Perhaps if it ever comes to be, I can look forward to yearly Christmas gifts from radiologists, orthopedists and MRI manufacturers. (Hint…if you’re ever in Richmond, feel free to take me out for a nice steak dinner!)
In the area of bone and joint health, I have always found it astounding that our health care system has never adopted a proactive view of screening for joint problems. To evaluate joints, especially weights bearing joints such as the spine, knees and hips, regardless of whether an individual has pain or not.
According to researchers, osteoarthritis (OA) is a condition which annually increases health care expenditures by $186 billion. Let’s put this into perspective. Though there are more than one hundred different types of arthritis, the cost of diagnosing and treating OA and its effects exceeds the combined yearly revenues of Microsoft, McDonald’s, Amazon, Visa, Nike, and EBay.
The Centers for Disease Control and Prevention (CDC) states that today, 27 million Americans suffer just with OA. To make matters worse, estimates are that by the year 2030 there will be a 248% increase in the number of adults in the U.S. diagnosed with this condition.
Medical experts concur with the CDC, stating that the increase in OA is due to obesity and longer-living adults. The latest research forecasts that the demand for knee replacements will increase 674% by year 2030, with hip replacement demand increasing nearly 200% for that same target year. That will keep a lot of orthopedists well-paid and orthopedic hospitals well-staffed.
Osteoarthritis is a degenerative type of arthritis and a major debilitating disease that causes gradual loss of cartilage, mostly affecting the knees, hips, hands, feet, and spine. It is also known as degenerative joint disease. If you’ve seen the malformed knuckles of an elderly person or ever had people tell you about their ‘bone spurs’, you know of it.
The operative (pardon the pun) word here is ‘disease’. Osteoarthritis is not merely an ache and pain condition. Rather, it’s a disease process where the cartilage or spinal discs between bones wears away. Over time, bone spurs grow in and around the affected joint, much like a weathered door hinge becoming rusted. Beside the pain of arthritis, it affects mobility too. Primary OA is due to aging and heredity. Secondary OA is due to prior injuries, surgeries, congenital abnormalities and carrying excess weight.
If you didn’t know about osteoarthritis and its prevalence, now you do. Let’s move on.
The crux of this blog topic centers on a commonly-held notion, shared both by patients and many front-line family doctors. The same logic that proves true for many common health issues does not stay consistent for joint-related maladies such as OA. To be more clear…
Organic problems such as diabetes, osteoporosis, cancer, heart disease and high cholesterol often exist when people have no symptoms. That is to say, one can FEEL GOOD and be diseased and dying. However, when it comes to joint-related conditions, the understanding is that until one FEELS BAD, they really don’t have a problem.
Organic conditions are handled proactively through the use of objective, screening tests such as pap smears, blood and urine tests, mammograms, blood pressure checks, bone density tests, and prostate/OBGYN exams. Doctors, patients and health payers buy into the value of these tests.
In contrast, joint-related conditions, such as OA, are identified when patients come to their doctor complaining of pain and symptoms. Hence, these patients and their joint conditions are handled reactively through the use of medication, pain management, therapy and surgery. There is no screening to identify loss of joint health before the pain comes.
Yet any rheumatologist, orthopedist or chiropractor worth their salt will tell you that the onset of any stiffness or pain will typically occur long after the beginning of the degenerative arthritic process in a joint. Osteoarthritis comes either as a result of either normal aging or from past injury to a joint.
Would one wait until his or her first heart attack to get their blood pressure checked?
Let’s take Mary Smith, a 42-year old saleswoman and mother of two. She visits her family doctor’s office complaining of neck stiffness and some intermittent tingling in her right hand that she’d had for the last six months. Ms. Smith had not suffered any recent falls, accidents, or lifting injuries. However, she has had what she felt was ‘stress-related’ upper back stiffness for the last 7-8 years. For this, she has taken over-the-counter pain medication several times a week to help her feel better.
On a visit to her family doctor, she is examined and has x-rays taken of her neck. The x-rays reveal osteoarthritis in the two lowest bones of her neck. The rest of the neck appears normal. The doctor tells Mrs. Smith that a little bit of OA is “normal for her age” and provides her with some pain medication. In time her neck pain feels better, so long as she continues her medication, but she still has tingling in the right hand.
Mrs. Smith is referred to an orthopedist. There, a more extensive history is taken, where she recalls being in a single, severe auto accident when she was 20 years old. She had been stopped at a streetlight and was subsequently rear-ended by a car going 50 mph. She was taken to the emergency room and being given pain medication. Her recollection is that a few weeks later, she felt better and all was seemingly well.
