It starts with setting realistic expectations for the season
For me, managing holiday stress with psoriatic arthritis(PsA) really comes down to protecting my energy: physically, emotionally, and socially. The holidays can be so joyous, but they can also be exhausting. Between navigating endless to-do lists, family dynamics, colder weather, travel, and packed calendars, it’s a time of year that can push my body and nervous system past their limits pretty quickly if I’m not intentional about how I move through it.
I’ve learned to start by setting realistic expectations. I used to say yes to everything, every invitation, every tradition, every last-minute errand because I didn’t want to let people down or miss out. But now I’m much more honest with myself about what I actually have the capacity for. I ask: What matters most to me this season? What can I let go of? That alone takes so much pressure off.
I also try my best to plan ahead in ways that reduce the chaos. I spread things out over a few weeks instead of cramming errands and prep into one weekend. I look at what else is on my calendar before committing to anything new, and I make sure to block off time for rest, especially if I know something will require more energy or recovery, like travel or a family gathering.
Comfort is another big part of how I get through the season. I’ve let go of trying to look perfectly put together in ways that don’t actually feel good. These days, I’m prioritizing warm layers, soft clothes, supportive shoes and whatever else helps me stay grounded and comfortable in my body. If that means showing up to the holiday party in sneakers and carrying heat packs in my bag, so be it.
Emotionally, I try to give myself space to feel whatever’s coming up. The holidays can stir up grief and frustration of not being able to participate the way I want to. I don’t force myself to be cheerful if I’m not feeling it. But I also try to stay open to small moments of joy and connection, even if they don’t look like I envisioned. Some years, that means new traditions, or quieter ones; it’s saying no to protect my peace and not feeling bad about it.
More than anything, I remind myself that I don’t need to earn rest or prove anything to anyone. Living with PsA means I already have to be mindful of how I use my energy all year long, but during the holidays, I double down on that to avoid stress and burnout. It’s not about doing everything. It’s about doing what matters, in a way that is mindful of how I feel!
It is totally valid to dread winters if you have arthritis, since the colder months don't go easy on the bones. Dr Vaish shares 5 ways you can manage pain
For many people living with arthritis, winter is far from magical. Cold temperatures, falling barometric pressure, and reduced sunlight can intensify joint stiffness and pain, making flare-ups far more challenging to manage. Understanding why this happens - and how to ease the discomfort - can make the colder months much more bearable.
According to Dr Vaish, cold temperatures can make your joint pain worse. (Pixabay)
Dr Abhishek Vaish, consultant orthopaedic surgeon, joint replacement and sports injury specialist from Indraprastha Apollo Hospital and Healing Touch Clinic, Okhla, New Delhi, told HT lifestyle, “Those with arthritis are harder hit by these chilly waves. As the temperature drops, the capillaries narrow, causing stiffness, joint swelling, and weariness. Additionally, their joints respond to an accumulation of pro-inflammatory chemicals, which complicates the situation.”
Why does this happen?
The following are a few causes of arthritis flare-ups during winter, as outlined by Dr Vaish:
Winter increases the sensitivity of the pain receptors.
Joint discomfort results from the air pressure dropping. When pressure drops, tissues swell, causing tension to accumulate between joints, resulting in discomfort.
Colder temperatures cause greater muscular spasms, which exacerbates joint pain and stiffness.
The cold decreases blood flow to the hands and feet, intensifying arthritic discomfort.
Vitamin D levels drop throughout the winter months due to decreased sunlight, which also weakens bones and joints.
Ways to reduce pain
Dr Vaish outlines five effective tips to lessen pain during the colder months.
1. Staying warm
Dr Vaish notes that the most effective way to ease the pain is to stay warm, ideally in a temperature-controlled environment that shields you from the cold. He elaborates, “It is obvious that staying indoors in an environment with proper temperature control is the best method to prevent the cold. However, layering warm clothing made of quick-drying fabrics like wool is one of the greatest strategies to prevent cold weather aches and pains if you must go outside. Wearing long underwear could also help keep your lower extremities warm if you have arthritis in your hips or knees. Keep your feet and hands warm as well! Extra warm socks and a nice pair of insulated gloves can be helpful. You can also spend some time in a warm bath if you arrive home with joint ache from the cold.”
