Over the years, Pathology Perspectives has addressed many complicated conditions ranging from methicillin-resistant Staphylococcus aureus infections to polycystic ovary disease. For this issue, however, we are going back to basics and reviewing a condition that almost all of us will experience, if we live long enough: arthritis.
It is important to begin this review of a familiar condition with the reminder that arthritis is not one problem. Rather, it is a collection of dozens of different issues, all of which lead to inflammation in the joints. Synovial joints are the type most frequently affected, but as we will see, cartilaginous joints between the vertebrae are also vulnerable to the effects of chronic inflammation.
The plural for arthritis is arthridites. It is possible for a single person to experience multiple forms of arthritis simultaneously; thus, a person can have comorbidities of arthridites. Some forms and stages of arthritis may respond well to massage therapy, while others need to be avoided when they are acute.
Basic Principles of Arthritis
In order to follow a discussion of what happens when a joint doesn’t function well, it helps to remember what happens when the joint is working perfectly. Most freely movable joints are composed of two or three bones, articular cartilage that caps their contacting surfaces, a joint capsule that wraps around the articulating bones, a synovial membrane that lines the joint capsule and secretes synovial fluid, and external supporting ligaments that reinforce the joint and limit movement to the desired range of motion. In addition, some joints have stabilizing ligaments inside the joint capsule (for example, the cruciate ligaments inside the knee).
When a joint becomes inflamed, a number of problems can follow. Inflammatory chemicals damage articular cartilage, fluid builds up inside the space, and bones may alter their shape and density. The net result is that inflamed joints don’t work well. They may lose some range of motion, they may become visibly and palpably swollen, but most of all, they hurt. When this happens at small joints like knuckles or wrists, this can obviously limit activity. But when it happens at the weight-bearing joints like knees and hips, joint inflammation can quickly become crippling, and may lead to a joint replacement surgery, as discussed in this column in the November/December 2010 issue (“Baby Boomers and Joint Replacement Therapy,” page 96).
Articular cartilage is at the heart of most joint dysfunction. At its best, cartilage is a smooth, rubbery, wet surface that slides along or pivots off a similar surface on the opposing bone. This allows for a lifetime of movement with a minimum of friction. Articular cartilage is invested with living cells called chondroblasts. These cells are able to create new connective tissue fibers and liquid matrix to preserve the health of articular cartilage, but they do not readily reproduce, so an injury to cartilage does not lead to an increase in the number and activity of chondroblasts. This means that when cartilage is damaged, its capacity for healing and repair is limited to what the existing chondroblasts can do.
Osteoarthritis: Use it Up, Wear it Out
Osteoarthritis is by far the most common type of arthritis. It is specifically related to wear and tear of the joint, which leads to cartilage breakdown and erosion of the contacting surfaces. Obviously, osteoarthritis is most debilitating at the weight-bearing joints (the knees and hips), but it can also occur at elbows, knuckles, shoulders, and elsewhere.
Cartilage breakdown is only the beginning of osteoarthritis; inflammatory chemicals inhibit chondroblast activity, trigger the synovial membrane to swell, and ultimately stimulate osteocytes in the epiphyses of the affected bones to become more active. Consequently, the condyles of the bone become enlarged, osteophytes (bone spurs) may develop, and cyst-like cavities may develop under the cartilage of the affected bone.
Spondylitis: Degeneration of the Spine
A subtype of osteoarthritis occurs specifically at the spine. Called spondylitis, this degenerative condition can affect the facet joints in the same way that osteoarthritis affects other synovial joints, but it can also affect the cartilaginous joints between the vertebral bodies in the intervertebral discs.
Remember that intervertebral discs are composed of a strong, dense outer ring of cartilage called the annulus fibrosus, and a softer gelatinous center called the nucleus pulposus. It can be a useful analogy to think of the vertebral bodies as articulating bones, the tough annulus fibrosus as a capsular ligament, and the gelatinous nucleus pulposus as the synovial fluid inside a joint. As the spine ages, especially if the stabilizing ligaments are lax or if the vertebrae are out of optimal alignment, shearing and compressive stresses can affect the health of the joint. The disc thins, and bone spurs may develop around the vertebral body or on the facet joints.
Two major differences distinguish spondylitis from osteoarthritis found elsewhere. One is that while osteoarthritis away from the spine can be deeply achy or sharply painful depending on activity and other variables, uncomplicated spondylitis—especially in the neck—tends to be experienced as an essentially painless, but progressive, loss of range of motion. The other difference is that for reasons that are not completely clear, the vertebrae are much more likely to grow osteophytes than other bones. These bone spurs are often silent, especially when they grow on the anterior aspect of the vertebral bodies. But when they grow in a place where they can put pressure on a nerve root or the spinal cord itself, this creates a pattern of nerve pain that is unique to spondylitis.
Autoimmune Arthritides: The Enemy Within
Rheumatoid arthritis (RA) is an autoimmune disease: an immune system attack against the synovial membranes of joints. RA can affect any joint, but it is most common at the ankles, knuckles, and occasionally the neck.
When a synovial membrane is under attack, all the typical signs of inflammation develop: heat, pain, redness, swelling, and loss of function. Like many autoimmune diseases, RA tends to occur in cycles of flare and remission. During a flare, B cells, antibodies, and many pro-inflammatory chemicals are present inside the joint capsule. The synovial membranes swell and fluid accumulates, which causes pressure and pain. The inflamed tissues release enzymes that damage cartilage and bone. Eventually, tendons and ligaments surrounding the joints may also be affected. All of these factors lead to the deformation of joint capsules and gnarled appearance of RA.
