Osteoarthritis: Disease or Late-Life Benchmark?

Osteoarthritis is a well-accepted diagnosis among physicians for a painful and stiff joint, but the other day I spoke with a rheumatologist who has a very different take on how to characterize these symptoms.

image courtesy Flickr user Jeff Rasansky

Dr. Nortin M. Hadler, a professor of medicine at the University of North Carolina, Chapel Hill, insisted on calling the condition “regional joint pain.” Calling it osteoarthritis reflected the over-medicalization that modern industrialized society imposes on ubiquitous conditions that shouldn’t really qualify as bona fide disorders, he said.

Dr. Hadler’s contention is that having a joint or two grow painful and less functional over the course of more than half a lifetime was inevitable for most people, as unavoidable as “headache and heartache,” he told me. “There is no person after midlife who does not have substantial regional joint pain,” and the older they get the more this colors their life. “It is abnormal [for a middle-aged or elderly person] to go a year without important back pain, or to go 3 years without important knee pain,” he said.

Dr. Hadler added that when people seek out medical care for such routine aches and pains of aging, there is really something else going on in the patient’s life. “The regional disorder can be viewed as a surrogate complaint,” he said. A patient might say “My knee is hurting,” but the reality is that their complaint reflects a broader difficulty they’re having.

He described a study he ran that compared two sets of similar elderly people with the same complaint of knee pain. One group had sought medical care, the other hadn’t. What also distinguished the two groups were their levels of loneliness and depression, which were both higher among those who went to see a physician, he said.

Removing osteoarthritis from the category of pathology and reclassifying it as a more benign and routine part of aging would, no doubt, come as a surprise to many physicians who specialize in studying and treating it.  Last September, I covered the annual meeting of the Osteoarthritis Reasearch Society International (OARSI) and, in counterpoint to Dr. Hadler’s contention, this meeting was attended by hundreds of experts and specialists who would be happy to detail the pathophysiologic processes that appear to define osteoarthritis. Back then, I posted an entry on this blog on the intriguing hypothesis that joint trauma (a severely twisted knee, for example) sets off an acute inflammatory cascade that can have profound long-term consequences for joint health and osteoarthritis development. This notion raises the possibility that a quick and potent anti-inflammatory intervention could help prevent or attenuate the longer-term irreversible damage, the same way that prompt treatment of a myocardial infarction can limit damage to the heart.

My guess is that the reality falls somewhere in between. I’m sure Dr. Hadler is right about some people. Their joint pain is really not too disabling and is something that many other people would just work through, but because of an overlay of coincident emotional and psychiatric issues, they seek medical care and in many cases find physicians who are willing, as Dr. Hadler puts it, to medicalize life and “create a society of the walking wounded.”

On the other hand, I also believe that as the result of some unusual trauma or bad genetics a person can develop a deteriorated and painful joint that is truly pathologic and outside the scope of normal wear and tear and really needs medical attention.

—Mitchel Zoler (on Twitter @mitchelzoler)

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Filed under Family Medicine, Geriatric Medicine, IMNG, Internal Medicine, Physical Medicine and Rehabilitation, Primary care, Psychiatry, Rheumatology

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