Dr Vaish highlights that staying warm is the best way to prevent pain. (Pexel)
2. Remain active and preferably indoors
According to the orthopaedic surgeon, one of the most effective ways to prevent arthritis discomfort is through regular exercise - a habit that also supports overall wellbeing. Dr Viash notes, “Regular exercise helps to increase muscle strength, flexibility, and energy levels, all of which can assist to lessen joint discomfort. Your joints will be least stressed by low impact exercises.” He recommends the following exercises:
Yoga
Elliptical trainers or indoor cycling machines
Aerobics
Strength training
Walk or run on treadmills or cushioned indoor tracks
If you've never exercised before, Dr. Vaish recommends, “You should start off slowly. Start out by exercising for about two to 10 minutes, twice daily. Rest well in between workouts. You can lengthen and intensify your workouts as you become more accustomed to your new pursuits.”
3. Use compression gear
The orthopaedician emphasises that compression gear is among the most effective tools for easing joint pain in people with arthritis. He explains, “For years, compression clothing such as arm sleeves, gloves, and socks has helped to ease joint pain. These things aid in boosting circulation, which has been proved to alleviate arthritis discomfort. Compression clothing can trap heat, acting as an additional layer to keep your hands and legs warm throughout the harsh winter months.”
4. Omega-3 fatty acids and vitamin D
Eating foods rich in vitamin D and omega-3s can strengthen bones and help reduce discomfort. But in winter, limited sun exposure lowers the body’s vitamin D production, leaving those with already low levels more prone to pain.
Dr Vaish recommends, “Adults should consume between 20 and 50 ng/mL of vitamin D daily. Consume meals high in omega-3 fatty acids, which are rich in vitamin D, such as salmon or mackerel. There are several items on the market that have been fortified with omega-3 fatty acids and vitamin D, such as milk and cereals. To enhance your consumption, you can also take fish oil and vitamin D pills. In fact, a teaspoon of cod liver oil can supply all of your daily needs for vitamin D.”
5. Keep a healthy weight
Dr Vaish stresses that maintaining a healthy weight is crucial for preventing aching joints, as excess load places unnecessary strain on them. He states, “According to studies, brown adipose tissue, which emits pro-inflammatory chemicals that might harm joints, is more common in individuals with high body mass indices (BMIs). Additionally, autoimmune disorders like rheumatoid and psoriatic arthritis can be brought on by inflammation. Additionally, obesity has been associated with a rise in knee arthritis cases. The greatest strategies to maintain a healthy weight are through a nutritious diet and an active lifestyle.”
Note to readers: This article is for informational purposes only and not a substitute for professional medical advice. Always seek the advice of your doctor with any questions about a medical condition.
While the damage can’t be reversed, new research offers promising ways to mitigate the pain and perhaps even slow the disease’s progress by targeting what drives it — things like body weight and mechanical load.
Three recent studies exemplify the trend.
1. Consider Weight Loss Drugs
Excess body weight has long been linked with increased knee arthritis risk. People with obesity have higher rates of knee arthritis, get diagnosed younger, and experience more pain and physical limitations.
“Just telling people ‘go lose weight’ is not going to work,” said Elena Losina, PhD, a biostatistician and professor of orthopaedic surgery at Harvard Medical School.
In a recent study, Losina’s research team created a model to project the cost effectiveness of five weight loss treatments for people with both obesity and knee arthritis:
Diet and exercise
Tirzepatide (Mounjaro, Zepbound), a type of weight loss drug called a GLP-1 agonist
Semaglutide (Ozempic, Wegovy), another GLP-1 medication
The model, which was based on a method called a Monte Carlo simulation, weighed each treatment’s price tag against its projected long-term impact on quality of life. For example, the more weight someone loses, the more pain relief they should experience, along with fewer movement limitations and a lower risk of health problems like type 2 diabetes and heart disease.
