Have you been told you have “bone-on-bone” arthritis? Or maybe you’ve been told you need a knee replacement because you have arthritis, but you don’t really have knee pain.
So what should you do?
There’s a lot of confusing information about osteoarthritis (OA), and it’s important to get accurate information and understand what can be done for OA.
In today’s article, we have the honor of interviewing Dr. Tasha Stanton, PhD who is an associate professor of Clinical Pain Neuroscience at the University of South Australia.
Prior to becoming an associate professor and researcher, Dr. Stanton trained as a phsyiotherapist in Canada and worked in the clinic for a while.
Her quest for knowledge and love of research drove her to complete her Masters and PhD.
Pain science has always intrigued her and that’s where the focus of her research is. She aims to find out what contributes to our experiences of pain and how we can use that knowledge to create better treatments. Within her research, she explores virtual reality and augmented reality to see how we can use those technologies to understand pain, as well as how they can be used for treatments.
Interview with Dr. Tasha Stanton, PhD
1. What is Osteoarthritis (OA)?
The definition really depends on where you look. So, OA typically involves changes to the joints, which is often how it’s diagnosed.
Possibly a more modern view, supported by more of the recent science of OA, would actually characterize it as a body-wide systemic, inflammatory condition.
Low-level inflammation that manifests in the joints.
What we’re understanding now is that it’s not a “thing” but it’s a process. An inflammatory process that contributes to the development, progression, and pain that comes with OA.
2. Is OA just a normal, inevitable part of aging?
Here’s where it gets interesting.
If we define OA merely as changes to the joint when we look at an X-ray or MRI, then actually, yes, it could be a normal, inevitable part of aging. Because actually many times when we look at scans, even people without pain will have a scan that indicates osteoarthritic changes.
So the changes on scans are more appropriately labeled “age-related changes.”
However, when we think of OA as the clinical condition that’s associated with pain, stiffness, swelling, and possibly reduced function, then I am going to argue that no, it isn’t a normal part of aging.
It’s not necessarily inevitable.
There’s certainly risks that can increase our risk for OA. For example, having a severe joint injury in the past. But that is not saying that is the sole, causative factor.
Let’s say you’ve had a history of that injury and you’re getting older, and maybe you’re not as active or eating as well, or maybe you’ve gained some weight. All of these things increase inflammation in the body, so those things together can increase the risk of developing OA.
So, no, it’s no inevitable. And I don’t like to think of it as something to just expect with aging.
3. OA is commonly referred to as “wear and tear” in the joints. Can you speak to how this is an inaccurate description of OA?
Just as I mentioned, wear and tear within the joint is not an accurate indication of OA.
When we think of “wear and tear,” many of the assumptions made aren’t supported in the literature.
For example, with “wear and tear” we presume that the heavier an individual is, it’s problematic, because it “wears” out the joint.
But, if we actually read into the literature around weight, what we see is if you’re heavier, but it’s because of greater muscle mass, that’s associated with maintenance of cartilage. Which means that wouldn’t be a progression of OA.
Whereas you’re heavier, but it’s due to higher levels of body fat, that’s associated with development and progression of OA.
So you can be heavier, but the reason why you’re heavier plays a very important role as to whether or not you have symptomatic OA.
This suggests that it’s not just load through the joint.
When people have heavier weight and it’s due to higher levels of body fat, it actually progresses OA in the hand, which is not a weightbearing joint.
We know that having higher levels of body fat increases inflammation. Fat creates adipokines, which is a molecule that promotes inflammation.
That’s just one example of how “wear and tear” isn’t an accurate description.
4. So is OA solely caused by inflammation then?
It really is a bunch of different factors all together.
It’s kind of the perfect storm of having a previous injury-although you don’t always have to- and having higher levels of inflammation for various reasons (which does increase with age).
All of these factors can come together to cause symptomatic OA.
So it’s not just one cause, but a multitude of factors.
5. What causes increased levels of inflammation?
As previously mentioned, having higher levels of adipose tissue (fat tissue), which release those adipokines, lower levels of physical activity, decreased sleep, and even low mood.
Low mood typically surprises people. Negative affect, or feeling not optimistic, can actually increase inflammation.
So how we feel can contribute to many physiological processes in our body, including increased inflammation, which can make OA hurt more and make it more likely to progress.
