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Musculoskeletal Health - Introduction

• This lecture covers arthritis, osteoarthritis, rheumatoid arthritis, gout, fibromyalgia, back pain, ankylosing spondylitis, and osteoporosis

Arthritis

• Arthritis is joint inflammation with pain. Includes over 100 conditions that affect joints
• Osteoarthritis is a type of arthritis involving degeneration of the articular cartilage. It is often referred to as wear and tear
• Rheumatoid arthritis is an autoimmune disease of synovial joints
• Gout involves uric acid crystal deposition in joints
• Ankylosing spondylitis is an autoimmune disease affecting the spine
• Psoriatic arthritis is an autoimmune join disease associated with psoriasis

Osteoarthritis

• Osteoarthritis (OA) is a degenerative arthritis of the articular cartilage, typically affecting the weight-bearing (larger) joints and seen mostly over the age of 45 years
• Signs and symptoms include joint pain (e.g., knee, hip) with a gradual onset unilaterally, often worsened by activity and relieved by rest
• Associated joint stiffness
• Joint swelling and deformity (due to osteophytes), with crepitus
• Heberden's nodes refer to swelling at the distal interphalangeal joints
• Articular cartilage composition includes extracellular matrix (water, collagen, proteoglycans) and chondrocytes
• The normal turnover of matrix components is mediated by chondrocytes, which synthesize extracellular matrix components and the proteolytic enzymes responsible for their breakdown
• Proteoglycans are formed of glycosaminoglycan (GAG) chains, such as chondroitin sulfate, which is bound to hyaluronic acid. This provides osmotic properties, critical to resist compressive forces
• Initial step in pathophysiology is a Proteolytic breakdown of the cartilage matrix
• Matrix metalloproteases (MMP) such as collagenase degrade the ECM, releasing fragments into synovial fluid, leading to the release of pro-inflammatory mediators (e.g., IL-1β, TNF-α)
• Level of proteoglycans drops, causing the cartilage to soften, thin, and lose elasticity, further compromising joint surface integrity. Causes fibrillations (vertical clefts) to develop along the normally smooth articular cartilage
• Over time, loss of cartilage causes a loss of joint space
• Erosion of damaged cartilage in an osteoarthritic joint progresses until the underlying bone is exposed
• Subchondral bone responds with vascular invasion and increased cellularity
• Bone thickening ('eburnation') and osteophyte (bone spur) formation occurs
• Overweight or obesity has a direct effect of mechanical load on cartilage
• Increasing age is related to loss of chondrocyte function, Erosion of chondrocyte telomere length and mitochondrial dysfunction are due to oxidative damage, associated with 'inflammaging'
• Previous joint trauma is associates with joint inflammation and onset of cartilage degradation
• T2DM can stimulate chondrocytes to synthesize proteoglycans, consider IR
• The number of OA genetic risk loci identified keeps increasing
• Other joint diseases such as gout and RA
• Nutritional deficiencies such as vitamin D prevent articular cartilage erosion by regulating collagen II turnover and bone metabolism
• Key x-ray findings include joint-space narrowing, osteophytes and subchondral sclerosis
• Radiography may not always correlate but is still a useful diagnostic tool

Natural Approach to Osteoarthritis

• Aims for an anti-inflammatory environment and synovial support through CNM naturopathic diet
• Dietary adjustments address causes by managing weight, improving insulin sensitivity along with dysbiosis and intestinal permeability
• Dietary changes to reduce arachidonic acid, a precursor to the inflammatory PGE2 series, substituting it with precursors to PGE1 series and EPA to PGE3 series
• Nutrient supplementation with Glucosamine which is used to support GAG and proteoglycan synthesis, stimulating collagen production
• Nutrient supplementation with Chondroitin which increases synovial lubrication, is anti inflammatory and inhibits many cartilage degrading enzymes
• MSM is anti inflammatory
• In joints, hyaluronic acid increases the amount of lubrication
• Vitamin C is required for bone chondrocyte matrix synthesis
• Vitamin K and D are required for K-dependent proteins in joint and cartilage calcification
• Herbal remedies such as Turmeric's curcuminoids inhibit NF-kB activation and pro-inflammatory cytokines like IL-1β and -6.
• Boswellia, also an herb, may help promote joint pain relief
• Hydrotherapy that includes contrast showers and/or salt baths provides relief
• Moderate exercise aids in strengthening surrounding muscles and builds joint circulation
• Warming oil blends can also encourage blood flow
• Essential oils provide muscle relaxing effects

Rheumatoid Arthritis

• Rheumatoid arthritis (RA) = a chronic inflammatory autoimmune disease characterised by synovial joint inflammation, potentially affecting all organs except the brain.
• Symptoms include symmetrical polyarthritis affecting small distal joints of the hands / feet and proximal joints
• Hand deformities (e.g., swan neck).
• Subcutaneous nodules.
• Complications include C1/2 vertebral subluxation, pleurisy, pulmonary fibrosis, kidney disease, Sjögren's syndrome, and carpal tunnel syndrome
• RANKL = Receptor activator of nuclear factor kappa-B ligand which regulates osteoclast activity
• Citullination, meditated by genetics and environmental factors, aids the recognition of APCs in autoimmune response
• APCs present antigens to CD4+ T cells, triggers T-cell differentiation. B-cells are activated to plasma cells creating autoantibodies
• T-cells stimulate macrophages in synovial joints producing inflammatory cytokines such as, TNF-a, IL-1, IL-6.
• Inflammatory cytokines stimulate fibroblast-like synoviocytes (FLS), releasing proteases, increased RANKL expression leading to bone density reduction
• Increased genetics by alleles of HLA-DRB1 is a risk, PTPN22 on the non-HLA, with smoking contributing with oxidative damage
• Prophyromonas gingivalis creates enzymes and proteins that target autoantibodies also caused by exposure to silica dust affecting activity and inflammatory cytokines
• Gut dysbiosis as a risk with Prevotella copri abundant in RA and abundance that is raised with Collinsella that have links to gut barrier function and high Collinsella abundance with positive SIBO breath test
• Test results show raised markers for infection and RF in about 70% with anti-citrullinated protein present before the the actual markers have become clinically inflamed
• DMARDs, or methotrexate, is a common prescription alongside NSAIDs for RA symptoms