The study found that tirzepatide gave people more years of healthier life than semaglutide, diet and exercise alone, or the “usual care” for obesity and arthritis (which may mean no treatment beyond monitoring symptoms). Semaglutide could still be cost-effective for some patients, the study found, but tirzepatide was rated as the best nonsurgical option overall.
For people with a BMI of 35 or above, gastric bypass surgery scored highest. It produced the best results and cost less over a person’s lifetime than either of the medications, partly because surgery is a one-time cost rather than an ongoing expense.
“Bariatric surgery has very high efficacy in terms of weight loss for a very long time,” Losina said. But it’s a drastic procedure, with all the risks that entails. That’s why most people who have the choice opt for medication over surgery.
Since the study came out, the U.S. government announced an initiative to reduce the cost of GLP-1 medications — “an exciting development,” Losina said.
Still, exercise remains the cheapest treatment option, and a second new study may help make it less painful.
2. Change the Way You Walk
Exercise is the most commonly recommended treatment for knee arthritis, and walking is the most commonly recommended type of exercise.
But the repetitive stress of walking — never mind running, basketball, or tennis — can sometimes worsen knee pain.
Arthritis typically begins in the medial compartment of the knee — the part closest to the other knee.
Medial arthritis is three times more common than lateral arthritis, on the outer part of the knee. That’s because, when you walk, 70% of the compressive force lands on the medial compartment.
The way you walk can make the problem worse by shifting even more of that stress to the inside of the knee.
But a recent experiment from researchers at Stanford and the University of Utah showed that gait changes could help patients with medial compartment arthritis shift some of that force to the outside of the knee, reducing pain and making exercise a more viable option.
Participants took a gait retraining program where they learned to turn their toe in or out when landing and pushing off, whichever put less pressure on the medial compartment.
Most of them (82%) were trained to turn their toes in slightly — by 5 or 10 degrees — when they walked. The rest were trained to turn their toes out.
After six weeks, all of them reported mild to moderate reductions in walking-related pain. After a year of maintaining the modified gait, their pain had improved even more.
The Stanford protocol relies on experts and special equipment, so it can’t be replicated at home. But you can talk to your health care provider about making small changes to the way you walk. A physical therapist may be able to assess your gait to reduce pressure on your knee.
Fortunately, there is an exercise program that requires only internet access and a little floor space.
3. Try a Free Tai Chi Program
Physical therapist Kim Bennell, PhD, has been studying musculoskeletal injuries for three decades.
In recent years, she and her research team at the University of Melbourne in Australia have increasingly focused on exercise, as it’s the most effective nonpharmaceutical, nonsurgical arthritis treatment.
One continual challenge: too many barriers to exercise for the people they were trying to help.
Some live in remote areas without access to facilities or coaching. And some who live in cities and suburbs either don’t have transportation, aren’t mobile enough to get to a facility, or can’t afford to join a gym or pay a trainer.
“So we decided to design and test unsupervised programs that we could offer free,” said Bennell, a professor at the university’s Centre for Health, Exercise, and Sports.
Her team’s most recent study featured an online tai chi program designed for adults with knee arthritis. Participants were given access to a series of 45-minute tai chi videos, led by one of the study’s co-authors, and instructed to do three 45-minute sessions per week.
After 12 weeks, 73% of the participants reported a clinically meaningful reduction in knee pain while walking, along with improvements in physical and mental well-being.
This is the third online exercise program Bennell’s team has created for knee arthritis patients. The first was a six-month strength program, published in 2021. That was followed by a three-month yoga program in 2022.
All three are free to access for anyone who wants to try them. So far, Bennell said, they’ve had 60,000 users from 120 countries.
“The tai chi program seemed to give better results for pain, compared with the yoga program,” Bennell said. Research shows tai chi can improve strength, mobility, balance, and endurance, which may lead to more controlled movement patterns, with better joint stability. The strength program was similar to tai chi in terms of pain reduction.
Arguably the most important factor for the program’s success: “Participants did report high satisfaction with all three programs and were highly likely to recommend them to others,” Bennell said.
Arthritis is a pervasive challenge that affects millions globally, significantly impacting livelihoods through pain and disability. With over 100 types of this condition, including osteoarthritis, rheumatoid arthritis, and gout, the struggle is both physical and emotional. As millions grapple with the realities of arthritis symptoms, the connection between excess weight and the severity of these symptoms is becoming increasingly clear.
