World Osteoarthritis

Author’s note: My dad wanted me to add that this blog post may put you to sleep or leave you with a sense of “so what.” I almost decided not to post it, but then realized that there are people out there who do not prefer Yahoo News-style stories, or The 5 Easiest Ways to Water Down Health Science to Make it Readable and Unfortunately Incorrect. There are people who want the bigger, more academic piece. So I decided to post.

Once upon a time I was a graduate student. And I had to write a lot of papers and stuff. Even back then, I was fascinated with “the how and why” of stuff. All of my papers read like investigative journalism. I think I missed my calling.

This paper, Cultural Factors That May Affect Current and Future Prevalence of Osteoarthritis in Various Geographical Regions by Katy “I’m a Huge Nerd” Bowman, was a huge catalyst in both my squat work and why I eat so much olive oil. And I mean a lot. I get about 60% of my daily calories from fat. Eaten, mostly, while sitting on the floor.

Anyhow, the original paper is very academic and not written well. I’ve become a much better writer since I became a writer. Turns out there’s something to the concept of practice! I’ve tidied it up a bit, but left all of the smarty-pants references in, so you could cut and paste and copy it and turn it in to your biomechanics teacher and get an F for plagiarizing. Shame on you. Go write your own paper, punk.

Here’s the abstract. This is what people typically read instead of actually reading the whole thing. I never recommend doing that when it comes to scientific content because you need to read the meat of the article to really get it. But, if you’re busy I totally understand.

Abstract

Osteoarthritis (OA) is widespread in the United States, and is currently increasing world wide. The reason for variance of OA throughout the world has not yet been determined. Economical and sociological factors such as literacy rate and gross national product would seem to have some correlation to the level of incidence, but this is not evident in the current literature. There is, however, evidence that cultural factors such as movement and dietary habits can possibly contribute to the likelihood of a particular region developing more OA than another. Forecasts show that without strong intervention, this global burden of injury will have huge financial implications. Increase of OA is likely due to a combination of sociological, ecological, economical, and cultural factors. Improvement in preventative treatments such as education, exercise, and nutritional programs could possibly be hindered by the sociological and psychological perception of injury, as well as the fact that current medical treatment for OA generates billions of dollars of revenue each year.

That is a lot of words to say that American risk factors for osteoarthritis like gender and age don’t hold up in other countries, which means the physiological state of a human being a male or a female or of a certain age isn’t really the problem. So, what are the risk factors, really, that people should be aware of? And, is this information about real risk factors being hidden from us so that Big Corporations can continue to make a gajillion dollars?

As you can see, I used to be a lot more “conspiracy theory” than I am now. I don’t think that anyone is deliberately keeping known information from the people (in this case, anyway) but I do think that the heads of health information have become so ingrained by their own cultural-based info that they can’t hear a different story, even when scientifically valid.

Let’s hear some more, shall we?

In the year 2000, the World Health Organization (WHO) released the beginning of a series of documents quantifying the scope of world wide injury and the corresponding economic burden. This data showed musculoskeletal conditions (osteoporosis, rheumatoid arthritis, osteoarthritis, and low back pain) to be the most common source of physical disability and chronic pain (13). The total cost of these diseases in the year 2000 has been estimated at $254 billion dollars in the United States alone. In developing countries receiving foreign aid, this cost was $100 billion dollars for injury care, an amount far exceeding the amount of total foreign aid awarded (14). High costs being a catalyst, the WHO, in collaboration with the Bone and Joint Decade Monitor Project (a group of international scientific and medical experts) began a project of global assessment. Health care costs and prevalence rates for all countries were assessed, as well as potential treatments, provisions of care, and possible prevention.

 

For the first time, efforts were made to calculate current and projected prevalence of various musculoskeletal conditions from every region of the globe. Examining osteoarthritis (OA) closely, data showed developing countries of the Americas and Europe ranked at the top, almost even with the rate of industrialized nations; North America, Europe, Australia, New Zealand and Japan (13). Regions with the lowest current and projected prevalence of OA were countries of the Eastern Mediterranean, North Africa, and South East Asia (13).

Osteoarthritis, a loss of articular cartilage most common to the knee, hip, and hands, is most likely caused by a combination of mechanical, chemical, or physiological reasons. Physical disability and pain generated by this condition affects 4-5% of the Western adult population and is increasing as the number of older adults increase. With this musculoskeletal disorder growing at such varying rates throughout the world, the economical, sociological, and cultural differences between these regions could offer insight into the mechanism of OA, guide potential treatments and aid in developing preventive programs.

 

Movement habits vary around the world. Postures required for daily living differ due to cultural factors, level of industrialization, and personal preference. Sitting preferences of cultures with less OA prevalence, such as those found in South East Asia and the Eastern Mediterranean are very different from those of North America and Europe; studies on joint kinetics created during daily knee movements in populations with high prevalence of OA are few and far between. Ranges of motion and kinematics for the knee in cross-legged floor sitting, have been calculated for knee replacements in Eastern regions of the world. These regions currently reject arthroplasty as a treatment due to the current joint angle limitations of replacement hardware.

