Podcast: Arthritis – treatments facts and fiction

Podcast Transcript

Welcome to The Bone and Joint Playbook, Tips on Pain Free Aging with Dr. John Urse. Today’s topic: Arthritis.

Terry OBrien: Hey there everyone I am Terry OBrien and I am really thrilled to bring you the very first episode of The Bone and Joint Playbook with Dr. John Urse. This is an ongoing series of podcasts that features orthopedic topics, lets just jump right into it and I’ll let Dr. Urse tell us about himself

Dr. Urse: Well thanks Terry. I am board certified orthopedic surgeon. I went to Ohio State University undergrad and did my orthopedic surgical residency training here in Dayton and a clinical fellowship in total joint replacements up at Harvard. I co-founded a large orthopedic group called, Orthopedic Associates of Southwest Ohio here in Dayton some 33 years ago and about five years ago got involved with the inaugural course in North America on stem cells and platelet rich plasma, many of which are things we are going to talk about later in this talk about arthritis today.

Terry OBrien: Well that sounds great so I know today this is our very first episode and what we decided to talk about on our very first episode is arthritis. So is it possible you can describe to everybody A. what arthritis is and B. maybe how it comes about and how people get arthritis

Dr. Urse: Yeah well arthritis is simply inflammation of a joint and arthritic conditions that we get throughout our life are among the leading causes of disability in the United States. So that causes people pain, it causes them limited movement and it contributes to their inability to climb stairs, to sleep, to get in and out of a car and do every day activities. So I think the contributing factors are from a lot of different areas. Some people have an injury to a joint and they break a bone in the knee joint and that leads to an uneven knee surface, some people have rheumatoid arthritis where you have an immune response and your body kind of attacks your joints and it can attack the hands, knees, shoulders and hips. Other people just have wear and tear arthritis or osteoarthritis. That is the most common kind and we get it with aging. As we live longer a lot of these things just are the results of more activities we have accumulated, perhaps with repetitive micro trauma or doing the things we like to do.

Terry OBrien: Doctor, what is micro trauma? I’ve never heard of that.

Dr. Urse: Well it would be like working in a assembly line at a General Motors plant and putting a part on a shelf 1,500 times a day and that repetitive movement with your arm overhead or squatting with parts or runners who repetitively run on hard surfaces like a concrete sidewalk or roads, have that impact and repetitive trauma is much like wear and tear on a break shoe of a car its just over time there is a wear pattern.

Terry OBrien: Dr. Urse is is possible to slow down the progression of arthritis? Or is it just the fact that you’re going to get older and it’s going to get worse over time? That seems to be what I think when I think about arthritis.

Dr. Urse: Well thats a great question Terry. The things we like to tell people is that our job is to help slow progression so that the body parts we have can continue to be ours and not an artificial joint which may be the culmination of a really bad joint down the road i.e. a joint replacement or whats called a total knee or total hip or total shoulder. The way we preserve our joints is we modify some of the activities we do. We think of the running surfaces were on, an asphalt track is certainly more forgiving than a concrete sidewalk. Perhaps we look at our waistline and understand our weight effects the knees and hips. In fact if someone loses 20 lbs thats a threefold benefit on their knees so thats sixty less pounds of force across your knees if you lose 20 lbs. I tell my patients that if your knees hurt losing a little weight over time and getting a program to modify your diet and increase your exercise and activities is a great way to do one approach to what is called joint health.

Terry OBrien: So what are the treatments for arthritis? I know there are injections that you do but are there other treatments, over the counter medications you can take what are my options when it comes to treatment.