RA flares can also affect many other tissues, including the serous membranes around the heart and lungs, the liver, blood vessels, and bursae. Another important difference between RA and osteoarthritis is that RA is not related to wear and tear—people of any age, and activity level, can be affected by this disease.
Many autoimmune diseases are diagnosed more often in women than in men; RA shows this pattern with a ratio of about 3 to 1. Another type of autoimmune arthritis is much more common in men, however. Called ankylosing spondylitis (AS), this condition is very similar to RA, except that it usually begins in sacroiliac joints and works its way up the back.
As AS progresses, fusions can occur at the vertebral bodies (this is sometimes called “bamboo spine”), but they also occur at the vertebral-costal joints. If the ribs fuse to the spine, the thoracic cavity can no longer expand and contract with the breath, putting the person at increased risk for pneumonia and heart failure.
Gout: The Enemy Outside
Gout is one of the oldest diseases in recorded medical history. It used to be called “the disease of kings,” because it was associated with rich living. Ben Franklin, King Henry VIII, and Johann Wolfgang von Goethe all had gout.
Unlike any of the other arthridites so far discussed, gout involves damage that begins outside the joint capsule. Uric acid, a naturally occurring byproduct of digestion, is produced in high levels when a person consumes foods that are high in purine. These foods include red meat and organ meats, some types of fish and shellfish, asparagus, cauliflower, legumes, mushrooms, and spinach. When purine-rich foods are consumed in large amounts, especially along with alcohol, uric acid can accumulate in the blood faster than the kidneys can excrete it. When uric acid concentrates, it forms microscopic needle-like crystals. These crystals are heavier than blood, and they form most readily at lower temperatures. This means they often congregate in the feet, where they collect around the joint capsule at the first metatarsal and proximal phalanx of the big toe.
Acute gouty arthritis is excruciatingly painful, and when a person has had it once, he or she is vulnerable to repeat episodes, especially if the kidneys are impaired in any way that inhibits the excretion of uric acid. If one visualizes the tiny needle-like crystals corroding the joint capsule at the base of the big toe or elsewhere, it becomes self-evident that manipulating—or even moving—a joint in this acute phase of inflammation is a terrible idea.
What about Massage?
Where does all this leave the massage therapist? Short-run choices in the world of arthridites are actually easy: if a joint is hot, red, painful, and swollen, we obviously stay away. Consider inflammation a local caution and work elsewhere depending on the individual case. A person who is in a flare of RA, for instance, may also have inflammation in other tissues; this makes most types of hands-on bodywork impractical. With gout, however, the inflammation is limited to the affected area; so if the kidneys are healthy, massage elsewhere on the body is probably safe and appropriate. Osteoarthritis—the type of joint inflammation we are most likely to see—is rarely hot, red, and swollen; it is often painful, but that pain is deep and achy rather than sharp and acute. The safety of massage in this situation is fairly secure: unless we push joints beyond a comfortable range of motion, massage is unlikely to make osteoarthritis significantly worse. Whether massage can help with the pain of arthritis, however, is a different issue.
When a person has joints that hurt, especially when this is a situation that persists for long periods of time, the muscles that surround the joint naturally begin to tighten in order to stabilize this weak spot. Postural and movement patterns then adapt in order to reduce short-term pain, but these patterns are often not efficient or pain-free themselves.
The research on manual therapies in the context of joint inflammation is generally very supportive. A quick check of the US National Library of Medicine (www.pubmed.gov) with the search terms massage and arthritis pulls up about 130 research projects where massage was a factor in asking questions about how people can treat or address joint pain. One particularly exciting study looked at full-body Swedish massage for participants who had been diagnosed with osteoarthritis of the knee; a simple treatment regimen led to significant reductions in reports of pain compared to the control group.1 Several compelling conclusions can be drawn from this pilot study: one is that massage is a successful mechanism to reduce the pain of arthritis that does not involve taking painkillers; another is that massage in this study was not specifically directed to the knee, which means you don’t have to be a knee specialist to be effective; and finally, it opens a new question about whether massage as an intervention to manage joint pain can be part of a larger strategy to delay the necessity of joint replacement surgery.
The validation of massage therapy as a viable treatment option for people who are dealing with the pain of osteoarthritis is an important milestone in the development of our professional scope. It is likely that as osteoarthritis and other arthridites become an increasing public health issue, more and more interest in noninvasive and non-pharmacologic strategies will develop. It’s up to us to take advantage of this opportunity by honing our skills—not only to work with this population, but to be able to form partnerships with other health-care providers by using the research that validates our work.
1. A. Perlman et al., “Massage Therapy for Osteoarthritis of the Knee,” accessed November 2011, http://archinte.ama-assn.org/cgi/content/full/166/22/2533.
Reprinted with permission from Associated Bodywork and Massage Professionals.
Ruth Werner is the president of the Massage Therapy Foundation. She is a writer and NCBTMB-approved provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2009), now in its fourth edition, which is used in massage schools worldwide. Her latest book, Disease Handbook for Massage Therapists (Lippincott Williams & Wilkins, 2009), is also available at www.lww.com. More about Ruth at her website: www.rutherwerner.com