Arthritis affects different people in different ways, as there are numerous signs. These signs and symptoms of osteoarthritis may appear earlier or the onset can be much later. Nevertheless, it is useful to identify signs as it helps medical professionals to diagnose arthritis, and give a prognosis.
INFLAMMATION IS NOT THE BAD GUY IN OSTEOARTHRITIS
WHAT IS INFLAMMATION?
“Inflammation is a local defensive response to tissue injury of any kind, including trauma and infection. Its general purposes are (1) to limit the spread of pathogens and ultimately destroy them, (2) to remove the debris of damaged tissue, and (3) to initiate tissue repair.”(Saladin, 2004)
THE 4 STAGES OF INFLAMMATORY HEALING
(USING A SKIN BURN AS AN EXAMPLE:)
1. 0-10 hours after the burn is the:
The burn damages blood vessels which then leak out blood into the surrounding tissue. This bleeding may not leave the body, it is often internal bleeding. Our bodies do everything that they can stop internal bleeding, lest we bleed to death. The body responds to bleeding by sending clotting agents to the damaged area to block the leakage up.
Using the analogy of a bad skin burn:
> This is the stage where the burn starts to weep.
2: 24-48 hours after the burn is the:
ACUTE INFLAMMATION PHASE:
This is where the body gets the damaged skin ready for regeneration. After the bleeding has stopped, a temporary vasodilation response occurs. Where the walls of the capillaries become more permeable. This allows inflammatory mediators to travel out of the blood system into the interstitial space. It also aids in the removal of damaged tissue debris, blood which reduces the risk of infection. During the acute inflammatory phase dead tissue is “disinfected” and dragged away from the damaged area. Then inflammatory mediators leak out into the circulatory system, in a process of asking for help.
It is because of vasodilation that inflamed areas swell up. Vasodilation results in a rush of fluid into an area. Swelling has a number of beneficial and unwanted side-effects, called cardinal signs:
> Loss of function
It creates an artificial barrier to the range of motion, physiologically limiting the range of motion. This helps to protect unstable joint and muscles, it stops ligaments and/or muscles from being repetitively re-torn.
It is no wonder that excessively swollen joints can be painful. Mechanical swelling causes pain as different nerves get compressed:
- Ruffini-type endings= slow adapting
- Pacinian corpuscles= fast adapting
It is due to the high level of pressure within a joint that the nerves get compressed.
Swollen joints also chemically activate nerves:
- Nocioceptive Free nerve endings.
Nerves are chemically irritated by a variety of different inflammatory messengers called cytokines. Nerves are more often than not irritated within joints with ongoing swelling, as cytokines accumulate.
2: Using the analogy of a bad skin burns:
Inflammation is akin to a nurse painfully cleaning a burnt, to stop an infection from developing.
3: 48 hours - 4 weeks after the burn is the
If the above acute inflammatory phase has cleared the path for the next phase of healing. Then the damaged area sends out inflammatory messengers in the area.
These inflammatory mediators stimulate stem cells. Telling the body to send nutritious resources to the area. The growth phase occurs in damaged areas, that have the enough resources.
The growth phase is characterised by the space where the dead tissue resided being replaced with new tissue.
Pressured by the fact that tension could result in the vulnerable area getting damaged again. The body lays this new cross-linked proteins down fibrous proteins called type III collagen fibres. Type III collagen is great at resisting tensile load, but not so good at lengthening safely under load. Furthermore the collagen fibres are laid down in a rushed manner, resulting in a disorganised mesh.
Regenesis of tissue in the growth phase occurs in a 4-step process, which results in new tissue being created.
>> When it comes to growing new bone tissue
A1: Mesenchymal Stem Cells proliferate into specialised osteochondroprogenitor stem cells.
A2: These osteochondroprogenitor stem cells create fibroblasts.
A3: Fibroblasts differentiate into Osteoblasts
A4: Osteoblasts create new bone cells.
>> The regeneration of “softer” cartilage, occurs through a similar system of:
B1: Mesenchymal Stem Cells proliferate into specialised osteochondroprogenitor stem cells.
B2: These osteochondroprogenitor stem cells create fibroblasts.
B3: Fibroblasts differentiate into Chondroblasts
B4: Chondroblasts produce new cartilage tissue.