Murray Hewlett, CEO of Affinity Health, sheds light on this connection, stating, “Arthritis already places a tremendous burden on the body, and carrying extra weight adds even more strain to joints. The good news is that even modest weight loss can significantly reduce pain, improve mobility, and enhance quality of life for those living with arthritis.”
Understanding Arthritis
Arthritis encompasses various conditions, primarily characterised by joint inflammation and persistent pain. The most common forms — osteoarthritis, where cartilage wears down over time; rheumatoid arthritis, an autoimmune disorder; and gout, caused by uric acid build-up — all lead to debilitating symptoms such as stiffness, swelling, tenderness, and limited range of motion. This not only hampers daily functions, but also takes a toll on overall well-being.
The weight-arthritis connection
Research consistently demonstrates that carrying excess body weight amplifies arthritis symptoms. Here’s how:
Increased Joint Pressure:Extra weight places undue pressure on weight-bearing joints such as the knees, hips, and ankles. For instance, every kilogram of body weight adds approximately four kilograms of pressure on the knees during walks.
Faster Cartilage Breakdown:The additional load can expedite cartilage wear, leading to faster degeneration in osteoarthritis patients.
Worsened Inflammation:Fat tissue releases inflammatory chemicals that heighten arthritis symptoms, affecting not just weight-bearing joints but also hands, wrists, and other areas.
Reduced Mobility:Excess weight may lead to inactivity, creating a cycle of declined muscle strength and intensified joint pain.
Increased Risk of Other Conditions:Obesity is linked to diabetes, heart disease, and metabolic syndrome, complicating both arthritis treatment and general health management.
What you can do
Taking proactive steps towards managing weight can yield significant benefits for arthritis management. Here are some recommendations:
Focus on Healthy Weight Loss:Even modest weight reductions of 5-10% can lead to noticeable improvements in pain and function. Aim for sustainable, gradual changes over aggressive dieting.
Adopt a Joint-Friendly Diet:Consuming a diet rich in anti-inflammatory foods can aid in weight management while alleviating arthritis symptoms. Focus on fruits, vegetables, whole grains, lean proteins, and healthy fats, while minimising processed foods and sugars.
Stay Active:Physical activity, particularly low-impact exercises like swimming, walking, and yoga, can alleviate pain and enhance flexibility. Always consult a healthcare professional before starting any new exercise programme.
Strengthen Supporting Muscles:Building muscle around affected joints helps reduce stress and bolster stability. Consider physical therapy or guided strength training.
Manage Pain and Inflammation:Use over-the-counter pain relief or prescribed medications and explore complementary therapies, such as massages or acupuncture, for flare-up relief.
Seek Professional Support:Working with healthcare providers, such as doctors, dietitians, and physiotherapists, can yield tailored management plans.
Emotional Health
The physical struggle of living with arthritis can take an emotional toll. Anxiety, frustration, and even depression are all too common. Engaging with friends and loved ones, joining support groups, or consulting a professional can help maintain a positive outlook during challenging times.
While managing arthritis alongside excess weight may seem daunting, embracing small, consistent lifestyle changes can lead to significant improvements, says Hewlett. A balanced diet, regular low-impact exercise, and professional support not only ease symptoms but also enhance mobility, ultimately promoting a healthier, more confident life.
Worsening levels of pain may indicate a more serious issue
Arthritis is a widespread condition in the UK, especially among those aged 60 and over.
While some level of discomfort can be a natural part of ageing, ongoing or worsening symptoms may indicate a more serious issue that shouldn’t be ignored.
To learn more, Justine Musiime, a chartered physiotherapist with a special interest in rehabilitation for older adults, revealed three of the most common types of arthritis in later life.
She also shared some key insights about when to seek professional advice for symptoms and why early intervention is so important.
Osteoarthritis
The most common type of arthritis in older people is osteoarthritis.
“Osteoarthritis is mainly the degeneration or wear and tear of the joint,” explains Musiime. “It mainly affect the knees and the hips, but can also affect other joints in the hands and the spine.”