Dr. Urse: There are a lot of things we can do and a couple of ways we can attack arthritis is attack the lining which is the cells that make knees swell or joints get full or thickened and thats called the synovium. So things that are anti-inflammatory in nature reduce inflammations. Some of these can be in foods and some things are pro-inflammation which are harmful to your joints. So if you have gout which is one of the causes of arthritis from an inflammation cause, you might want to avoid red meats, red wines and what are called high purine foods things like cheeses and things that are high in protein content. A lot of people can google what a gout diet would be, but you want to avoid the things that are bad and then things like antioxidants that are natural things that help inflammation such as fish and flax seed oils other things that help reduce inflammation. I try to keep my patients off anti-inflammatories like Advil, Aleve and Motrin. Those are ok for a dose or two if you have a headache or sore back from planting your spring garden, but you don’t want to be on those medicines long term they have side effects for your stomach and kidneys. In fact last year over 100,000 people went to the emergency room with serious GI complications from anti-inflammatories. 16,000 people die and over 80% of those people didn’t even know they had a problem. So they’re taking something for their knees and it may actually be causing more harm internally than their knee problem which is simply arthritis, arthritis is never going to kill you. I like to use what are called natural anti-inflammatories things that are herbal remedies some of these take the form of plant derivatives, Turmeric and Curcumin are from the same curry type plant your body takes the Curcumin up better in the gut itself and if taken with black pepper extract, you increase the Curcumin uptake by 2000% and can usually find those at a health food store. I tell people that fish and flax seed oil are also natural anti-inflammatories that are good for joints and easy to take. Some of the other herbal remedies are Boswellia which is derived from Frankincense, the wise men knew something I guess. Boswellia works in a double blind study works just about as well as Motrin for inflammation benefits so if you can take an herbal remedy that isn’t going to have side effects to your stomach or kidneys in the long run that is a great option for your body parts and arthritis treatment.

Terry OBrien: You know one of the things that I worry about as a musician, piano player, guitar player is arthritis where my fingers get bent up. I’m not sure what kind of arthritis that is but that does worry me a lot. what are some things you can do and what kind of arthritis is that that cripples people from playing piano.

Dr. Urse: Well again we talked about two things we can attack in the joints that can effect you getting arthritis or the progression of arthritis. One we talked about the lining cells called the synovium. They’re kinda like the things that give you the fluid in the joint and the lubricator joints. The things that keep joints from actually rubbing bone on bone is the cartilage which is the white stuff at the end of a chicken bone. When the cartilage wears down, bone starts to wear on bone which is what you see on x-rays as joint space narrowing or some of these arthritic conditions which can be on your hand or weight bearing joints such as your knees, hips or ankle. In your hand commonly you can have rheumatoid arthritis which effects the knuckles at the base of the fingers and the middle knuckles where the fingers bend. And then wear and tear arthritis just osteoarthritis that effects the hands just as they effect the knees. So we want motion, motion is lotion thats why we tell people to keep active, play the guitar, get in a knitting club get out there and get a squeeze ball, keep your fingers moving. There are cartilage growth factors that you can take, glucosamine and chondroitin are both found to be helpful in slowing arthritis progression. So that doesn’t mean that you’re going to get rid of your arthritis, but it may slow how much wear and tear you get. Glucosamine and chondroitin are two different nutritional products. Glucosamine is actually not a glucose product so it doesn’t effect diabetics, but it does have a little bit of benefit on cartilage protection. Chondroitin is actually derived from bovine sources so people who are vegans needs to stay away from that. There is a slight cross reactivity with glucosamine and shellfish allergies because it comes from the exoskeleton from a shellfish. So other than those two caveats from a vegan taking chondroitin and a shellfish allergic patient taking glucosamine. Those two are great for hands and slowing progression. Other things that help hands and flexibility in hands are cherry tart juice and some of the simple things like castor oil, you can rub castor oil on your fingers or your small toe joints. Those are pretty easy and are a topical application. I have told my patients I am ok if you’re going to use something like a CBD oil, anything you can find that helps you decrease some of the other things that might be more harmful are fine with me. You know what is helping your body.

Terry OBrien: Well I guess as a follow up question, what do you find to be the most popular treatment, rub oils or ointment on your knuckles or joints to make them feel better. What do you find to be the most effective in treating things?

