressed, inadequate secretion of digestive enzymes, overgrowth of toxic organisms within the intestinal tract, inadequate numbers of beneficial intestinal bacteria, insufficient levels of protective antibodies, and Leaky Gut Syndrome (weakening of the lining of the intestinal tract). The lining of the intestinal tract functions as a selective barrier; it must absorb nutrients from food into the bloodstream while at the same time keeping toxic compounds out. Leaky Gut Syndrome refers to a malfunctioning intestinal barrier that is allowing toxins entry to the bloodstream. Stress, poor nutrition, alcohol consumption and use of non-steroidal anti-inflammatory drugs are some of the factors that contribute to development of Leaky Gut Syndrome. Ironically, non-steroidal anti-inflammatory drugs are the main treatment used by conventional medicine in dealing with arthritis. 

Once toxins enter the bloodstream, the liver plays a role in their detoxication. The liver also contains immune system cells. These immune cells also produce the cytokines that are involved in the arthritic process. Natural therapies that restore normal gastrointestinal and liver function are essential to balancing the immune system and lowering production of joint–destructive cytokines. 

Another condition that results in inflammation, and subsequent joint damage, is oxidative stress. This is an imbalanced state whereby free radicals predominate over antioxidants. Oxidative stress can result from many factors, such as: pollution exposure; toxin exposure, including exotoxins (toxins derived from sources outside the body) like the heavy metals mercury, lead, and cadmium, and endotoxins (toxins derived from within the body) such as those produced from bacteria, yeast, viruses and parasites; trauma; radiation; electromagnetic fields; alcohol; cigarette smoke; medications; stress; allergens; cold; excessive exercise; dietary factors such as excess sugar, saturated fat, and fried oils; malnutrition; various disease states; altered physiologic states such as maldigestion/ malabsorption, inflammation, and insulin resistance. Minimizing sources of free radical production and consuming a broad array of antioxidants are essential. 

Some of the other chemical mediators of joint destruction can also be dealt with directly. Gamma tocopherol (a form of vitamin E), vitamin B12, reduced glutathione, the amino acid citrulline, and the spices curcumin and rosemary can all help neutralize nitric oxide. 

Series 2 eicosanoids are another class of proinflammatory chemicals. The non-steroidal anti-inflammatory drugs (NSAIDs) work by inhibiting production of some of these compounds. However, NSAIDs also inhibit other eicosanoids that are necessary for healing to take place. The net result is that NSAIDs impair the body's production of new connective tissue. So, while NSAIDs reduce pain, they actually accelerate the arthritic process! This fact has been documented in animal studies. What's more, thousands of people die every year from taking NSAIDs due to other side effects, including gastrointestinal bleeding and alteration of kidney function. Fortunately, series 2 eicosanoids can be safely reduced by limiting consumption of red meats, organ meats, dairy products, shellfish, refined carbohydrates, alcohol, coffee, and partially hydrogenated vegetable oils (found in most convenience foods). Foods and supplements that should be consumed in order to reduce production of the series 2 eicosanoids include cold water fish (such as mackerel, salmon, and sardines) or fish oil supplements, flax seed oil, borage oil, vitamin E, zinc, selenium, proteolytic enzymes, bioflavanoids, curcumin, ginger, boswellia serrata and quercetin. 

Other joint destructive enzymes include collagenase, elastase, hyaluronidase and chondroitinases. Supplements of OPC (grape seed extract and Pycnogenol), purified chondroitin sulfate, and shark cartilage can inhibit these enzymes. Quality of these supplements can vary tremendously. This is especially true of chondroitin sulfates, with some supplements being totally worthless. The product I recommend for chondroitin sulfate is Cosamin DS by Nutramax Laboratories. This product also contains manganese ascorbate and, most importantly, glucosamine hydrochloride. Glucosamine and chondroitin sulfate are key components of connective tissue, imparting the specialized shock–absorption properties to cartilage. When taken in supplemental form, glucosamine spurs the body's production of new connective tissue and helps in the repair of arthritic joints. 

Many different nutrients play important roles in connective tissue synthesis. It is therefore important to correct any and all nutrient deficiencies. These can be identified by analyses of blood and hair samples. Vitamin C is of particular importance to joint health. It is necessary for the formation of collagen. 

Joint repair is also influenced by pH balance. Synthesis of new connective tissue is markedly impaired by excess tissue acidity. Acids are formed in response to consuming animal protein, grains, sugar, coffee, and alcohol. Stress, toxicity, and deficiencies of many nutrients also increase acid formation. Aerobic exercise and consumption of fruits and vegetables help neutralize acid. The body's pH balance can be measured with some accuracy from urine or saliva. Collect the first morning urine and dip a strip of litmus paper into it. A normal pH is about 6.4 to 7.2. Below 6.4 is acidic. 

Several other natural supplements are often helpful in cases of osteoarthritis. Niacinamide is one of these. High and frequent doses of niacinamide have been found to be very effective. Niacinamide eases pain and stiffness, resulting in measurable increase in joint range of motion as long as supplementation is continued. 

The health of joint tissues is also greatly influenced by various hormones; one of the most important of which is cortisol. Cortisol is an anti-inflammatory stress hormone produced by the adrenal glands. Under stress, cortisol levels rise. However, very prolonged stress exhausts the adrenal glands and results in subnormal cortisol levels. High cortisol levels produce a catabolic state whereby joint tissues will degenerate. Inadequate cortisol levels reduce the body's manufacture of inflammation–suppressing proteins and can also contribute to arthritis. Cortisol levels are influenced not only by mental-emotional stress, but also by biochemical stress such as low blood sugar and inflammation. Cortisol levels need to be considered in combination with its more anabolic partner hormone, DHEA. These hormones are best measured from saliva. Any imbalance in these hormones needs to be corrected with holistic natural therapies. 

An action plan for osteoarthritis treatment should include: 

1. Chiropractic evaluation and treatment to optimize joint mechanics and identify and reduce any sources of structural stress to the musculoskeletal system. 

2. Moderate exercise. This should include strengthening, cardiovascular, stretching, and passive exercise. 

3. Adequate rest, with breaks taken during the day to lie down. 

4. Consumption of plenty of pure water, as cartilage is predominantly water. 

5. Normalization of gastrointestinal and liver function in order to lower immune activation. 

6. Elimination of oxidative stress by reducing sources of free radicals and consuming a broad array of antioxidants from food and supplements. 

7. Supplementation of nutrients that neutralize nitric oxide. 

8. Dietary and supplement strategies to balance production of eicosanoids. 

9. Supplementation of glucosamine and chondroitin sulfates to aid cartilage repair. 

10. Testing for and correction of any nutrient deficiencies. 

11. Measurement and balancing of pH levels. 

12. Evaluation and balancing of cortisol and DHEA levels. 

Obviously, full implementation of this program requires the guidance of a knowledgeable healthcare professional. In my opinion, a holistically oriented chiropractor is best suited to this task.