In osteoarthritis, the protective cartilage on the ends of your bones breaks down and bony growths can develop, according to the NHS website.
It is estimated that around 8.75 million people in the UK have seen a doctor about osteoarthritis, according to Versus Arthritis’ website, and pain and tenderness are common symptoms.
“The pain is usually worse in the morning,” says Musiime. “So, after someone has been asleep, when they wake up they often feel terrible pain when they try to move. There can also be swelling as well.
“Sometimes people will also hear a crunching noise when they try to move the affected joint.”
However, the severity of osteoarthritis symptoms can vary greatly from person to person, and between different affected joints.
The exact cause is not known, but several things are thought to increase your risk of developing osteoarthritis such as joint injury, age, family history and obesity, according to the NHS website.
Osteoarthritis is also more common in women than men.
I think if people are displaying symptoms, they should seek help as soon as possible (Alamy/PA)
Rheumatoid arthritis
“Rheumatoid arthritis is an autoimmune disease where the body’s immune system starts attacking the joints by mistake, causing inflammation,” explains Musiime.
Symptoms of rheumatoid arthritis can include swollen and tender joints, swelling and stiffness in joints in the morning that lasts for longer than half an hour, severe tiredness and a general feeling of being unwell, according to Versus Arthritis.
Over time this inflammation can damage the joints, cartilage and nearby bone.
According to the NHS website, the condition usually affects the hands, feet and wrists and there may be periods where symptoms become worse, known as flare-ups or flares.
The NHS website also states that a flare can be difficult to predict, but with treatment it’s possible to decrease the number of flares and minimise or prevent long-term damage to the joints.
While rheumatoid arthritis can affect adults of any age, it’s most commonly starts among people between the ages of 40 and 60, according to Versus Arthritis.
Gout
“Gout is caused by an accumulation of uric acid in the body,” explains Musiime. This can lead to crystals forming around your joints, which causes pain, according to the NHS website.
“This mainly affects the big toe, causing it to be swollen, painful and sometimes red,” notes Musiime. “Sometimes you might also see skin peeling off.”
Things that can trigger a gout attack include an illness that causes a high temperature, too much alcohol or a very large meal, dehydration, a joint injury or certain medicine, according to the NHS website.
When should people seek help about their symptoms – and why is it important?
“I think if people are displaying symptoms, they should seek help as soon as possible. With the different kinds of arthritis there are different ways of managing the symptoms,” says Musiime. “Arthritis can affect people’s everyday life, even doing basic things like cooking, cleaning and dressing. I have met patients with arthritis who are unable to wash themselves.
“Arthritis isn’t curable, but seeking professional advice can help manage the symptoms and might be able to help slow the progression down too.”
Medication is a common pain management strategy for arthritis.
“I always tell my patients that they need to take the pain medication they have been prescribed because it can help take the edge off the pain,” says Musiime. “It also means that the medication will be in their system for when they start or try to get up and walk.
“Patients with arthritis are often prescribed non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, but it’s best to talk to your GP to figure out the best medication for you.”
It’s also very important to stay active.
“Swimming is good because being in water means there is less pressure and pain on the joints and walking is also really good,” says Musiime. “But, any exercise that you enjoy engaging in is good, as long as it does not make the pain excruciating to the extent that you are not able to function. Any movement of the joints and strengthening the muscles around those joints is very important.”
We might finally be able to spot osteoarthritis early… and bring it to a halt
In recent years I’ve had to come to terms with the fact that my knees aren’t what they used to be. They’re creaky and they’re achy. They crackle when I sit down, and they hurt when I stand up.
The pain’s not awful, so I get on with my daily life – but it puts me off running, which keeps me active as I get older. And every stiff stride is accompanied by the same worry: could I be developing osteoarthritis?
I’m not alone in this concern. Knee pain is remarkably common.
A study in the journal Rheumatology found that half of those aged over 50 (my age bracket) had experienced knee pain in the previous year, and that a third had visited their doctor because of it.
The culprit? Osteoarthritis is the most common cause. Osteoarthritis is a disease of the joints, with large, weight-bearing bones, such as the knees and the hips, most likely to be affected.