6. I’ve Been Told I have OA and my cartilage is never going to heal, so is there anything I can do for OA?
First of all, cartilage is not the only player in the game of OA.
We see in those with OA that there are many different changes within the pain system itself. This means it’s on high alert, so everything is more sensitive.
This relates to some of the mechanisms that work within the pain system in terms things like temporal summation.
Temporal summation is the “wind up” or how quickly things become sensitized- which is increased in those who have persistent pain.
Also the descending, inhibitory systems that dampen things down, making them less sensitive, don’t seem to be functioning correctly in those with OA.
So, to answer the question, there’s really a couple things here. First, you can have symptoms with very little damage to the cartilage, because of a variety of factors.
Second, we have evidence to suggest that people that are undergoing exercise for OA have healthier cartilage than people who aren’t.
So it does suggest that exercise and activity- loading that joint- is actually really good.
And this makes sense with the physiology. Cartilage doesn’t have a blood supply, so the way it gets nutrients is actually through loading.
So when you’re walking, loading the joint, doing exercises, that’s nourishing the cartilage!
We know that loading is what stimulates daughter cells from these specialized cartilage makers in the cartilage itself to go forth and find areas that are damaged or vulnerable.
So I think this idea that “My cartilage is shot and there’s nothing I can do” isn’t supported by the evidence. There can be other contributors to pain beside cartilage and the other contributors respond really well to increased activity and reduced inflammation.
7. You talk about the three key ingredients- AKI- for recovery (recovery is defined as: returning to the desired level of functioning with little to no pain). Could you discuss what these are?
Increasing knowledge, increasing activity, and decreasing inflammation.
They’re key because they work as a team.
When you think about baking bread and you think about the ingredients by themselves- water, flour, yeast- they’re nothing special.
But when you put them all together, you get bread-delicious!
Similarly, with OA, when we put all the facets together, they start to help each other.
When you move more, you start to have reduced levels of inflammation. Reduced levels of inflammation can actually help you learn better. This helps you understand more about OA and why certain things are good for you to undertake and not being fearful of it.
So all of these work together and have the potential to have this exponential effect.
8. You did an interesting study on how negative emotions impact our inflammatory response, showing that those who recalled a negative event experienced higher levels of pain and inflammation. Do you have any tips for readers on how to reduce inflammation through recognizing/changing emotions/thoughts?
That study basically showed that when you recalled the negative event, you had increased levels of cytokines in your blood.
Some of those were related to inflammation.
In terms of reducing inflammation through recognizing and changing thoughts, I want to focus on the fact that just changing thoughts and emotional responses isn’t enough for most people to have a significant impact.
Eating, though, is something that can have a greater impact.
For example, the Mediterranean diet has been shown to have good ability to reduce inflammation, so that’s a key aspect.
But it is relevant to consider other things that are adding on, and emotions and thoughts come in here.
One way to do this is to look at how you talk about your osteoarthritic joint.
Do you say, “My bum knee,” or “I’m crippled,” or “The bad leg?”
Just thinking about changing those words yourself and how you relate to your own body can be an interesting experiment for you to do to see how this impacts your mood and how you’re thinking about your own condition. As well as how you’re thinking about the prognosis of your condition.
And then as you have a greater mood, see how that impacts your desire to go out for a walk or just move in general.
So I think in addition to direct effects on inflammation, we can start to see the greater impact of changing or altering mindset on how we approach life.
9. My doctor says the best way to decrease knee pain caused by OA is to lose weight. Will weight loss help?
Yes, for the most part.
It tends to help people who do have extra body the most- which talk to us after the holiday season and many people will be in that same place.
But that by itself is not always sufficient.
That’s where increasing knowledge and increasing activity are important to be able to navigate situations and to understand how best to approach something new- like an activity you’ve been invited to when you have a painful knee.
10. If decreasing adipose tissue helps with OA, does that only help in load-bearing joints?
No.
And that’s why we really think that OA is more systemic inflammation, because the sore thumb will start to feel better when you’ve lost more adipose tissue.
So that speaks to a body-wide response.
11. I’ve been trying to lose weight and haven’t had much success. Is this the only way to decrease pain caused by OA?
No.
And I think having a main goal of losing weight can be really hard and be really discouraging.
