PWAC Victoria: Paula Wild, Writing Sample

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Your Aching Joints

by Paula Wild ©

Baby boomers are swelling the ranks of those needing hip and knee replacements. Here's what you need to know about joint health. Published in Reader's Digest, Feb. 2004.

Osteoarthritis is no longer a disease of the elderly, and is resulting in record numbers of hip and knee replacements. Here's all you need to know about joint health.

The pain was unbearable. Bob Kingston couldn't sleep for more than 45 minutes at a time and, despite a steady dose of Tylenol 3, he performed his job as a hospital worker with tears in his eyes. Sitting, sleeping, standing--every position hurt. But Kingston had to work or he'd lose his Victoria condominium. "The constant pain was grinding me down," he admits. "I was reaching the cracking point." He was only 48 when an X-ray revealed he had the hip joint of a 90-year-old and was experiencing advanced osteoarthritis (OA).

Often referred to as "wear-and-tear" arthritis, OA is the primary cause of joint pain. The point where two bones meet is made up of cartilage--a smooth substance that absorbs shock and allows bones to glide over each other. Hips and knees--two of the largest and hardest-working joints--are particularly susceptible to OA.

OA affects one in ten Canadians and can occur at any age. It's 2.5 times more prevalent than heart disease and six times more common than cancer. No one knows what causes OA but heredity, excess weight, joint injuries and being over age 45 are major factors. Studies indicate increased risk for people who jog, regularly walk long distances over rough ground, sit or stand for prolonged periods, and frequently lift heavy objects.

One of the most popular and effective fixes is total hip or knee replacement surgery. Bob Kingston is one of the growing number of baby boomers (those born between 1946 and 1965) turning to this remedy for early onset OA. A decade ago, the number of surgeries in this age range were much lower. A January 2003 report from the Canadian Institute for Health Information reveals that all total hip and knee replacements in Canada increased by 34 percent between 1994 and 2001 (from 32,147 to 42,917). Although the majority of patients were 65 or older, the number of total hip replacements (THRs) performed on those 45 to 55 rose by 43 percent (from 2,310 to 3,013), while total knee replacements (TKRs) for that age group increased more than 90 percent (from 938 to 1,779).

Part of the reason is that boomers have higher expectations than the previous generation of how physically active they can be. Adds Cathy Simon, a licensed physiotherapist and owner of Active Physiotherapy Clinic in Saint John, "Often, boomers are either inactive or they overdo it," she says. "Excess weight and poor posture adds to the problem."

Of course, although it's relatively easy to stress a joint with extra weight or sudden movements, not all joint problems require a replacement; sometimes the solution is as simple as the right shoes. Lisa Kronick, a 44-year-old medical worker and avid exerciser in Toronto, reports "zero pain" after visiting a podiatrist about crippling knee pain. "He advised me about appropriate shoes and made me custom orthotics."

But some injuries are more serious. Kathe Lieber, 53, was running to catch a bus when her right leg buckled. The Montreal writer had torn her knee cartilage, a common joint injury. Lieber took a taxi home and spent weeks trying medications, rest and exercises for the inflammation and pain. "Stairs were a real problem," she recalls. Eventually she agreed to arthroscopy to trim the torn cartilage, which relieved her pain and restored the range of motion.

Women injure their knees more often than men, since there's a wider angle between hip and knee. And hormonal changes affect the elasticity of the body's ligaments. Researchers suspect, too, that women's knee muscles do not contract under stress--thus protecting the knee joint--in the same way that men's do. A University of Michigan study revealed that women who play sports involving jumping and pivoting are up to eight times more likely to injure their knees than men playing the same sport.

Extra pounds also add strain. In 1993 Wendy Horsler fell down a flight of stairs and injured her knee. Ten years later, the 49-year-old executive director of a nonprofit society developed severe OA. But she had to lose 50 pounds before her Saint John surgeon would perform TKR. "I had to first reduce the pressure on my knee," she says.

Relief

Although there is no cure for OA, medications can reduce joint pain and swelling. Exercise, applications of heat and cold, and relaxation techniques are also helpful. Other people find relief through acupuncture and massage.

Some complementary therapies are backed by scientific data. If taken when a person has early to moderate OA, 1,500 to 2,000 mg of glucosamine (sometimes combined with chondroitin sulfate) taken throughout the day may decrease pain and improve function. Studies show promising results from the use of static and pulsing magnets. But all therapies should first be discussed with your doctor.

Maggie Collins, owner and yoga instructor at Wellness Lifestyles in Montreal, tried every treatment she could think of before agreeing to a THR at age 52. "I was diagnosed with OA, possibly because I've been so active all my life. All the cartilage in my hip was worn away--bone was rubbing on bone--and the pain was unbearable. When a joint reaches that point, surgery is the only choice."

Since 1938 surgeons have been replacing hips--the largest ball-and-socket joint in the body--with combinations of plastic, metal and ceramic. New technology has improved these implants although each still has the potential for problems. "The implant choice depends on the patient's age, activity level, amount of joint deterioration and overall bone health," explains Dr. Ethan Lichtblau, a Montreal orthopedic surgeon.

In hip replacement, the surgeon separates the thighbone from the hip socket. The femur head (ball-like portion of thighbone) is removed and the socket reshaped to accommodate the implant, which resembles a ball on a short stick. This is held in place with special cement or a slurry made from the patient's own bone. Soft tissue such as muscles and ligaments cut during the procedure are attached to the new joint.