Worldwide, it impacts more than 500 million people, causing pain and disability. But, despite being a common affliction, there are no drugs to slow its progression… yet.
Currently, in the early stages, you can only guess whether your niggly joints are arthritic or not.
The narrow spaces between the femur (thigh bone) and tibia (shin bone) in this 55-year-old patient’s legs indicate arthritis - Image credit: Getty Images
That’s because diagnosis, which involves symptom assessment, examination and sometimes imaging, tends to happen in the late stages of the disease, when much of the damage is already done.
In fact, osteoarthritis is thought to begin years, or perhaps even decades, before symptoms escalate and the joint degenerates.
This means there’s a huge window of opportunity when the disease could be curtailed, if only there was a way to detect it earlier and stop it in its tracks.
With a billion people projected to have osteoarthritis by 2050, better diagnostics and new therapies have never been more needed. But as our understanding of the disease improves, researchers are now tantalisingly close to reaching that goal.
“There’s a lot of progress being made,” says Peter Gowler, research liaison manager at the charity Versus Arthritis, “yet osteoarthritis is very often dismissed.”
With new detection tests on the horizon, all that could be set to change.
Common risk factors of arthritis
Often, when people visit their doctor with symptoms, like mine, that are painful but manageable, they get told that they probably have a ‘touch’ of arthritis.
“But they wouldn’t say that for any other disease,” he says. People don’t talk about a ‘touch’ of heart disease or a ‘touch’ of multiple sclerosis.
At that point, the doctor’s diagnosis is a well-meaning guess. Although clinicians know what osteoarthritis ‘looks’ like in its final stages when the cartilage is well worn, there’s currently no test that predicts the progression of early knee pain.
We know there are things we can do to help prevent the disease. These include maintaining a healthy weight relative to your height and body type (ask your doctor if you are unsure what this means for you) and keeping active.
Contrary to popular belief, regular running has been shown to strengthen the knee joint and make osteoarthritis less likely.
But we also know there are risk factors that make the disease more likely. These include being older, being female, being overweight and having had a previous joint injury.
I score three out of four here, but while this checklist tells me I’d be wise to adopt preventative measures, it still doesn’t tell me if I’m in the early stages of the disease or not.
The mystery of early arthritis
“One of the big problems we have is we don’t have a way of defining what early osteoarthritis is,” says Gowler.
Early on, the changes that occur inside the joint are subtle, but standard imaging methods, such as X-rays and magnetic resonance imaging (MRI), aren’t sensitive enough to detect them.
At Aberdeen University, physicist Dr James Ross and colleagues have been developing a new type of MRI, called Field-Cycling Imaging (FCI).
Where traditional MRI uses a constant magnetic field to create images of the body, FCI can dial the strength of the magnetic field up and down.
“This allows us to see how different tissues respond to different magnetic fields, and see how their properties vary,” he says.
Dr Lionel Broche works with Ross on developing FCI scanners that can detect osteoarthritis early - Image credit: University of Aberdeen
The team took cartilage samples from the knee joints of people with advanced osteoarthritis, and from healthy controls, and then imaged them with their benchtop FCI scanner. The machine is a prototype, so it doesn’t produce images, but it does generate graphs.
“Clinicians get excited about pictures,” says Ross. “Physicists, like me, get excited about graphs.”
Huge differences were seen in the signals from the two tissues, showing that FCI can distinguish osteoarthritic cartilage from its healthy counterpart. But Ross thinks the method is so sensitive that it could also pick up earlier changes.
The next step, which is currently underway, is to see if it can. As part of the PIOKNEER study, researchers will give annual FCI scans to 300 individuals who have sore knees but no diagnosed osteoarthritis.
The participants will be followed for five years, during which time some, but not all, are expected to develop osteoarthritis. The hope is that FCI will be able to detect early signs of the disease.
An arthritis blood test
In the US, meanwhile, researchers are developing a blood test. At Duke University, scientists analysed the blood serum (what’s left in the blood after the solids like blood cells have been removed) of 200 women.
Half of the women had been diagnosed with osteoarthritis, and the other half were healthy controls.