>> The process of producing new muscle cells is the most longwinded as
C1: Mesenchymal Stem Cells proliferate into specialised muscle stem cells (myosatellite cells e.t.c)
C2: Specialist muscle stem cells differentiate into fibroblasts
C3: Fibroblasts differentiate into Myoblasts
C4: Myoblasts create contractile cells (e.g: muscle)
3: Using a bad skin burn as an analogy:
This is where the burn is operated on, and a skin graft is put into place.
4: REMODELLING PHASE:
At the end of the growth phase a mesh of disorganised type III collagen fibres is left in situ. This is less than optimal as it is not as resistant to tensional forces as organised collagen fibres.
The remodelling phase is where this fibrous mesh of collagen type I, is re-organised. For all the collagen type I fibres have a life span, and naturally die, in a process called programmed cell death. Dead type I collagen fibres get broken down by enzymes called proteinases. This breaks down big chunks of proteins into proteins that can be absorbed into the body and recycled.
Dead type I collagen fibres will either be replaced by type III collagen fibres, which are more fit for purpose. Or they will not be replaced. It is force that determines whether a dead type I collagen fibre will be replaced or not. For force is the language of our cells.
The tissue gradually becomes more organised. Eventually making the tissue better able to extend without tearing when placed under tension. Through a combination of destroying dead wood and old trees are replaced with more sustainable trees.
4: Using a bad skin burn as analogy
This is where the skin graft slowly starts to become less obvious.
TAKING IT BACK TO OSTEOARTHRITIS:
What is Osteoarthritis?
“OA should not be thought of as a single disease, but rather as the clinical endpoint of numerous disorders leading to the eventual failure of one or more joints of the body.” (Sokolove, 2013)
Is inflammation to blame for Osteoarthritis?
Inflammation gets a bad name, when it comes to “diseases of old-age”. It always seems to be at the crime scenes, of metabolic diseases from cancers to cardio-vascular conditions.
Which in no way indicates that one of the healing phases somehow criminal. As our inflammatory system, is merely doing what it has been doing for millennia. It is trying to help us out. It is all too easy to forget that correlation does not imply causation.
THE REAL ISSUE IS A LIMITED ABILITY TO HEAL + REGENERATE:
It is is in the growth phase of tissue healing where most of the issues happen. When the body does not have the resources to feed cellular division/growth. Then the tissue generating stem cells produce the alternative types of cells instead. In an area of nutrient deprivation stem cells will compensate by initiating the growth of other types of tissue, such as:
> fibrotic tough collagen fibres instead, in the form of a fibrous scar. This reduce the risk of future tearing. This scar will not function well if/when stretched too far, and will not be able to contract like the tissue was before an injury.
> Adipose tissue, when the stem cells do not have access to protein or are not able to stimulate growth, then fat will be used as a substitute. This is common place. If you were to ultrasound the muscles of the thighs of someone over 80, most of the muscle mass will actually be made up of fat deposits.
Our body does what it can to self-heal, in the face of a lack of resources. Our inflammatory system is not at fault, when we get painfully stuck in the inflammatory phase of the healing cycle. Inflammation is doing its job of preparing the area new tissue to be laid down.
DON’T SCAPEGOAT THE NURSE
Blaming inflammation for osteoarthritis is akin to saying the hospital staff are at fault for a major skin burn. Just because it hurts when they clean and disinfect the burns does not make them criminals.
At first glance, it would appear that the nurse is responsible for the pain. It is easy to scape-goat, and the nurse in-front of you is the most obvious target, especially if they cause you acute pain.
If you were to dig a little bit deeper it would become clear that the nurse is NOT at fault, they are stopping things from getting worse!
The nurse is actually stopping infection, preparing the skin for the upcoming operation. Because the nurse is not able to do the skin graft. The real issue is the lack of resources available within the hospital to carry-out the next stage. Probably a lack of experienced surgeons is the underlying issue.
Our own internal nurse called inflammation does cause pain, as it makes joints swell up. But it is not at fault for a backlog caused downstream. Our internal nurse is doing its part by trying to deal with the fact that there is a backlog. As there is a delay further up the chain. So no matter what you read try your best not to blame your bodies own nurse, called inflammation. For without the next phase in the healing process can never occur.
THE IMPERFECT GROWTH PHASE
For the body to replace dead specialised cells like for like with new healthy cells is not easy. For damaged tissue to be replaced like for like, it requires that the specialised stem cell be present. Inevitably the body with fail in its ability to regenerate new like-for-like specialised cells, in what we call aging.