Dr. Urse: Well that’s a good question, but there are two parts to that question. One of them is what is the science shown has any evidence for helping arthritis in the hands. I’ll use the hands as an example for your guitar playing. The first is chondroitin and glucosamine have been shown to help arthritis progression in hands, so if you pick something that we know is a supplement like that then that is one option, the second thing is the juices like the cherry tart juice or some of the oils like fish oil and flax seed oil and I tell people to take 2 teaspoons of flax seed oil and just put it in applesauce, because applesauce is going to make it taste ok, and everyone has had grandma stick cod liver oil in their mouth, it doesn’t take too great, but if you put it in applesauce you can tolerate anything. The second part of that question is what is the good brand to get and that is up to you as a consumer to find a good brand. The United States Pharmaceutical which is USP.org actually looks at nutritional products and vitamins because the FDA does not regulate the vitamin industry, so if your selling a vitamin in the store you can have 15% of what the label says in the pill and sell it and no one is going to tell anyone differently. Which is unfortunate because now you have a crappy vitamins that you spent a lot of money for, you might have bought it at the mall thinking “oh its gotta be good”, it may not be. You have to be a consumer warrior you have to find what nutritional you’re using and find good brands and see how they work for you. Most people should have a benefit from whatever brand they’re using within six weeks, if you don’t see a benefit, you probably have a lousy brand or your body isn’t burning it well.

Terry OBrien: Earlier you said movement or keeping moving is a important treatment so what are some of the therapies or treatments you would do if someone was to come in and visit you and say, “hey hands are hurting” what are the therapies or treatments you might recommend to that patient.

Dr. Urse: Again my adage for any joints is motion is lotion. Again if your knitting or doing embroidery or playing guitar you are using your hands and keeping them moving. That is the best thing, is just simply move. Get a squeeze ball while you’re watching Gone With The Wind or whatever you have on TV, just keep your hands active. Therapy can show you ways to strengthen muscles or stretch what are called the ligaments and tendons around the joint so you maintain flexibility. There are things like pilates, yoga and other relaxing techniques for joints, but we know in arthritis, when we look at evidence based medicine one of the strongest indicators for what is going to help your knee or hip or your body part with arthritis is physical therapy and formal therapy is worth going to for at least a visit or two and I tell my patient to have them show you what to do at home I got a couple of gym pieces in my basement that I probably use as coat hangers, but I would like to do is set up a way to have people help themselves and the therapists can show you that. We know that when we look at things that help and things that aren’t so helpful, in the really strong helpful category is physical therapy especially for lower extremity joints such as the hip, knee and ankle.

Terry OBrien: You know one of the things I don’t know if we’re going to cover it in detail in this segment, but in future segments we are going to talk about stem cells and PRP and how those treatments can be applied to help people with arthritis. So what are the things that you can say about stem cells, PRP or other injections that you can give to people to help them cope with the pain of arthritis

Dr. Urse: Well the first thing I do Terry is examine the patient and look at their x-rays. We like to look at how the joints look, how bad are the hips, knees, shoulders or hands and whats been done up until now. So we always start with simple things, therapy, braces, arch supports if it’s a lower extremity and if it’s out of alignment. We then talk about the things you mentioned such as injections and for most joints we can always inject cortisone which is fast acting, but not necessary very long lasting and has a few side effects as it can raise your blood sugar a little bit. Second type of injection you can use is a gel injection called a visco supplement and these are a way to get a six month cushioning for a knee. Most insurances pay for that, some of the larger carriers are not even paying for that anymore. If you’ve heard of the gel injections such as Synvisc, Gel One, some of these are literally a goop that goes into your knee and actually like a WD-40 for your joint. If that helps for six months, that works for about 70% of people, then that can always be repeated.

Terry OBrien: So are you saying I would walk into the door into your office and five minutes later you would give me an injection and I would walk out of the door?

