“Sometimes the most difficult thing is to be able to see the most obvious thing!”

–Mehmet Murat Ildan

It was more than 70 years ago when the Arthritis Foundation was formed. It’s purpose was in helping to curb what was then deemed “the oldest crippling disease known to man.” Well we’ve come a long way…and some of it hasn’t become good news.

By 2040 the number of adults with arthritis is expected to hit 78.4 million, most of whom will have osteoarthritis or OA. (1)

Today there are 54 million adults in the U.S. with doctor-diagnosed arthritis (2). Newer adjusted estimates believe the number to be far higher at 92 million adults with arthritis or joint symptoms consistent with arthritis (3)

Despite a decline in length of hospital stay (8.9 days in 1992 to 3.4 days in 2013), the United States Bone & Joint Initiative (USBJI) reports that total hospitalization charges for knee replacements have increased by five times – $8.4 billion in 1998 to $41.7 billion in 2013 (4)

Annual all-cause costs (both direct and indirect) attributed to OA and allied disorders averaged $486.4 billion nationally between 2008 and 2014. And from 2013-2015, about 30% of adults aged 18-64 reported a work limitation or not working at all, due to arthritis (4)

If we jump back a full seven years ago, total medical costs and earning losses due to arthritis were $304 Billion – or about 1% of the U.S. GDP. (Murphy, 2017) I could go on and on…but you get the very sharp point I’m laying out on costs and impact from arthritis.

Osteoarthritis or OA is the most common form of arthritis. As a chronic condition whose cause is a breakdown of cartilage that lines the shared bone surfaces in the joint. It impacts many joints – with the knees, hips, neck and lower back most commonly affected.

Over time, the decrease in normal joint gliding from the worn cartilage causes bone surface changes. Osteophytic protrusions or bone spurs are eventually formed. And these spurs further cause damage to the cartilage – lending to a positive feedback loop until a joint may become bone-on-bone.

The medical profession has largely been taught to understand, treat and educate patients on arthritis in a more reactive vs. proactive manner. Due to the lag between onset, symptoms, dysfunction and economic/lifestyle impact, it long overdue to update this paradigm.

Especially with today’s focus on chronic disease, comorbidities, cost, and population health, we must focus more strongly on earlier detection of OA. And we can start with some misunderstandings from both the doctor and the patient side.

Many people attribute OA as normal or common to aging. While this may be true in certain cases, it is hardly the only reason that we are seeing more OA and having surgeries and joint replacements at younger ages than ever before.

In fact, studies show:

  • Between 2002-2014, almost two-thirds (64 percent) of adults with doctor-diagnosed arthritis were younger than 65 years old. (Barbour -MMWR [65] 2016)
  • The overall number of people in the U.S. with symptomatic knee OA is nearly identical between those 45 to 64 years old and those 65 or older (about 6 million in each age group). (Deshpande – 2016)

The tissue and joint damage of OA can be subsequent to a previously damaged or overused joint. This is extremely important to fully understand and appreciate.

Let’s take an 18 year-old boy who had a moderate to severe whiplash injury to his cervical spine from an auto accident.

No broken bones and two weeks later, he feels much better. So he and his doctor believe all is well. However, orthopedic studies as far back as 1975 point to the fact that violent whiplash injuries can be a contributor to future single-level arthritic changes in the joint. (7)

Four weeks after the injury he feels fine and returns to normal range of motion. A decade later at 28, he find himself feeling everyday low level stiffness and consistent pain level of 3 out of 10 in his lower neck and right trapezius muscle.

He may think it’s just stress or his work. Perhaps he takes over the counter pain relievers. Eventually he may go to his doctor and be given prescriptive pain relievers or a muscle relaxer. After all, he’s 28 and with no sign of an injury or accident and low pain levels, it’s easy to conclude it’s nothing too serious.

The pain is off and on for years. Eventually he get’s a simple x-ray taken may show mild or moderate degeneration with just one disc – and the rest of the spinal discs as normal. So the doctor tells the patient, “well, you got a little degeneration, but that’s normal as we age.” And perhaps all is forgotten or masked.

Then at age 38 he begins to feel something new – tingling down his right arm. It happened the next morning after he did some heavy weight shoulder presses at the gym. An MRI determines that his C5-C6 disc had a moderate to severe postero-lateral right-sided disc bulge.

So the weightlifting caused the herniated disc, right? But if that were true, wouldn’t it stand to reason that EVERYONE who did shoulder presses would have to have arm tingling the next day?

Why him? Because the arthritic joint and longstanding damage to the related cartilage and tissues set up this injury. Worst of all – the doctors and the patient never put the two issues together in relationship.

Now think about all the people who have had a multitude of past injuries in the spine, shoulder, hips, knees, and ankles.

  • How many of these people will have early onset of OA – years before major symptoms?
  • How many will think their aches and pains are worth masking with medication?
  • How many WOULD LIKE TO KNOW if it were truly something more?

Getting the picture? Time and awareness matters. Because perhaps if the man knew he had a degenerated disc and was told to not do certain exercises, it could have prevented further damage.


