Wednesday, May 31, 2006

The Wilder Shores of Arthritis - Fit the Sixth And Last

Some hope appeared in the 1990s with the development of glucosamine and chondroitin as alternative drug therapies. Both have been investigated thoroughly, but not thoroughly enough for NICE; they're not in the British National Formulary nor freely available on the NHS. So information about them is somewhat limited. They are both substances that occur naturally in the body; glucosamine is an amino sugar and chondroitin a protein. Glucosamine is believed to be essential for cartilage formation and repair, while chondroitin gives cartilage elasticity. So far so good; it seems logical that supplements of these might help to repair, if not prevent, the tissue damage. The medicinal form of glucosamine you can buy over the counter is derived mostly from sea fish such as crabs, lobster and shrimps, and chondroitin from sharks (sharks, a very primitive life-form, do not have bones in their bodies, only cartilage).

Glucosamine has been extensively studied, and the general conclusion seems to be, that it gives results better than placebo in two respects: pain relief and slowing-down the degenerative process. For chondroitin the picture is considerably less clear. They both seem to be reasonably free of toxic side-effects at therapeutic doses, although studies of long-term usage have not yet been completed. They do not either prevent or reverse the damage, as far as is currently known. Wouldn't you know it, the commonest reported side-effects of glucosamine are gastro-intestinal; plus ├ža change.

In recent years several studies have been done on the use of music therapy in controlling, or at least alleviating, chronic pain. As far as joint pain is concerned, it is claimed that listening to music can have "statistically significant" effects on the level of pain experienced, "reducing pain, depression and disability and increasing feelings of power", although the British Pain Society is more cautious about such results, noting that the effects are of short duration and do not amount to much more than "distraction". As against this, clinical trials purport to have shown that music can release endorphins and change catecholamine levels so as to relieve pain, decrease blood pressure, heart and respiratory rate, oxygen consumption, and serum lactic acid levels.

If anyone is interested, a couple of useful references are listed at the end of this blog.

Surely the oddest prophylactic/treatment for rheumatism and arthritis must be the wearing of copper bracelets. Odd, because any effect is almost certainly pure placebo; I say almost, because there may be things about the role of copper in the human metabolism not yet discovered. The theory is, as I understand it, that traces of copper are absorbed through the skin under the bracelet and are in some way beneficial to the disease. The enzymes cytochrome c oxidase and superoxide dismutase are essential to normal cell function; both contain copper atoms which is why some copper (about 70 mg per average adult, with a daily intake of 1-2 mg) is essential to life, but copper is so ubiquitous in foods of all kinds that deficiency is virtually unknown.

There is a very rare condition, Menke's disease, where the gene responsible for copper use is lacking, but it is incurable and untreatable, and leads to death in early infancy. In any case, copper's function is principally with the liver, muscles, and brain; it is not, as far as is known, more than marginally necessary for the normal function of joints, bones and collagen. Deficiency, induced artificially in clinical trials, produced raised cholesterol, hypertension, anaemia and lethargy, not joint disorders.

Moreover, copper itself, in excess, is a poison. Wilson's disease is a genetic disorder resulting in the inability to utilise copper properly, so that it builds up in and damages the brain; it is treatable. Workers on fruit farms and vineyards used to be exposed to high levels of copper sulphate from sprays (Bordeaux Mixture) and suffered accordingly. They would be liable to inhale the sprays and absorb some through the eyes and mucous membranes. But it is, after all, unlikely that the wearer of a copper bracelet would absorb any of the copper at all, intact skin being a very efficient barrier.

The most likely derivation of copper bracelet therapy goes back to magic and the very ancient, still continued, practice of wearing of protective amulets and talismans. Nonetheless, if you think it is doing you good, then it probably is, psychologically at least, so why not?

I have deliberately left surgical intervention till last. This is, after all, a very recent option. Emergency orthopedic surgery, for fractures and battle injuries, is probably as old as mankind, but surgery for arthritis comes under the heading of elective surgery. Anaesthetics, blood transfusions, and antibiotics were needed to render surgery safe, especially the latter as bone infections used to be killers and are still very difficult to treat even today. Also needed was the development of modern hypoallergenic lightweight metal alloys, and plastics and glues.

The first elective orthopedic surgery was done, as early as the 18th century, on cases of bone and joint deformity due to rickets, polio, or TB. The first arthritic-specific prosthesis I can find was made of ivory, for the femoral head, and was developed by Ernest William Hey Groves (1872-1944) in the nineteenth century. Rejection must have been a problem in the days before immunosuppressive drugs. Modern total hip replacements date no further back than the 1960s, when Sir John Charnley developed prostheses of metal and high density polyethylene, attached to the existing bone with methylmethacrylate cement. Since then, uncemented arthroplastic techniques for the hip have appeared, and, in the 1970s, total knee replacements using similar methods. Nowadays, shoulders, elbows, wrists and ankles can also be replaced.

It is perhaps not always appreciated, though, that these replacements have a limited life. Anyone requiring them early in life is liable to be readmitted to hospital fifteen or twenty years later, suffering, quite simply, from metal fatigue.

One change there may yet be, and it's not medicinal. As was pointed out in The Summer of a Dormouse - one of the contributors to The Goldfish's BADD thread - ageism is a powerful factor in deciding which medicines get developed, which treatments get researched. Up until now, the diseases of age have got a very poor slice of this particular cake, and osteo-arthritis, traditionally, has been seen as a disease of the elderly. (Rheumatoid, being recognisably a disease suffered by younger people as well, gets a much higher profile.) So who cares if an eighty-year-old can't get out of bed in the morning? He's not an Economic Unit.

Well, first, it is becoming increasingly clear that osteo is not exclusively a disease of the old. Second, even eighty-year-olds may be needed in the workplace if current trends continue. So research into the "diseases of ageing" may well get an economic and political impetus at last.

McCaffrey, Ruth and Freeman, Edward: "Effect of music on chronic osteoarthritis pain in older people" Journal of Advanced Nursing 44 (5), 2003, p. 517-524
Siedlecki, Sandra L and Good, Marion: "Effect of music on power, pain, depression and disability" Journal of Advanced Nursing 54 (5) 2006 p. 553-563