Wrinkles is a classic example of where the body makes do without the specialist stem cells. Our bodies make do and encourages other stem cells to step up and replace the dead skin cells, with sub-optimal skin.
As a baby we never have to worry about suffering from a lack of the right stem cell for the task at hand. Resulting in an effortless and efficient growth phase, that does not leave us stuck in the inflammatory phase. It is only as adults that a reduced capacity of healing to be specific growing, leaves us stuck in the inflammatory phase. The older we get the more likely we are to suffer from chronic inflammation, where the body cries out for growth to replace dead cells.
It is so easy to blame inflammation for a painful joint. When the inflammatory-immune system is merely trying to make the most of a bad situation.
Inflammation is rarely the root cause of pain, even when it is chronically swollen. Just because it is always at the scene of pain, does not mean it made the scene. Correlation does not mean causation. Just because the paramedic was always at a scene of an injury does not mean that they caused the injury/trauma. Inflammation is like the nurse in the hospital, whom can only do what is humanly possible.
Chronic musculo-skeletal inflammation is natural by-products of a limited capacity to heal due to:
- Repetitive damage.
- An inability to regenerate tissue.
- Kallakuri, 2012, innervation of cervical ventral facet joint capsule
- Duan, 2010, In vivo measurement of the subchondral
- Saladin, 2004, anatomy and physiology, the unity of form and function.
- McLain, 1998, Mechanoreceptor endings in human thoracic and lumbar facet joints.
- Doorn, 2012, Therapeutic applications of mesenchymal stromal cells: paracrine effects and potential improvements.
- Osteoarthritis as an inflammatory disease (osteoarthritis is not osteoarthrosis!) Berenbaum, 2013
- (Role of inflammation in the pathogenesis of osteoarthritis: latest findings and interpretations, Sokolove, 2013)
- Cavanaugh,2006, pain generation in lumbar
- Ozsvar, 2015, Elastin-based biomaterials and mesenchymal stem cells
WHY I LOVE PHYSICAL AND EMOTIONAL PAIN: Pain is good. Dr Martin Seligman describes emotions as “less reactions to the present than guides to future behaviour.” There is nothing more guiding, or informative than a painful emotional response. Pain gives us a purpose. Without pain all of us would be apathetic and none of us would be motivated to do anything. Because nothing forces a reaction, or motivates like pain. Nothing galvanises us to survive like the unpleasant experience of pain. It stops us from being too reckless, and exceeding “safe limits”. Pain tells us to avoid dangerous behaviour, pain helps to keep us safe, so that we can survive for another day. Suffering makes us care. If nothing ever hurts us, we would constantly repeat the same damaging mistake over and over again. Discomfort is a tool that has kept our ancestors out of avoidable trouble. —————————— WHAT IS PAIN? “Pain… is a neurological response.” Ollie Pearce It is an amplified message that our nervous system tells us. This message is only painful after it has been amplified. This amplification does not just happen in our heads, but in our nervous system, that is housed in: - In our body's peripheral nerves - In our spinal cord - In our primitive brain. Pain is not fixed because the software of our nervous system is not static. Pain changes and is often intensified which scientists call sensitisation, in either the head or or nerves in our body. In essence pain is not all in our heads, it is also partly in our tissue. Emotional or physical pain is a warning signal from of our nervous system. Emotional pain and physical pain are undeniably interlinked. Any reaction to a stressor, including pain response spreads through our nervous system the more intense it is. For example an emotionally provoking stimulus, can spread like dominoes. An emotional stressor can cause physical pain, or a physical stimuli, can stir up strong emotional feelings. The links between the different parts of our nervous system, pain researchers call Neuro-tags. It is our subconscious way of anticipating an issue, before it pops up in an attempt to protect us. Pain is our nervous system flagging up an impending threat. This threat can be against our existence or anything that we have placed huge importance on such as financial status. Pain starts its life as a piece of neutral information. It only becomes a pain if our danger processing system flags this piece of information as representing a threat. If it is deemed to be threatening it will shout it out to the whole nervous system. Our internal alarm system analyses whether there is enough credible evidence that the danger is brewing. It does this by sub-consciously pre-conceiving what is going to come up. If it feels a pain response is required, then it will promote protective promoting behaviour, be that to fight or run away. To summarise what pain is. It is an exaggerating intensifier, that amplifies signals that it deems to be a threat to our future survival. The whole nervous system only amplifies sensory signals, if it anticipates damage to be around the corner. ================================ PAIN AND OSTEOARTHRITIS: The level