Dr. Urse: Well yeah you would walk out the door, but you would want to get approval for that because those cost about $1400. So the insurances have to be notified that you need it and yes you have enough arthritis in there and maybe we are looking at a more serious long term solution for your bad knee or hip and that would be a joint replacement or something that you would want to avoid or delay. Ao that is why I bring up these other topics. So if we look at four types of injections you can get, cortisone is fast acting, but not very long lasting, gel visco supplements are slower to work but can last for up to six months. There are two other what they call biologic injections that use your own blood or own biology to make you better. The first is platelet rich plasma or PRP. That’s obtained from a simple blood draw from your arm just like you would get your cholesterol checked at a lab, that is then put in a spinner device called a centrifuge and then that has about 1000 anti-inflammatory proteins and those can be put right into a joint where an area of discomfort is to cut down the inflammation, remember we talked about the lining cells called the synovium. When they get inflamed you get more fluid on your knee or more swelling on a joint or area. That is one of the best effects that platelets have they reduce that inflammation in the joint. What they can’t do is they can’t help rebuild the cartilage. The only cells that have that capability are the stem cells. So stem cells are the final type of injections that we offer people. Those are derived from your bone marrow, we take that from a small area on the back of your pelvis and that blood is taken out and spun in a device called a centrifuge and then that spot in the knee, shoulder or hip using an ultrasound to place it exactly where it needs to go. The advantage of stem cells is they have 20x the anti-inflammatory factors that help pain and inflammation, but they also have growth factors that can help with cartilage growth over time. I tell people these are not going to make your knee or hip look normal, but they are going to delay a bigger surgery such as a joint replacement for perhaps put that off until a later time.

Terry OBrien: So if I have arthritis in my knuckles or hands can you treat with stem cells or PRP for my knuckle?

Dr. Urse: Well we haven’t gotten the stem cells for the small finger joints yet, first of all there is not much fluid in there to begin with. Some of my partners are actually doing a study right now with PRP into the small joints of the hand so we are seeing if those are going to be beneficial. The studies for the stem cells have been in the larger joints the shoulders, hips, knees and the lesser degree the ankle. There are some places that are done spine injections with stem cells. You may have heard Jack Nicklaus went to Munich Germany to get his stem cells put in his back and was out playing tennis the next day, even though I didn’t know he played tennis. So, it’s a brand new area of medicine called orthobiologic’s, its the orthopedic applications of your biology and it has been in the North America market for about five years and thats when I started doing a lot of these. I still do joint replacements for my patients, I do whatever they need. I have some patients that are overweight, too big to even have a surgery they may be a candidate for stem cells, I have patients that are too young and some that are too old, and some that have bad hearts that have a high medical risk factor for surgery and there not surgical candidates or they don’t want surgery or their brothers cousins dentist had a bad outcome with one and they’re not interested in hearing about surgery. These are things we offer people to give them the choose on how to take care of their arthritis.

Terry OBrien: So Dr. Urse let me make sure I got this right. If i come in and get stem cells do I immediately feel better? How long does it last if I get a stem cell injection?

Dr. Urse: Well again we are getting a couple different things from the stem cells. Again, we will combine the stem cells with some of the platelets in your arm because of the factors that are in platelets so when that is given most people get an immediate or relatively early benefit from your injection and that is the anti-inflammatory effects that help swelling and some people say they sleep better the first few nights and have better motion, etc. Some joints actually take longer to respond, the hip historically takes longer to get better after a stem cell injection compared to a shoulder which is the fastest as we do not walk on our shoulders, knees are somewhere in the middle so most people feel better quickly with their knees. On my website drjohnurse.com there is a whole series of testimonials of people who have had injections and how they are walking, we ask them questions about when did they feel better, how quickly did it occur, what amount of improvement did you see over what period of time. We also have some information people can read and the science behind it and the articles in what is called my blog section if you want to read information about that.

Terry OBrien: So what are the success rates for stem cells and PRP? Is it everybody will work for everybody off is it a 50/50 shot? What is the success rate?

Dr. Urse: Well I think they effect everybody. I think that people obviously have different outcomes in how they feel. One of my blogs looks at my pain and function scores which are specific to a joint as far as a rating regarding pain and function. For instance the Oxford Knee Score will as you how your knee feels what can you do what can’t you do how much discomfort are you in are you taking any medications and those are all done before you do any injections. Then those questions are asked at three, six, twelve months and yearly after that. When I look at my last 140 knees that had stem cells, all but two were significantly better in regards to pain and function at the six month mark. So thats a lot of improved people now again some people don’t want to live with 30% of their discomfort and they say they just want to have their knee replaced and thats their choice, but again these have very little downside. I call the downside to stem cells and PRP are financial misery, because there are some costs that the insurance companies don’t cover but they don’t have side effects because its your blood, so you aren’t going to react its not blood doping its a safe way to take your own blood and put it in another part of your body by concentrating these certain cells to get an effect.