Traditional squatting, cross-legged sitting, and kneeling postures require an average maximum flexion of 111-165° (4, 5, and 7). Hip ranges of motion also have large hip flexion requirements of 90-110° (4, 7). Cultures that sit in chairs excessively are found to have both a higher incidence of OA and joints angles much less than their floor-sitting human counterpart. Other unique movement factors of these low OA prevalent regions are the religious practices found there. Many countries of North Africa, Eastern Mediterranean, and South East Asia are home to the largest populations of Muslims, a religion with mandatory prayer rituals that require a dynamic flow of squatting, kneeling, and bending (10). This bout of activity occurs five times daily, five to ten minutes, from childhood to the end of lifespan. This cultural habit creates a regionally-wide “movement program” that could be responsible for joint health among this population.

 

Another factor, less mechanical in nature, is the dietary intake of the Eastern Mediterranean (EM) region. Over 90% of the world’s olive oil is produced in this area of the world, and not surprisingly, much of it is also consumed in this area. Average percentage of dietary fat for this region is 40% of total energy intake, with almost all of it in the form of olive oil (8). Due to the population’s low occurrence of heart disease, especially the decrease in heart valve inflammation, this type of diet has often been researched. During one of these research studies, an isolation of the compound oleocanthal, naturally derived from extra virgin olive oil, was identified (11).  This compound has proven to be a non-steroidal anti-inflammatory, performing much like the types of non-steroid anti-inflammatory drugs (NSAIDs) given to treat symptoms of OA. Data has never been collected on the possible dietary link between oleocanthal intake and its effect on OA, but some connection could possibly exist. The same dietary intake of olive oil can also be found in Northern Africa, a low osteoarthritic region, due to the proximity of the Middle East and cultural influences of large former EM populations found within this region.

 

As compared to the developed nations of the world and the developing countries of the Americas, North Africa (NA), the Eastern Mediterranean (EM), and South East Asia (SEA) all show a significantly less osteoarthritic population. Why this is true is undetermined at this time.  With almost no OA of the hip, and half the rate of knee OA than the countries of highest prevalence, these regions share similar cultural factors. Joint ranges of motion are consistently greater than those of the countries with the highest prevalence of OA. Bouts of structured deep hip and knee flexion in the form of religious activities are consistent throughout the entire life expectancy, as opposed to the sedentary lifestyles of the countries (or urban regions of countries) with the highest prevalence. Whether or not daily intake of anti-inflammatory compounds has any effect on a condition with inflammatory responses is still undetermined, but worth examining. Osteoarthritis is increasing all over the world and at best, the populations where it is less prevalent should serve as a window into potential preventative treatments with little to no cost or effort.

 

Gender, age, certain occupations, and obesity have all been credited as OA risk factors. Worldwide, women have almost twice the rate of OA (18%) than men (9.6%) (13, 14).  This could be linked to the obesity rate among females, that is also almost twice that of males (2, 6, 12) or perhaps the use of higher-heeled shoes as research has began to show correlations between heel heights and knee and hip degeneration.  Certain occupations, such as farming, also show a greater incidence of hip OA (13).  Of course age, providing a greater period of loading, is also a risk factor for all joint locations of OA.

For unknown reasons, OA, as well as rheumatoid arthritis have always flourished in industrialized countries as well as urban areas of lesser developed countries (13).  As developing countries began to mimic Western culture, socioeconomic changes are impacting daily movement habits as well as dietary ones.

Prevalence of OA has not been shown to correlate directly with a region’s economic status, level of industrialization, or literacy rate. If OA prevalence was based on those things, then the United States, one of the wealthiest, most schooled, and technologically savvy countries should have the lowest rates of OA. Unfortunately the opposite is true. Preventative programs involving diet and exercise intervention are minimally researched and implemented even less.  This lack of proactive treatments has been recognized by Australia, and efforts there are being made to demonstrate the difference in economic spending between preventative and medical treatments to the government as well as its peoples (9).

Some research has been conducted on exercise intervention as a treatment for OA.  A decrease in leg strength is often found in those with OA, especially in females (1,3). Quadriceps strengthening exercise programs for knee OA have been researched, but have shown little to no improvements. This could be due, however, to the intensity (high) of the exercise programs tested. A review of current exercise treatments shows that supervised exercise sessions are more effective when compared to home programs, and the combined effect of weight loss and exercise is superior to exercise alone (1).

Kinesthetic and balancing-type exercises showed significantly greater improvement in measured functional status and quality of life for those group participants than those of the strength-exercise only group (3). Muscle stretching movements and balance/motor skill enhancement meet the WHO’s call for novel exercise treatments to be developed for the prevention and treatment of OA (1). There are many theories regarding gait patterns and placement of the patella on the knee as potentially increasing the risk of OA. There is no definitive information on how the force vector of the patellar tendon can change the mechanics of the knee, or possibly increase the chance of developing OA. If the chance of developing OA is increased with mal-alignment of particular force vectors or problematic gait, then treatments that address center of pressure, joint flexibility, and motor skill acquisition would make a positive contribution to this widespread problem. Using regions with little occurrence of OA as a model, cultural movement habits should be examined further to find possible mechanical, structural and physiological benefits to regular deep bending. Exercise programs to balance mal-alignments and physiological changes stemming from one’s culture (especially a long term restoration to the natural lengths of human muscle found in floor-sitting cultures) has not been researched. The effect of joint mechanics, especially in regards to articular cartilage’s proteoglycans, hyaluronic acid, and lubricin content and synthesis, is a large void in modern medicine.