of discomfort one feels in a joint with osteoarthritis is NOT a direct measure of how much “it has worn away.” Over many years as a Physio technician, and osteopath I have seen and treated so many joints. - Including arthritic joints with full movement in, little to no swelling, yet it was causing immense pain. - Other times joints that were not painful at all. Yet were swollen, and enlarged. Both my clinical experience and research agrees that, joint pain is NOT a direct measure of how developed osteoarthritis is. ================================ LIKE THE SIRENS IN A WAR ROOM, HOW MUCH IT HURTS IS ONLY A REPRESENTATION OF THE REALITY OF THE SITUATION At the centre of countries military operations there is a siren. This siren has different levels of alertness. The intensity of the siren depends upon the information the “war room” has gathered from multiple intelligence sources. The level/state of alertness is not fixed, it is dynamic. All it takes is one source of intelligence to be very threatening, and it will go into overdrive. The state of alertness is only proportionate to the interpretation of information. It is not necessarily an accurate representation of upcoming danger. Pain is similar. Pain and damage are not the same. How much pain we will feel is NOT dictated by the amount of tissue damage!!! Osteoarthritic Pain, for instance, is our implicit perception as to whether tissue is in danger. A leading pain scientist Moseley said, “pain does not provide a measure of the state of the tissues.” Pain doesn’t accurately represent the state of the tissue. The volume of the pain that we feel is not dependent on any specific bit of physical tissue. Pain is an amplifying process determined by our software, NOT the damage residing in our physical tissue. Sometimes the damage is amplified, and other times it is dampened or even put on mute. As physical Damage won’t necessarily register as pain. I see this on a weekly basis as an Osteopath, when somebody has all the signs of a crush fracture of their spine, but they do not feel any pain whatsoever. ———————————— THE LEVEL OF ALERTNESS IS BASED ON INCOMPLETE INFORMATION: Sometimes the information that is presented to the war room does not represent reality. Having an array of every type of intelligence source inundate a war room would overwhelm it. We can only get an incomplete thin-slice, of an update about the state of the environment of each intelligence source. Invariably, information gets filtered out. First by the intelligence sources which supply it, if it is not important enough to worry about. Filtering does not stop there. The war room itself will discard more information then it will ever action. It is an imperfect filtration system. Pressing concerns frequently get missed, while things of little consequence get all the attention. This leads to a war room: > Giving off false alarms > Missing dangerous situations. As the filtering stages at the intelligence sources and in the war room itself are 2-points of failure. Point of failure not only happens in war rooms it also occurs in our nervous system. An example of our nervous system muting itself when there is still damage present in the tissue. Is when we drink after hours of being dehydrated. Drinking almost instantly stops the painful feelings of dehydration, yet our tissues are still dehydrated as it takes minutes before tissues can rehydrate themselves. The nervous system also gives off false alarms, when there is no issue. An obvious example of this is phantom limb pain. Where the nervous system is on red-alert about an ongoing onslaught on the part of the body. When the given body part no longer exists! ———————————————————————————- MULTIPLE INFORMATION SOURCES CAN TRIGGER THE SIRENS TO GO OFF Unlike a smoke alarm that only looks out for one danger. Anyone of many different intelligence sources can trigger a war rooms sirens indicating a red-alert state. These intelligence sources, are often called cells, as they operate independently, being a system in their own right. Our nervous system is no different to a war room. As multiple systems, regularly feedback changes in the air. The difference is instead of terrorist movements, it is “factors from across somatic, psychological and social domains” (Moseley), that get feedback to our nervous system. If any of these systems feedback something threatening, then all of the nervous system will get stirred up, and potentially amplify this sensory input to deafening levels. Any of our nervous systems sub-systems can play a trigger the nervous system to amplify the information, which is called the pain response. =================================== INFORMATION WON’T GET (PAINFULLY) AMPLIFIED UNLESS IT GETS THE GO AHEAD. The level of alertness, warns all the members in the war room if an attack could be imminent. It is the powers that be that determine if a red-alert status is warranted. They switch up the master volume switch if they critical members of the war room all agree that a dangerous threat looms. If a risk is deemed to be very dangerous, then they will make sure everyone else knows about it. They want every to be extra alert, to be galvanised enough, to be ready for action. So that the anxious fight or flight stress response will not be