Natural Approach to Rheumatoid Arthritis

• Naturopathic diets to reduce inflammation, promote antioxidants, follow paleo diet patterns that removes common food allergens
• Evaluate the oral microbiome
• Supplement and restore through Vitamin D, omega-3s and nutrients that suppress Th17 pathogenicity
• Herbs like turmeric and resveratrol
• Support with minerals and tissue salts

Case Study Example

• In RA case study, client "Sue" who is a 37yr old female with wrist/ankle pain with a 4ys of dealing with RA is presented.
• Sue states they felt generally "run down and exhausted" from pain due to having to take care of her father
• Sue took steroids and with high dose of prescription medication
• Sue has a diet of high coffee, low veg intake
• She is recommended to assess causes and determine supplement options

Gout

• Gout = arthritis due to deposition of monosodium urate (MSU) crystals within joints causing acute inflammation
• Monoarticular arthritis most commonly affecting the 1st metatarsophalangeal joint (big toe). Most often affecting men
• Pain, swelling, redness and heat. Shiny skin. Can awaken patients from sleep
• Can affect other joints (e.g., knee)
• Inability to use the joint during symptomatic episode
• Reaches peak within 24 hours, often with fever and malaise
• Hyperuricemia is the key risk factor related to purine metabolism and interleukin imbalances with the enzyme, xanthine oxidase, contributing
• Dietary factors such as meat are high risk as they can leads to increases degradation of the liver via ATP synthesis
• Genetics that ABCG2 mediates and genetic variants that effect urate
• Reduce high doses of diuretics

Natrual Approach to Gout

• Support gut health, optimize Omega 3 ratio, avoid alcohol and refined fats to manage uric acid levels
• Celery and Nettie have been shown to be effective, especially when combined with the the avoidance of coffee.
• The target recommendation for protein is .08g
• Maintain body warmth and drink hot fluids

Fibromyalgia

• Fibromyalgia (FM) = a condition of chronic widespread pain and abnormal pain-processing mechanisms
• Fatigue, sleep disturbance, stiffness, headaches, bowel disturbances, anxiety and depression
• American College of Rheumatology (2010) diagnostic criteria = a widespread pain index (WPI) score of 7+ and a symptom severity scale (SS) score of 5+; a WPI score of 4-6 and a SS score of 9+
• Symptoms lasting at least three months at a similar level
• No other existing health issue can explain symptoms or a differential
• Common causes are emotional or physical trauma with links to disrupted cortisol and hypo thyroidism reducing hormone release
• SIBO links to pain and altered bacteria composition like Faecalibacterium, and has an interplay in neurotransmitter functions
• Gluten reactivity in the form of celiac disease links to common FM
• GAPS (Gluten, alcohol, processed foods, sugar) should be avoided

Natural Approaches to Fibromyalgia

• A Gluten free diet is one diet to adhere to support symptoms in FM
• Supplementation with magnesium, vitamin D, coenzyme Q10 and herbs such as valerian can provide benefits

Back Pain

• Back pain = pain occurring anywhere in the back, commonly the lower back
• The global prevalence of LBP is approximately 8% with at least 60% of adults dealing with it at some point in their life.
• Back pain if broadly categorized as either mechanical or non-mechanical (can be acute or chronic, lasting more that 12 weeks)
• Mechanical: caused by movement
• Back pain onset can gradually appear which comes with a spinal degeneration
• Inflamed joints may have reliving through movement, where degenerative aspects get worse throughout the day
• Trauma is a risk with heavy lifting, or emotional such as increased tone that has correlation with negative thoughts or beliefs
• Non-mechanical: unrelated to movement
• Systemic diseases or renal and thyroid conditions can be causes
• Natural support with stress and inflammation reduction and diet and support through hydrotherapy and body awareness
• Herbs such as turmeric and ginger can also reduce these issues

Ankylosing Spondylitis

• Ankylosing spondylitis is a specific type that is common in men 20-30s and is under diagnosed with inflammatory arthritis and chronic findings causing pain, tenderness, fatigue and the most extreme effects with vertebrae sublaxation

Natural Approaches to Ankylosing Spondylitis

• A low-carb and dairy exclusion lifestyle will alleviate the symptoms
• Supplement with Vitamin D, or anti inflamation and herb combos

Osteoporosis

• Osteoporosis = low bone mass and micro-architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk
• Osteoporosis causes a wide range of health problems which causes symptoms like vertebral fractures and hip or bone loss from high cortisol to menopause to smoking ,inactivity or diet choices
• Asymptomatic signs can be located in vertebrae
• Dual energy x-ray measures and the common support is bisphosphonates but causes side effects

Natural Approches for Osteoporosis

• The focus is to reduce inflammation and ensure optimal nutritional intake such as with vitamin D
• A multi mineral support can provide calcium,boron and manganese
• Exercise to promote balance and weight support where possible