The myth of medication's value in the treatment of chronic functional injury.
“He who has health has hope, and he who has hope has everything.” Ancient Proverb
If you drill down deep enough into what makes up our wishes and dreams, it all comes down to freedom. Whether it is financial, spiritual, physical, intellectual or in health, what motivates us most is the desire to be free. Quality in health is the cornerstone to achieving freedom in every other area of your life, because without vitality, liberty in other areas has little or no meaning. When it comes to aging and the treatment of longstanding mechanical injury, so much of our freedom and quality of life is tied to efficiency of mobility. It is more often than not the insidious erosion of pain free movement over time that triggers the domino effect of aging. Evolution has designed us to be magnificent movement machines with the health and efficiency of every facet of our being directly influenced by the quality of our ability to get around. Our current health care system’s failure to acknowledge this defies all logic, ignores our evolutionary development and is ultimately creating generations of weaker and sicker human beings.
I have been in practice for close to 40 years and over that period of time have seen a quantum shift in understanding of long-term mechanical injury as it applies to mobility and weight bearing joints. When I started practice in 1978, medications were the keystone treatment for virtually all longstanding injuries to the spine, pelvis or related joints. It was assumed that once an injury was established long enough to be considered chronic, that there was a permanence attached to the process and the best plan of management would be to control associated discomfort, related inflammation and restrict activity. There was little concern for the long-term consequences of medication use, or the domino impact of loss of mobility to health. Here we are 39 years later and although the long-term ramifications of extended use of medications is well documented and the health implications associated with chronic injury to weight bearing articulations has been established, the preferred strategy for management has not changed. In fact it has gotten more absurd, dramatically less effective and ultimately unmanageable from a cost and disability perspective.
I am not a “drug basher”. I appreciate the value of medications when used in the appropriate circumstance and acknowledge the value as a component in any strategy to manage long standing musculo-skeletal injury. Having said that… I see the use of drugs as the primary form of treatment for mechanical injury and dysfunction as just not logical.
To do such pays no respect to functional mechanics, the interrelationship between joint structures that work as part of the same mechanical chain or the body’s inherent ability to heal. If any part of a functional chain such as hip to foot is structurally compromised, common sense alone dictates that over time other components of that same chain will eventually be impacted and start to break down. In my years of practice, I experience this daily with patients. It is critical to understand that most medications prescribed for chronic joint injury are in the family of non-steroidal anti-inflammatory or “NSAID”. Drugs in this category include but are not limited to products belonging to the sub-group of COX-2s, products that exhibit COX-2 properties, examples include, but are not limited to:
Ibuprofen (Advil, Motrin)
For many of my patients, I encourage the use of these medications on a short-term basis to help control swelling and reduce discomfort, but never long term. Use of these drugs over extended periods without proper companion rehabilitation is a recipe for disaster and can actually foster advanced deterioration while compromising the body’s natural healing capacity. The most vulnerable component of the joint complex is the Hyaline cartilage that lines the joint. To better comprehend the impact medications can have on the development of arthritis, it is critical to understand the importance of this magnificent substance.
Cartilage is nature’s shock absorber and is found between all weight bearing joints. It is the loss of this cartilage due to wear and tear that is, by and large responsible for joint breakdown and resultant arthritis. Cartilage is produced by cells called chondroblasts which are found along the vulnerable edge of the cartilage end plate. This is the place where new cartilage growth occurs. The following taken from “Chiropractic-Help.com entitled “Hyaline Cartilage”, illustrates the nature and vulnerability of this magnificent tissue.
In Hyaline cartilage the protein collagen fibers that are imbedded in the chondroitin matrix are very uniform giving cartilage its hard, uniform and slippery-white appearance. Hyaline cartilage (HC) is vulnerable because it has no blood supply; it is utterly dependent on the continuous supply of fresh synovial fluid to provide nutrients and oxygen, and remove waste products.
It's very hard and slippery, enabling us to bend our knees, move our toes, take a great deal of weight in the hip, and flex and extend our spines, all with minimal friction between the opposing joint faces. Take particular note of the little white arrows in the diagram above. They show the movement of nutrients from the synovial fluid as it sloshes about in the joint, not literally, to the hyaline cartilage on the ends of bones. Cartilage is flexible and very resistant to compression - it's that property that interests us with the hyaline cartilage on the ends of bones. As articular cartilage, hyaline is found covering the contact surfaces of bones in synovial joints. It reduces friction, more slippery than ice, literally, and acts as a shock absorbing tissue.