delayed. Our nervous system predicts how safe it thinks we will be, by determining how vulnerable we believe we are. Feeling vulnerable is defined by a subconscious analysis of following four crucial components: -> Perception of Point A: (what is the current state of play?) -> Perception of the Current environment (Is the environment familiar?) -> Perceived level of competence (Am I able to complete the task?) -> Perception of Point Z: (is this standard of safety achievable?) If the answers to these questions indicate that one is vulnerable, then our nervous system will size up the level of risk, by asking: A-> How much damage will happen? (Will this action hurt me?) Then weighs the answer up against: B-> How important is it that the task is done? (How meaningful is the outcome?) If one feels vulnerable and A outweighs B, then the nervous system will amplify the threatening messages. The volume of the sirens up will be amplified. Scientists call this central or peripheral sensitisation. In essence, it is a stress response like a war room that has just been placed on red alert. The whole nervous system encourages that everything is aware of the threatening message. As it feels a threat may be looming. The intensity and duration of the red alert siren is only a representation of the level of threat. The deafening sirens are NOT necessarily signs of unfixable damage. If B outweighs A, then a purposeful motivation will override discomfort. Frequently a surge of adrenaline means that one will not even register getting shot until after a task has been completed. If it is essential that a job is completed, then an expectation is formed. =============================== ONE’S ASSUMPTIONS DETERMINES WHETHER GO-AHEAD IS GIVEN Before a critical war room cabinet members put everyone on red-alert, they will discern as to whether they feel the evidence representing an imminent threat is credible or not. My friend Ollie Pierce says: “Perception is a crucial part of how we feel pain.” Because a war room cannot analyse all of the information about all of its intelligence sources, it assumes. Hence the level of alertness in a war room is not necessarily based on the likelihood of circumstance arising. It is determined by the perceptions of a few key people. >>>>> “Perception is manageable because the brain generates its own scene so that the world remains stable.” Our pain response is triggered to protect against the perceived threat, not necessarily an actual threat. It is anticipatory thoughts/guesses that make us scream the most. Perceptions, (including that of professionals) are composed of: - the current frame of reference. - what we pay most attention to. - That which we associate with the given stimuli. So whether or not we act from a place vulnerably facing a substantial uncontrollable force, comes down to our perceptions. For what we focus on gets magnifies out of all proportion. Using the example of persistent osteoarthritic pain. Where sensory information from the joint is amplified out of all proportion. An unconscious assumption is probably going on. It is our accurate and inaccurate guesses that become beliefs that we live by. ============================= OUR ASSUMING BELIEF’S TELL US WHAT TO EXPECT The alert status of a war room is set by whether or not the war room expects to be safe or damaged in the upcoming future. In our nervous system, a red-alert status is called sensitisation. If we believe that there is enough credible evidence to substantiate our hypothesis that X means Y will happen, then we will expect it. Which is why many say things like: “This soreness (X) means pain (Y)” Expectations are associations, for instance, if I feel X then Y will happen. This comes from a belief about X. According to the father of positive psychology Dr Martin Seligman, “the mind is mainly drawn to the future, not driven by the past.“ This tendency to live in/for the future would plunge us into chaos if we had no idea about what our future will involve. So we guess, we pre-emptively expect a scenario an outcome. Our entire belief system is built upon anticipating. Pain scientists use a term called neuro-tag, which is, in essence, a connection. This connection starts out as a bit of software code, where the nervous system expects X to result in Y happening. Neuro-tags predict causality, linking a cause with an outcome. Over time software connections become hardware. Just like if we don’t use a joint, the structure of a joint will slowly stiffen things up as the functioning of the joint doesn’t demand mobility. In other words how the brain thinks gradually rewires the brain. In short connecting assumptions - neurotags - shape how our nervous system is combined. Intertwined together, all the neural connections (neuro-tags) within an organisms nervous system is called a neuromatrix. Just like neurotags, the neuromatrix is not fixed, it adapts according to what our beliefs tell us to expect. Continually rewiring our nervous system in the process. =================================== CHRONIC PAIN IS A PERPETUAL RED ALERT Ultra-vigilant war rooms that are governed by paranoid generals may keep a war room in red-alert indefinitely. Those working in a war room that is perpetually running on red-alert, often have the looming threat