Although osteoarthritis is a disease of the joints, they found differences in the composition of the women’s blood. Specifically, levels of just six different proteins distinguished the two groups.
The discovery provides the basis for a diagnostic test, which the researchers found was 85-per-cent accurate in identifying the disease and 74-per-cent accurate in predicting its progression.
For some of the women, the test detected signs of the disease eight years before joint damage was visible on X-rays.
Here then is a test with the potential to spot those individuals with achy joints who, very likely, will go on to develop osteoarthritis.
This opens up a window of opportunity in which drugs, designed to tackle the core biology of osteoarthritis, can get to work.
On the road to recovery
At present, the only treatments that exist for osteoarthritis focus on relieving symptoms, rather than countering the underlying disease.
People are often offered pain relief and anti-inflammatory medications, such as ibuprofen.
Steroid injections into the affected joint can sometimes bring temporary relief, while studies show that taking glucosamine, which is found naturally in joints, can improve pain and mobility in some of those with knee osteoarthritis.
Not everyone benefits, however – and when the disease progresses, the only option is surgery. Every year, around 1.5 million people have a total knee replacement.
This can improve mobility, but the procedure isn’t risk free. And while 80 per cent are happy with their new knees, many of the remainder struggle with ongoing pain.
Knee replacements are amazing feats of medical technology, but don’t work for everyone - Image credit: Getty Images
That’s why scientists have been devising new, disease-modifying therapies. In the last 20 years, the treatments have been tested in hundreds of clinical trials, yet none have made it through to the clinic.
There are lots of reasons for this. Some just didn’t work, and others caused unpleasant side effects. But another key issue is the growing realisation that osteoarthritis isn’t a single disease.
“Osteoarthritis is complex,” says Prof Nidhi Sofat from St George’s, University of London. “There are lots of different subtypes.”
The sort of osteoarthritis that a menopausal woman develops, for example, will be different to the sort of osteoarthritis that develops in the wake of a knee injury.
Some people will have a strong genetic component to their disease. Others will have an internal biology that’s inherently more inflammatory, or worse at healing.
Each of these subtypes will have its own intricacies and its own bespoke biology. As a result, they’re likely to respond differently to different drugs.
The problem comes when all of the subtypes are lumped under the same label of osteoarthritis and chucked into the same clinical trial.
Drugs that could work for one of the subgroups might be being overlooked because they don’t work so well for the rest. The baby is being thrown out with the bathwater.
Even positive results can sometimes be misleading. In one clinical trial for a medication called tanezumab, pain improved, but inside the joint the disease accelerated.
Some of those taking the medicine needed knee replacement surgery sooner than was expected, prompting the FDA to pull the plug on the trial.
It’s important then, for new drugs not just to focus the pain caused by osteoarthritis, but on the physical changes that happen to the joint too.
Towards a cure for arthritis
For a long time, the focus was on cartilage. Cartilage is the smooth, slippery tissue that covers the surface of bones and helps them to move freely against each other.
In osteoarthritis, the cartilage deteriorates – but changes also occur to the bone, the lining of the joint capsule (called the synovium) and the tissues surrounding the joint.
Sofat’s research focuses on bone – specifically, tiny abnormalities inside the bone, called bone marrow lesions. In osteoarthritis, these lesions can form early, and co-localise with the pain that people feel.
By dissecting out the lesions and studying them, Sofat has shown they display a whole slew of molecular traits, including signals related to inflammation, pain, nerve and blood vessel formation, cartilage formation and bone cell activity.
It’s as if the bone is trying to make new joint tissue, Sofat explains, but then falling short.
There’s a mechanical component to the process, too. We already know that people whose joints are ‘a bit wonky’ – with ligament problems, for example, or spinal misalignment – are more likely to develop osteoarthritis. This is thought to be because the anomaly puts extra pressure on the joint.
Prof Deborah Mason from Cardiff University has demonstrated the molecular repercussions of this.
She grows osteocytes, which are the most common type of bone cell, in a squishy collagen gel, and then puts pressure on them – literally – using a 3D-printed mechanical loading device.