Restorative and somatic type exercises currently fall outside the curriculum presented in general rehabilitation and current therapy training and teachers of this type of movement lack the training found in anatomical and mechanical science. It is no surprise that skilled practitioners in culturally-free therapeutic exercise prescription are missing from current treatment options.

 

As kinesiologists, we can no longer allow the path of human movement science to steer primarily towards athletic performance and rehabilitation from athletic injury. Exercise treatments are needed worldwide. Preventative exercise program development, implementation and prescription all fall under the wide breadth of the science of kinesiology. Other sciences such as those that focus on post-injury rehabilitation exercise are not responsible for this task. Responsibility for this issue cannot be continually placed on the shoulders of the medical community. This is a costly problem of lifestyle-based illness and injury. Glimpses into the possibly beneficial movement and dietary habits of other places and cultures can inspire possible research that can ease financial burden globally, or potentially generate or improve treatments for a population of epic (and growing!) proportions.

WAKE UP!!!

Me again. Are you reading with one eye closed? I guess interest is in the mind of the beholder. I find this stuff a-mazing. Because it means that the sense of fatalism we have about the state of our health is a conditioned, cultural-based notion. It is also a huge wake-up call to stop doing things just because we always have always done them. There are huge changes that need to happen in the bigger sense, but also inside our tiny yet limitless minds. Start by getting rid of your furniture. And adding 1/3 cup of olive oil to your day. It doesn’t get much easier than that!

1.  Bennell, K., Hinman, R. (2005). Exercise as a treatment for osteoarthritis.  Current Opinion in Rheumatology, 17:634-40.

2.  Bermudez, O. I., Tucker, K.L.  (2003). Trends in dietary patterns of Latin American populations.  Cardernos o Saude Publica, 19:S87-S99.

3.  Dracoglu, D., Aydin, R., Baskent, A., Celik, A. (2005).  Effects of kinesthesia and balance exercises in knee osteoarthritis.  Journal of Clinical Rheumatology, 11:303-10.

4.  Hefzy, M.S., Kelly, B.P., Cooke, T.D., al-Baddah, A.M., Harrison, L. (1997). Knee kinematics in-vivo of kneeling in deep flexion examined by bi-planar radiographs. Biomedical Scientific Instrumentation, 33:453-8.

5.  Hemmerich, A., Brown, H., Simth, S., Marthandam, S.S.K., Wyss, U.P. (2006).  Hip, knee, and ankle kinematics of high range of motion activities of daily living.  Journal of Orthopaedic Research, 24:770-781.

6.  Mokhtar, N., Elati, J., Chabir, R., Bour, A., Elkari, K., Schlossman, N.P., Caballero, B., Aguenaou, H. (2001). Diet culture and obesity in Northern Africa.  Journal of Nutritional Sciences, 131:887-892.

7.  Mulholland, S.J., Wyss, U.P.  Activities of daily living in non-Western cultures:  range of motion requirements for hip and knee joint implants.  International Journal of Rehabilitation Research. 24:191-8.

8.  Panagiotakos, D.B., Pitsavos, C., Chrysohoou, C., Stefanadis, C., Toutouzas, P. (2002). Primary prevention of acute coronary events through the adoption of a Mediterranean-style diet.  Eastern Mediterranean Health Journal, 8:1-9.

9.  Segal, L., Day, S.E., Chapman, A.B., Osborne, R.H. (2004). Can we reduce disease burden from osteoarthritis?  Medical Journal of Australia, 180:S11-S17.

10.  Shelley, F.M, Clarke, A.E. (1994). Human and Cultural Geography: A Global Perspective.  Dubuque, Iowa:  William C. Brown, pp 214-228.

11.  Smith, A.B., Han, Q., Breslin, P.A., Beauchamp, G.K. (2005).  Synthesis and assignment of absolute configuration of (-)-oleocanthal:  a potent, natural occurring non-steroidal anti-inflammatory and anti-oxidant agent derived from extra virgin olive oils.  Organic Letters. 7(22):5075-8.

12.  Snodgrass, J.J., Leonard, W.R., Sorensen, M.V., Tarskaia, L.A., Alekseev, V.P., Krivoshapkin, V. (2006). The emergence of obesity of indigenous Siberian. Journal of Physiological Anthropology, 25:75-84.

13.  Woolf, A.D., Pfleger, B. (2003).  Burden of major musculoskeletal conditions.  Bulletin of the World Health Organization, 81:646-656.

14.  World Health Organizaion (2001). The Global Economic and Healthcare Burden of Musculoskeletal Disease.