imprinted on their foreheads. So they remain perpetually on the look out, for a potential threat. In this state of red-alert, confirmation-bias rules the roost. Every piece of information will be more likely to be labelled as proof of a threat. For we are more likely to see or hear something if we expect it, as sub-consciously we are on the lookout for it. Because everyone predicts an upcoming threat, the war room will be perpetually waiting for something terrible to happen. Our internal alarm control system, like a like a war room tries to monitor the levels of multiple variables accurately. It uses these representations to determine as to whether it should mute of amplify its alarm siren. Sometimes it gets stuck in a red alert mode. Our nervous system is not immune to being over cautious to trying to keep one safe even though the damage may be small or even non-existent. This is, in fact, a common state of affairs for many, as 1/4 of us are in a state of chronic pain. Where pain hangs around like a friend, you hate. Even though“the relationship between pain and the state of the tissues becomes less predictable as pain persists” (Moseley). It doesn’t stop the stress of our internal war room bellowing at us. Which effects nearly every area of someone's life who is stuck in a cycle of sub-consciously focusing and worrying about impending doom. If the stress response is ongoing, the discomfort drains us, so we withdraw into a state of depression, which is the nervous systems way of reserving energy in my opinion. =============================== CHRONIC PAIN IS BUILT ON A FOUNDATION OF RESTRICTING EXPECTATIONS: - “Not moving till the pain goes away.” - “It must be serious if it hurts.” - “Why can’t someone fix this pain for me?” - “I’m broken.” - “This pain must mean it is bad.” All of these problem focused hypothesis predict pain, making the believer expect pain. They also assume that pain level accurately represents the state of the tissue. Which increases the likelihood that the pain level of the believer will be higher. ”Believing pain to be an accurate indicator of the state of the tissues is associated with higher pain ratings”(Moseley) Restrictive assumptions, usually overestimate future risk, blindsiding us to a potential opportunity. These close-minded expectations, restrict the number of possible solutions to the pain. As only a complete quick cure becomes acceptable. When a quick remedy is nothing more then an ideal dream, those with restricting beliefs tend to remain stuck in pain. Frequently they become obsessed with it and find it hard to focus on anything else. Thus a positive feedback loop is created. Where ones attention is on the lookout for pain, and they are unable to focus on viable solutions, that might break this often spiralling, self-perpetuating cycle. If these beliefs artificially exclude the only realistic solutions, then the odds that the pain will reduce are next to none. Chronic pain is often not useful as it can be more about our interpretation of threat, and less about the actual state of play. If we perpetually avoid exposure to “threats” then will isolate ourselves from vital information that could inform our nervous system about the actual state of our tissue. ================== REFERENCES - Reconceptualising Pain According to Modern Pain Science, Lorimer Moseley. - The relationship between perceived promotion of autonomy/dependence and pain-related disability in older adults with chronic pain: the mediating role of self-reported physical functioning. (Matos, 2016) - https://www.bettermovement.org/2014/a-systems-perspective-on-chronic-pain/ Hargrove, 2014 - Ollie Pearce - Connectome, Sebastian Seung, 2012 - Homo Prospectus, Seligman, 2016
WHAT IS THIS NEWLY FOUND ORGAN?
In March 2018, researchers published a study in which they examined the space between tissue. This space was always assumed to be empty, but they discovered that it was in fact filled with a vital fluid called interstitial fluid. This fluid is so substantial that on average it takes up about 20% of our total body mass, weighing 10+- litres. Compared to the skin that makes up 13% of total body mass. This re-discovery (as it has only been missed due to the modern methods by which tissues are examined), is essential as it has started a debate as to whether this fluid has been the most significant organ in our body hitherto not known about. This substantial mass of interstitial fluid resides in the space between tissue. It bathes all of our cells that are not surrounded by blood. It has been ignored in modern science until now. Some people call interstitial fluid extra-cellular fluid because it is external to/outside of the cell. In this study in March 2018, this interconnected fluid mass was deemed to be an organ called the interstitium. This substantial net-like mass is undeniably the primary human fluid system as it is our primary fluid compartment and one upon which our life depends. “Unlike a more solid, contained organ like the heart or the liver, the interstitium is a network of tissue that surrounds nearly every organ system in the body. Just as our skin hugs us on the outside, this tissue layer wraps around organs inside our bodies.” (Malderelli, 2018)
WHAT DOES THIS ORGAN HAVE TO DO WITH HEALTH?