She has found that one burst of pressure changes the activity of more than 7,500 genes, many of which are related to inflammation, bone activity and pain pathways.
Studies like those by Mason and Sofat are important because they highlight some of the key biological changes that underpin the disease. This is helping to inform drug development.
Mason, for example, found that the activity of genes related to the neurotransmitter glutamate become altered. So, she has treated rodents with artificially-induced osteoarthritis, with an injection of a drug that lowers levels of the chemical.
The result? She discovered that it reduces pain, swelling and joint degeneration.
“If we give it very early on (at onset, before they get osteoarthritis) as a single intervention, we can reduce their disease at the end stage by about a third,” she says. “We find that quite promising.”
Now, the team are planning to test the drug in human clinical trials.
Future treatments could lie with a type of cell called mesenchymal stem cells, which have the potential to develop into many other types of cells - Image credit: Getty Images
Meanwhile, Sofat is encouraged by a different drug, called pentosan polysulphate. The drug, which was previously used to treat bladder issues, is known to have both anti-inflammatory and cartilage-protecting properties.
“We’re seeing change at the level of the whole joint,” says Sofat, who was involved in one of the trials.
The hope is that, by targeting early molecular changes with medications that affect the whole joint, osteoarthritis could be prevented. Drugs could modify the disease process and patients need never develop full-blown osteoarthritis at all.
Cellular solutions for arthritis
Another approach involves cell therapy. In the UK and elsewhere, cell therapy is available for early osteoarthritis in the guise of Autologous Chondrocyte Implantation (ACI).
The technique involves taking a small sample of cartilage from an undamaged spot in the problem knee, then growing those cells (known as chondrocytes) in culture for a few weeks, before returning them to the joint immobilised in a scaffold-like membrane.
(‘Autologous’ means the transplant cells come from the patient’s own tissue.)
Vets treat an elderly gorilla using stem cell therapy at Budapest Zoo, in Hungary - Image credit: University of Sheffield
At the RJAH Orthopaedic Hospital in the UK, experienced clinicians have treated more than 600 patients.
“In the first 12 months, most patients experience a good level of symptomatic relief,” says bioengineer Prof Karina Wright, who works at the hospital and Keele University. “This can be retained for many, many years.”
The technique is available in a dozen or so specialist hospitals in the UK, but its use is currently restricted on the NHS to a subgroup of patients who have minimal osteoarthritis, no previous knee surgery, and a hole in their cartilage that is bigger than a 1p coin (which, at 20mm or 0.8 inches in diameter, is a little bigger than a dime).
So, researchers are looking at other, cell-based options. Stem cells are attractive because they can make other cell types, and potentially be used to repair the damaged joint.
The focus is on a particular type called mesenchymal stem cells, which can be isolated from tissues (such as bone marrow and fat) and coaxed to make bone, cartilage and other tissue types. They also secrete useful molecules that stimulate tissue regeneration.
When they’re injected into the joint in animal models of osteoarthritis, they reduce inflammation, lessen pain, promote cartilage regeneration and improve joint function.
“There’s lots of preclinical evidence for mesenchymal stem cells,” says Wright. Indeed, the treatment is already available for some animals.
Some vets offer stem cell therapy for osteoarthritis in dogs and horses, and in 2023 an elderly gorilla called Liesel, who lives at Budapest Zoo in Hungary, had mesenchymal stem cell injections for her osteoarthritic knees and hip.
Liesel the gorilla had mesenchymal stem cell injections for her osteoarthritic knees and hip - Image credit: University of Sheffield
Wright and colleagues have been comparing their tried-and-tested ACI treatment against mesenchymal stem cells and a combination of both cell types in 114 patients with osteoarthritis of the knee.
Slowly but surely, new drug treatments and cell therapies are emerging, as are early tests to identify those most at risk.
As researchers unravel the biology of the disease and what makes one person’s osteoarthritis so different from another’s, we move towards an era not of ‘one treatment fits all’ but of ‘which treatment fits best.’
At this point in time, I don’t know if my knee pain will develop into osteoarthritis, but I do know that if I can just hang on, in the not too distant future, there will be tests and treatments that help me.
