In private practice, I hear patients say all the time "I have arthritis" or "I degenerative disc disease". While I do appreciate them telling me this as part of their medical history, I place a lot less value on this diagnosis than they do. The problem with these terms is that patients can hang on to them and use them as a crutch. With a diagnosis of arthritis, it changes the patient's perspective from optimism to one that is doubtful of recovery. Patients often think that the only thing they can do is wait until they are a candidate for surgery. It makes perfect sense to the patient, if their joint is degenerated then that must be the cause of their pain and if they have arthritis then there is nothing that can be done to restore that joint back to optimal function or manage their pain. But I’m here to tell you that there is hope and that a lot of these thoughts that we automatically think about arthritis are not necessarily true.
One of the first problems with these diagnoses is that it is heavily dependent on radiographic findings and the relationship between imaging findings and pain is imprecise. For example, in a study by Culver et al. they assessed over 5000 knee MRIs of asymptomatic, uninjured patients. They found that in adults 40 years or older, 19-43% of them had MRI findings consistent with osteoarthritis. This isn’t just the case with knees either, the same trends can be seen in the spine and hips. Brinjikji et al. completed a systematic review including spinal imaging findings for over 3000 asymptomatic patients. They used this information to calculate age-specific prevalence estimates. It is estimated that 80% of 50-year-olds have signs of disc degeneration. By age 80, it is estimated that 96% of people without spinal pain would have disc degeneration seen on imaging (CT or MRI). It is important to remember that for all of these studies, these are patients without pain!
If you look at the images above, who has back pain? Most people pick the picture on the right as the painful side, but the truth is we can't tell just from a picture.
You might be saying to yourself, “So what?! I don’t care about the people that have signs about arthritis and no pain, I do have pain!”
It is true that MRI findings of disc degeneration are more prevalent in adults with low back pain than asymptomatic individuals (Brinjikji, 2015). However, the majority of MRI findings also have a low predictive value for individuals with low back pain. The important conclusion that I want the reader to come to from this discussion is that with degenerative changes it is important to focus on function instead of structural findings. Because we can’t change the degeneration that has occurred at that joint (structure) but we can improve function and your level of pain.
Osteoarthritis and Exercise
Numerous studies have shown positive effects for exercise on both pain and function in individuals with osteoarthritis. This has spurred the growth of programs such as Exercise is Medicine, which describe that both aerobic and resistance exercise can help people with osteoarthritis. Exercise is a broad term and it can mean anything from a dedicated walking program to aquafit, yoga or resistance training. If you are new to exercising or it has been a long time since you last exercised, don’t be afraid to ask for help and guidance from a health care or exercise professional. Also, don’t be surprised if you are sore from your workout. This is a natural response for our body and as your body adapts to the exercise program you will find it easier (as your function improves). Just remember to do a slow and steady progression of your exercises and try not to increase what you are doing each week by more than 10%, as this may increase your risk of injury.
My chiropractic and kinesiology educational background, has provided me with the knowledge to provide exercise prescription for individuals of all capabilities. Most people look at exercise as, “How much?”. What I mean by this is that we report on how far we walked or ran, how many repetitions of an exercise we did or how much weight we lifted with each exercise. While the "How much" is important, I also look at the “How?”. As a chiropractor, I study the biomechanics of how you move because there are certain movements or postures that may predispose you to an injury or worsening pain. For example, the dynamic knee valgus (knock-knee) position has been related to increased incidence of ACL and patellofemoral knee pain (Weiss, 2015). Part of my goal with each patient is to restore pain-free range of motion to allow proper joint mechanics and then provide rehabilitative exercises to help enforce that new movement pattern.
To wrap things up, there are a few points I would like everyone to take away from this article.
1. Arthritic or degenerative changes seen on radiographs do not have a strong link with individual pain experience.
2. Focus on your function, not the structure
3. There are a variety of conservative (non-surgical) treatments (i.e. exercise, education, chiropractic care, physiotherapy etc.) which can help improve your function and decrease your pain.
4. As a chiropractor, I do care about your arthritis. But my focus is on improving your function and pain perception instead of focusing on the imaging findings.
I would like to close out this blog with a provocative quote from Dr. Stuart McGill, that I hope makes you reconsider degenerative changes associated with osteoarthritis.
Thanks for taking the time to read this blog and if you have any questions or comments please don’t hesitate to contact me.
Dr. Chris Grant