Without that flow of fluid, carrying nutrients and oxygen to the living hyaline cartilage, it would soon lose the ability to heal itself and begin to degenerate.
This shock-absorbing and cushioning substance is to a major degree what separates us from joint dysfunction, arthritis and pain. It is healthy living tissue capable of self repair like any other of the body’s component parts. Under normal circumstances it is designed to last a life time. But having said that, it is susceptible to breakdown and deterioration through injury, repetitive strain, postural alteration, obesity, lack of movement, nutritional deficiencies, smoking and drug use. So how do these medications often prescribed to treat joint dysfunction actually contribute to it?
In a paper published in the Journal of Prolotherapy entitled: “The Acceleration of Articular Cartilage Degeneration in Osteoarthritis by Non-Steroidal Anti-inflammatory Drugs”, by Ross Hauser MD, the author succinctly articulates the downside associated with the use of these drugs for the treatment of arthritis and associated pain.- “The use of this non-steroidal anti-inflammatory medication has been shown in scientific studies to accelerate the articular cartilage breakdown in osteoarthritis. Use of this product poses a significant risk in accelerating osteoarthritis joint breakdown. Anyone using this product for the pain of osteoarthritis should be under a doctor’s care and the use of this product should be with the very lowest dosage and for the shortest duration of time.” One would think that this should be cause alone for not using this medication long-term, but there is a far more heinous downside.
We have been conditioned to see discomfort as a bad thing and that the absence of pain is equated with a condition’s resolving. Both of these beliefs are horribly wrong and dangerous. In the case of chronic injury where the only treatment is often inflammation and pain management through medication, nothing could be further from the truth. Pain is a very valuable warning sign that something is wrong with the body. To do nothing more than attempt to manage the pain is akin to covering up the warning light on your car’s dash and thereby hoping the problem it represents goes away. This inevitably leads to bigger problems with greater consequences especially when it comes to the management of chronic injury. In short, the use of these types of medication over extended periods of time without appropriate rehabilitation will inevitably result in greater destruction of joint complexes, more pain and eventual impairment. Now the information on the impact of NSAID medications is well documented, but what might surprise you is the number of other widely prescribed drugs that can create or exacerbate arthritic change. In an article published in the Journal Podiaty Today, April 2012, titled: “Pertinent insights on Drug Induced Arthralgia with Commonly Prescribed Drugs” the author, Robert G. Smith, DPM, MSc, RPh, CPed, cautions that many commonly prescribed medications have significant statistical likelihood of either creating or impacting arthritic changes in those using the medications. His research demonstrated the following:
Reported arthralgia adverse effects occurred with 78 out of 117 drugs reviewed (66.7 percent). This research revealed that 14 medications have prevalence rates of 5 percent or greater for drug-induced arthralgia. These medications and prevalence rates for drug-induced arthralgia are as follows:
Risedronate (Actonel®, Warner Chilcott) 11.5 to 32.8 percent
Fluticasone (Flovent®, GlaxoSmithKline) 1 to 19 percent
Conjugated estrogen (Premarin®, Pfizer) 7 to 14 percent
Rosuvastatin (Crestor®, AstraZeneca) 10.1 percent
Venlafaxine (Effexor XR®, Pfizer) 1 to 10 percent
Clopidogrel bisulfate (Plavix®, Bristol-Myers Squibb/Sanofi Aventis) 2.5 to 6.3 percent
Clonidine (6 percent)
Pregabalin (Lyrica®, Pfizer) 3 to 6 percent
Carvedilol (1 to 6 percent)
Meloxicam (0.5 to 5.3 percent)
Atorvastatin calcium (Lipitor®, Pfizer) 5.1 percent
Olanzapine (Zyprexa®, Eli Lilly) 5 percent
Tramadol (1 to 5 percent)
The point in presenting this is not to discredit the above medications, but rather caution those currently taking these drugs who suffer from arthritis, or who notice an increase in their symptoms, or suddenly develop arthritic/rheumatic concerns. If this is the case, contact your physician to see if there may be alternate medications or therapeutic alternatives that may more safely address your needs.
The take away here is quite simply the fact that independent of appropriate rehabilitation and therapy, the long-term use of medications for the treatment of chronic joint dysfunction is actually dangerous and will inevitably contribute to further deterioration and discomfort. The key here is early active management to identify and control dysfunction. This has to start with education as to the long-term implications of ignoring mechanical injury, coupled with reasonably priced access to appropriate rehabilitation.
This is not rocket science….it is just common sense.
Going forward we will explore the best lifestyle strategies to treat your arthritis and maintain pain free mobility.