Terry OBrien: So is the last stop on this journey of treatments joint replacements, hip replacement things like that? Are there other things we can do or is joint replacement it?

Dr. Urse: Well I always list that as number four, you know so when you see me and I show you your x-rays and you say, boy I am rubbing bone on bone and my leg is killing me or my hip is bad my knee or whatever. Say you have tried therapy, injections, bracing, etc. maybe you have talked about stem cells or maybe you can’t afford them or maybe you don’t want to do it. There are some things like cholesterol medications that effect stem cells that don’t let them work as well so if you cant stop your statins, which are your cholesterol pills, then you may not even want to do stem cells. So if you get to the point it affects your everyday activities you can’t walk a block, can’t climb steps, can’t get out of a car, can’t sleep through the night and can’t enjoy your life because of your hip, knee or shoulder you should look at the option of getting a new joint. That is obviously predicated on your age and your occupation and the fact that you should not run or jump after you get an artificial joint. So if you say you want to keep running, I tell patients I wouldn’t run on an artificial knee or hip. Bo Jackson had a couple hip replacements in his 30’s and tried to play pro sports after that and had two revision hip surgeries. So an artificial joint, you want it to last a long time and then that is when I talk to you about are you at an appropriate age are you at the appropriate level of misery to want to have a joint replacement, then I think I can tell you a little bit about what that involves.

Terry OBrien: Dr. Urse this sounds like we have gone through a lot of different options for treating arthritis. We are going to come back in different episodes and talk about other orthopedic topics. Before we leave the folks today is there any one or two recommendations you might have for folks suffering with arthritis that you can leave us with.

Dr. Urse: Well, I think they should embrace the fact that they can really delay surgeries and they can improve their lifestyles by activity modifications, dietary changes, weight reduction and getting the right information that is best for them. It may be that their best choice is a joint replacement, in that case if its your hip you should ask your doctor what approach are they going to use?Posterior or anterior approach. Some of them are muscle sparing some of them have faster recovery, some allow to sit in a chair and cross your legs more efficiently. There are other benefits to certain ways we do surgeries. I would tell them to ask their doctor if they are getting a knee replacement, are they going to utilize any computer navigation, any 3D models, any blue tooth aids. Otherwise, I call it optical navigation the doctor just uses his eyeballs like Mr. Goodwrench using his thumb on your tires, it’s probably more accurate using computerized systems. Even now we have robotics for joint replacements for hips, knees and shoulders. There are technological advancements that are going to make these I think be replaced more accurately which hopefully would improve their duration and how long they last. But there has to also be an expectation of what the patient needs and thats where they need to do their homework check out who they’re talking to have their surgeon done a lot of these are they experienced in different ways to do it you know, how are there results and make sure they kick the tires on who they’re talking to to take care of their problems.

Terry OBrien: So thank you Dr. Urse for taking the time today to do this podcast. I know as people like me are getting a little older and things are starting to creek information like this is going to be extremely popular. Can people in the southern Ohio region reach out to you, can they contact you directly at your office? How would they do that?

Dr. Urse: Yeah, our group is called Orthopedic Associates of Southwest Ohio you can look us up on OADoctors.com and look up my information about my stem cells and my blog page and some of the testimonials of patients who have had them and information about the procedures on my website, DrJohnUrse.com that will probably be on the screen for you here in a little bit. Again, we are incorporating telemedicine now just like this zoom conference for a podcast, we have people from out of state that come to see me and we are trying to do the telemedicine initial interviews to save them that trip where I can get the imaging studies they have sent to me and I can do a conversation much like I am doing with you, I can say, Terry based on those x-rays and your level of misery, stem cells are a great option for you or not. That can save you a trip and you only have to come in for the procedure and then there are details on how that would be done as an outpatient procedure at the office or in a hospital setting.

Terry OBrien: Alright Dr. Urse thank you very much. Again, I want to thank everybody out there for joining us for the very first episode of The Bone and Joint Playbook. Hopefully you will join us again for future episodes until then take care

Thanks again for joining us on The Bone and Joint Playbook with Dr. Urse. Join us again next time.