As for joint surgeries – let’s talk numbers:

  • 600,000 knee replacements per year (in 2014)
  • 400,000 hip replacements per year (in 2014)
  • Surgeons perform around 1.62 million instrumented spinal procedures every year, with more than 352,000 fusions performed. (IData Research, 2019)

I’m not going to debate the need or non-need for surgeries and joint replacements. I will certainly concede that knee and hip replacements are of better quality than they were 25 years ago. I’m also not going to argue about overall management and treatment modalities for the other 100+ arthritic variants – outside of osteoarthritis.

But how many of these surgeries would have to be done IF the patient had known everything about their damaged joints far sooner in the process? Far before the serious pain, symptoms, and irreversible dysfunction set in.

PRE-SYMPTOMATIC DETECTION IS THE NEW GOAL IN OSTEOARTHRITIS

Many diseases have no visual cues in the early stages. At its current state, osteoarthritis (OA) is only detected after bone damage has occurred, when it is in an irreversible stage of the disease. Currently we have no reliable method for detection OA at a reversible stage.

Osteoarthritis is certainly not a life-threatening disease. However it is extremely costly to our businesses, healthcare system, and individual quality of life. In a great many cases where joint replacement is not possible (neck and back), it moves on to greater damage that through neurological means, can impact other parts of the body.

There’s no trick here. The very best time to know you have joint damage is when joint damage has started occurring. And since we know that we don’t carry a warning light and that early OA often carries no aches, pains or symptoms…we must look to bold, new solutions.

Today, some of the most cutting-edge science on early osteoarthritis has been focused on specific bio-markers, soluble proteins, or cytokines. Chemicals that are given off as part of the degenerative process involved in OA.

Machine learning and heuristic search algorithms are starting to be applied, in a manner to determine the disease onset, progress, and even future drug development and targeting. However, bio markers themselves cannot determine where joints are breaking down, much less multiple joints…when the patient has no aches or pain. Detection through imaging is the only way to tell which joints are in what stage of health or damage.

Cartilage is composed of collagen (a protein) and glycosaminoglycans (GAG), which are carbohydrates. When cartilage begins to degenerate even the slightest bit, there is a measurable loss of GAG seen on a special types of medical radiology, known as gagCEST sodium imaging – done within MRI technology.

The decrease of GAG is seen at even the smallest levels because this software tracks protons shared between GAG and water molecules. By using MRI imaging with gagCEST software technology, the MRI can detect early cartilage degeneration of knees, hips, and spines.

In 2018 researchers from Stanford University’s Department of Radiology presented a new technique for combining imaging with early metabolic and cellular markers for early knee OA.

I won’t get into specifics, but the process is a combination of positron emission tomography (PET) and quantitative MRI techniques. This and future technology on early OA detection will continue to thrive – especially in light of the new era in patient-centric healthcare and precision medicine.

So Steve…you really want to use MRI’s like preventative blood pressure or lab test screenings?
Absolutely. Because what we are doing now, at least in the management of osteoarthritis (OA) is so unintelligent and costly. I simply ask these questions:

Would people who knew of pre-symptomatic or asymptomatic mild or moderate OA have better reasons to change their lifestyle and their exercise habits?
How would this fit into today’s provider and payer efforts toward population health and helping to reduce and better manage chronic disease?
Would people be less likely to mask their symptoms with medication, perhaps avoid further damaging joints with existing osteoarthritis?
Why should people not know if they have real damage in their joints?
For the last question, if you’re saying because an MRI is too expensive, then we have a pricing problem. Perhaps MRI pricing could change based on reactive vs. proactive use. The last I checked, everything about OA, including medication, surgeries, and costs are all skyrocketing. This model is simply one of ‘too much, too late’.

At some point the healthcare industry is going to have to recognize that time and detection play a pivotal role in arthritis, just like in other chronic disease. This one may not cause death, but it contributes to pain, suffering, economic and job-related costs to such an extent – that it’s worthy of looking at smarter paradigms that give faster, more transparent information to the patient.

I welcome your feedback.

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DR. STEVE AMBROSE is a widely-recommended healthcare subject matter expert with deep understanding of payer, provider, and technology companies across many industry segments.

He can be reached at: steveambroseUCLA@gmail.com

 

 

 

REFERENCES:

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1.  Hootman, J. M., Helmick, C. G., Barbour, K. E., Theis, K. A. and Boring, M. A. (2016), Updated Projected Prevalence of Self-Reported Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity Limitation Among US Adults, 2015–2040. Arthritis & Rheumatology, 68: 1582–1587. doi:10.1002/art.39692
2.  https://arthritis.org/getmedia/e1256607-fa87-4593-aa8a-8db4f291072a/2019-ABTN-final-March-2019.pdf
3.  https://onlinelibrary.wiley.com/doi/full/10.1002/art.40355
4.  United States Bone and Joint Initiative: The Burden of Musculoskeletal Diseases in the United States (BMUS), Fourth Edition, Forthcoming Rosemont, IL. Available at https://www.boneandjointburden.org/fourth-edition/iiib10/osteoarthritis
5.  Ibid
6.  Foreman Stephen M., Croft Arthur C. Whiplash Injuries: The Cervical Acceleration/Deceleration Syndrome. 2nd ed. Philadelphia, Lippincott Williams and Wilkins, 1995 p-340
7.  https://journals.lww.com/clinorthop/Citation/1975/06000/Soft_Tissue_Injuries_of_the_Neck.6.aspx