During a total knee replacement, damaged sections of cartilage and small pieces of bone are removed. The ends of the femur and tibia (shin) are reshaped to fit the implant. A polyethylene plate is attached to the lower part of the implant and another round piece of polyethylene is cemented to the kneecap's back to facilitate movement. Knee implants are usually held in place with bone cement, although screws or pegs may also be used.

A THR or TKR is expected to last 15 to 20 years, but there are no guarantees. And even if an implant does last 20 years, anyone under age of 65 who has a joint replaced will probably require at least one revision.

In an effort to reduce revisions and ensure the best possible care for those receiving joint replacements, the Canadian Joint Registry, a nonprofit organization comprised of orthopedic surgeons, hospitals and joint recipients throughout Canada, was formed in 2000. "By assessing data on implants, surgery techniques, wait lists and rehabilitation, surgeons will be able to choose the best treatment for each patient," says Greg Webster, Manager of Clinical Registries at CIHI.

Although the success rate of THRs and TKRs is very high, the Canadian Orthopedic Association and the Canadian Arthritis Society are concerned about an emerging crisis in access to these procedures. A shortage of orthopedic surgeons and a lack of operating time means many patients are waiting six months for an initial consultation and up to two years for surgery--and all that time, the bones continue to deteriorate.

"Canadians are being forced to wait far too long for joint surgery," says Dr. Mackenzie. He advises people with joint problems to "get on a wait list now." In the meantime, consider taking a glucosamine supplement and focus on low-impact exercises like stationary biking, swimming and walking. "People say it hurts too much to move but that only leads to increased stiffness and pain," says Simon. "It's important for people to exercise within their limits." And, if your physician recommends surgery, see a physiotherapist to strengthen muscles around the joint prior to the operation and to arrange post-surgery physio.

Newer Treatments

Surgical procedures such as hip resurfacing, where the femur head is reshaped instead of replaced, are being used in some larger Canadian centres. Whereas THR patients are advised to avoid high-impact activities, those with a resurfaced hip have no restrictions. Sal LoVecchio, a Justice of the Queen's Bench in Calgary, was 59 when he had his hip resurfaced. "I really enjoy hiking, heli-skiing, golf and cycling," he says. "And I can still do all those things."

Hip resurfacing is only suitable for people under 65 with good bone density and no arthritic conditions in multiple joints. Recipients also need healthy kidneys to process any metal debris from the implant. "I would be cautious about performing hip resurfacing on a woman 55 or older due to concerns about osteoporosis," says Dr. Jim Mackenzie, a Calgary orthopedic surgeon. "Depending on her bone density, a woman over 55 might be better off with a traditional hip replacement."

Another new technique some doctors use on hips and knees is minimally invasive surgery (MIS). This has various versions, some employing incisions as small as two to five inches. MIS results in a shorter hospital stay but surgeons are limited as to size of implant.

Viscosupplementation is a relatively new procedure being used for knee OA. A gel-like substance is injected into the joint, restoring the lubricating and shock-absorbing properties of damaged cartilage. Treatment involves three to five injections and is usually effective for several months. Patients often receive viscosupplementation prior to the golf or ski season. But it doesn't work for everyone and there are questions about its cost-effectiveness: the shots can cost up to $360. Most provincial medical plans don't cover the procedure, though some private plans do. And depending on the patient's age, a $10 cortisone shot can be just as effective.

On the horizon are cartilage transplants and biodegradable plastics that can stimulate the regrowth of healthy cartilage. Australian researchers are working on a bone substitute seeded with the patient's own marrow stem cells. The idea is to create a substance that will provide immediate support yet be incorporated into the natural bone so rapidly that it will soon be replaced with new bone.

Joint Preservation

If your joints haven't given out, start taking care of them now. The first defence is a healthy body weight. Make good posture a habit, change positions often and learn how to lift and carry heavy objects properly. Eat a diet rich in antioxidants--found in fruits and vegetables, particularly prunes, raisins, blueberries, kale, spinach and brussels sprouts--and calcium. And pay attention to your shoes: wear high heels as little as possible and choose the appropriate shoes for sports activities. Dr. Robert Chelin, president of the Canadian Podiatry Association, suggests visiting a podiatrist to see if orthotics will improve your body alignment.

Participate in a regular exercise program that includes strengthening, range of motion and endurance exercises. But remember, alternate high-impact activities like jogging with laps at the pool or cycling. And racing to the gym to exercise during lunch hour isn't a good idea if you can't do a proper warmup and cool-down. "Baby boomers always want to do everything," notes New Brunswick physiotherapist Cathy Simon. "Hurrying is a good way to get hurt."

If you have any doubts about the right exercises for your body and how to do them, visit a physiotherapist or certified fitness instructor to learn the right exercises for your body. "One of the best activities a person can do is walk one to two miles every day," says Dr. Mackenzie. "That has a tremendous effect on your joints and overall health." Be good to your joints and they could last you a lifetime!

For more information, contact the Canadian Arthritis Society at www.arthritis.ca, or 1-800-321-1433.

Paula Wild
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Last updated: July 12, 2005 http://www.islandnet.com/pwacvic/wildp03.html