Upon performing some orthopedic tests, the patient demonstrated increased right hand tingling. With more specific imaging done for her neck, it was determined that even though she was only 42 years old, Mrs. Smith had the lower neck joints of a ‘normal’ 70-year old woman. This included the diagnosis of two moderately degenerated discs in her lower neck, as well as two bone spurs rubbing against nearby nerve root tissue. This was determined to be causing both the tingling in her hand, as well as what she always thought to be stress-related neck and upper back pain.
For Mrs. Smith, the auto accident most likely injured the joints of her lower neck to the point where although she felt better, the beginning of OA commenced in those damaged areas. The time for Mrs. Smith to start making changes in her life would have been perhaps when she was in her mid-twenties, or even when she had her first consistent period of aching in the upper back.
How many Mary Smiths do we know? How many times are people diagnosed with OA, after having many years of light pain and stiffness? How many times do people and doctors dismiss low-level pain as ‘just muscular’ or stress? Can OA be thwarted or lessened if patients knew of damaged cartilage before they feel their first ache or pain?
I’d like to see doctors, hospitals and insurance companies embrace regular joint imaging in determining the earliest signs of cartilage degeneration and osteoarthritis. This would be done from non-invasive MRI units millions of times a year. Just like one would have their regular screening tests for heart, blood, urine, etc., they would also go for a screening MRI.
Such screening would be a proactive measure for people starting at age 30, and perhaps earlier and more frequent for those who had prior-documented joint injuries. In this sense, soft tissue injuries could be better tracked, allowing a greater possibility for people to age in a far healthier manner.
Is the technology here yet? Well, it may actually be right around the corner. Let’s start off with a little understanding about cartilage, the way it becomes damaged, and the result of osteoarthritis.
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 on an MRI machine. 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 will now be able to monitor cartilage health of knees, hips, and spines. If degeneration is detected early, drug therapy may be able to make a long-term difference. Plus weight management measures and regular targeted strengthening exercises will have best effects. Most important though – doctors and their patients will be able to know, year in and year out, how the joints are aging. Hence, a way to monitor joint health.
I know what you’re thinking: patient expense, insurance coverage, long lines at MRI units, etc. Well devil’s advocates… the water seems warm, so jump right in with your comments at the bottom of this article.
But for now, let me at least fire off the first salvo, which comes in four parts:
1. CON. A lot of people don’t know, but there currently exists a pseudo-monopoly rule, inclusive of MRI units, in 36 states. MRI facilities are not allowed to be set up for business without first obtaining a Certificate of Need (CON) given by the state. The process can involve hundreds of thousands of dollars in legal fees, marketing studies, consulting fees and appeals. Many experts and even the U.S. Department of Justice oppose these state rules, rightly believing CON laws “create barriers to entry for health care providers, prohibit competition and drive up healthcare costs.”
Removing such laws will allow many more MRI centers to be opened. This will allow appropriate servicing of many individuals needing proactive MRI screening services, apart from current imaging patients. Even if those laws aren’t readily removed, the 14 ‘non-CON’ states will hopefully show success for the other states to consider.
2. A greater volume of services will drive down cost. MRI facilities will be far busier, but they will also be getting reimbursed for their work. Obviously, proactive MRI screening is not going to pay at current MRI reimbursement levels, nor should they need to. Insurance companies, through the AMA’s CPT code guidelines and reimbursement recommendations, can set fair and equitable screening measures and reimbursement rates.
For those MRI centers who DON’T want to perform screening services, the free market will allow for those that do. Perhaps there will be just those MRI centers that choose to specialize in screening services, as opposed to other types of imaging done. The beauty of a free market filling needs.
3. A greater reduction in the amount of future joint replacements and surgeries. I’m sure orthopedists won’t be happy with this one, but earlier detection, understanding and personal responsibility offers both benefits and detriments – depending on the side one is coming from. Patients will be healthier, while insurers and self-insured organizations will obviously be happy to reduce their medical costs. I’m sure joint replacement manufacturers will be sending me my Christmas coal.
4. More responsibility and better outcomes. People who learn about their joint problems earlier have time on their side. Plus, by keeping weight down, avoiding riskier activities, strengthening muscles and joint tissues, they have the best opportunity to prevent OA. Ask yourself how many heart surgeries have been avoided because of determining one has high cholesterol or blood pressure? It would naturally stand to reason that knowing of joint problems would yield similar reductions in surgery and better quality of life outcomes.
Feel free to comment below, as well as share this with others.