I would reframe the goal to be- reducing inflammation.
Take the weight loss goal and throw it out the window.
Instead, think about ways to actively reduce inflammation that includes slowly but surely changing your diet over time- having less processed foods, eating more fruits and veggies.
And finding ways and strategies that work for you. Maybe that includes building up the courage to say to family, “I’m trying something this month and I really don’t want be eating sweets. It would help if you didn’t offer it to me, because it’s really hard to say no.”
Focusing on decreasing inflammation is an important aspect, but increasing activity is also a helpful way to reduce pain.
12. I have knee OA and exercise seems to make my OA pain worse, is exercise making it worse?
For the most part, no.
Increased pain that we have during exercise with things like going for a walk or bike ride, or just steadily increasing our activity is not making things worse.
If you have been sitting on the couch and then you decide to hike up a mountain, I would argue that there’s risk of injuring yourself. Not necessarily that it would be that specific joint. It could be that you could strain your muscle, for example, because none of your body tissues or systems are used to that activity, so it’s too big of a stimulus.
If we start slowly but surely with activity, that gives us time to adapt.
13. Can I overdo it with exercise or should I just push through the pain?
Yes, we can overdo it.
Typically how we determine this is when we have the situations when the pain doesn’t go down within a few hours of the activity or for sure by the next day.
The same applies to swelling or stiffness- when they don’t settle down after activity.
I don’t recommend pushing through increased pain, but I do recommend working with a health professional to help you determine the level of activity that suits you where you’re at.
Then, slowly but surely you can increase that over time.
What that allows is our body’s natural bio-plasticity to work for us.
If we just give a little bit of a stimulus, that cues our body to adapt and our pain system is part of this, so that reduces our pain sensitivity over time.
Typically, once we’ve figured out certain levels of activity, when we do the slowly but surely over time, people will often feel the increases in pain when they’re exercising, which is entirely fine, as long as that’s within a comfortable range of normal and it’s not sticking around when you’re done.
What we’re doing is trying to push your pain system, and just giving it a nudge.
14. I’ve recently been diagnosed with knee OA, so I will need a knee replacement in the future, right?
No.
There’s a very real possibility that there may be no knee replacement surgery in your future, ever.
There’s good research that supports that staying active, eating well, and understanding your OA and the activities that are best for you can be enough and a knee replacement isn’t needed.
The thing is that for some people a knee replacement is the right thing to do and there are many people who benefit from it.
But, it’s really important to try these other options first, because the worst that comes out of trying is you go into a knee replacement being more fit.
15. If I don’t have a diagnosis of OA, is it preventable?
We don’t have very good evidence on that, partly because the studies are really, really hard to do.
As I mentioned before, there are some risk factors. These include previous joint injury, but typically, the best thing to do is to stay active and eat as well as we can, plus getting enough sleep.
Those aspects set us up for having less inflammation throughout the body.
16. What providers do you recommend someone with OA sees?
I’m a little biased because I am a physiotherapists, but I do think physiotherapists are good.
Ultimately you want to find a provider that you trust, and that you feel can help you negotiate with you the various information out there.
A lot of information is contradictory, so it can be really confusing.
I do think PTs are good for this because they have a good understanding of exercise. So they’re good at helping you increase that activity level slowly but surely over time.
We may well see this also with the remit of exercise physiologists.
I also think dietitians are a good person to work with, but we know that can be tough to do. So first just trying to reduce intake of those processed foods can be helpful.
It’s always important to find a general practitioner who isn’t telling you things like, “Oh well you’re knee hurts because you have osteoarthritis, so stop all the things you love doing, and just come back when it gets bad and we’ll replace it.”
If you’re hearing things like that from your providers, it’s really time to find another provider, because that’s not supported by the evidence.
17. Is there anything else you would like people to know about OA?
I really just want to go back to this message of hope.
It’s NOT inevitable that things are just going to get worse and you’ll have to have a knee replacement.
There’s a lot of things that you can do yourself, working with a health practitioner, that help your overall health and help the health of your joints.
Also, if anyone is interested, OPTP have copies of a book (Click HERE for the book) that myself and co-authors have written that explain many of these findings. It’s written for those with OA and clinicians, so it’s an excellent resource to work through.