Currently, our understanding of the Interstial fluid system is in its infancy making it impossible to say all of the ways that our lives depend on this mass of fluid. I believe that we can come to understand this network of interstitial fluid by looking at our lymphatic system. From our more in-depth understanding of our lymphatic system, we can find clues about our interstitium. “We strike at the source of life and death when we go to the lymphatic… This universal system of irrigation.” (A.T. Stiller, 1899) Just like a farmers field, to be fruitful, our joints require irrigation. A controlled supply of fluid in our bodies is needed to be supplied at regular intervals just as the irrigating flow of fluid determines the health of crops through the fields. A turnover of fluid being provided to the field needs to be frequent enough that the crop gets its fill of water. While the risk of flooding is reduced with sufficient drainage. It is this irrigation that the life of crops depends upon. Like so many human-made systems, a more complex and intricate version of it can be found in nature. In this instance within the human body itself. As we do not understand the interstitium, let’s examine our lymphatic system. From a deeper understanding of the smaller lymph filled fluid system, we can gain more of an idea about the more substantial interstitium system.
OUR LYMPHATIC SYSTEM
Our lymphatic system is a network of vessels filled with circulating lymph. Because lymph flows throughout this net-like circulatory system, in a sense it links everything together. It is composed of a pathway of vessels that connect lymph nodes, which in turn act as reservoirs and pumps. Both lymph vessels and lymph nodes contain lymph. Lymph is composed of “immune cells, antigens, lipids, and macromolecules.” (Shi, 2014) Unlike our thick blood, lymph doesn’t need to be kept contained in a fast moving high-pressure system. Lymph circulates slowly. What does lymph do? As lymph travels slowly it has the time “for lipid absorption, fluid homeostasis, and immune surveillance.” (Wang, 2010). It is as our inflammatory-immune system that our lymphatic system is better known.
INTERSTITIUM POTENTIALLY MORE IMPORTANT THAN LYMPH
There is a reason to believe that the interstitium circulation flows slowly because our interstitium operates under a low-pressure circulatory system. It has also been stipulated that it plays a “role in homeostasis by controlling extracellular fluid volume” (Margaris, 2012). In other words, like our lymphatic system, it helps to manage swelling as it maintains the fluid levels that our cells are bathed in. With our Interstitium being much bigger than our lymphatic system, it is probably even more influential when it comes to managing our immune system and fluid levels and has a far more significant influence on the vitality of the numerous cells that are bathed in interstitial fluid. Could the inability of our body to reduce swelling be because of our interstitium NOT our lymphatic system???
HUMANS ARE AN INTERCONNECTED MASS OF FLUID:
A.T. Still founded Osteopathy on a few principles:
It is through the medium of fluid that macromolecules are transported to the tissues most in need of nutrition.
BLOOD >>> INTERSTITIAL FLUID >>> BLOOD
“Plasma is continuously filtered from the arterial, capillary bed into the interstitial space, where excess fluid drains.” (Shi, 2014)
CSF >>> LYMPH >>> CSF
Our cerebrospinal fluid (CSF) is linked to our lymphatic system (Johnston, 2003)
BLOOD >>> LYMPH >>> BLOOD
The cardiovascular system is linked to the lymphatic system.(Choi, 2012). Around 10% of the plasma (the fluid upon which blood is based) in our blood gets left behind in our tissue. This tissue fluid then enters our lymphatic system via lymphatic capillaries. Once it is inside our lymphatic system, it becomes lymph until it exits the lymph system and re-enters our blood’s venous system, once again becoming blood plasma.
INTERSTITIAL FLUID >>> LYMPH >>> INTERSTITIAL FLUID
There are only two differences between interstitial (pre-lymph) fluid and lymph. Interstitial fluid resides outside our lymphatic and blood circulatory systems, and interstitial fluid does not contain as many proteins as lymph. It could be said that “The interstitial space is the primary source of lymph.” (Benias, 2018). Interstitial fluid enters and exits our lymphatic system via tiny “lymphatic capillaries which are highly permeable to interstitial fluid and macromolecules, such that, when the surrounding interstitial pressure changes, these lymphatics either expand and fill with lymph or contract and push lymph.” (Wang, 2010)
FLUID DYNAMICS AND JOINT HEALTH:
Many do not appreciate that, like fields, our joints require fluid irrigation. Our joints are not isolated structures; they are dependent upon fluid dynamics to survive and thrive. Trans-synovial flow is the term used to describe the inflow and outflow of the components that make up synovial fluid. “Synovial interstitium. The path into the joint cavity from a capillary.” (Levick, 1996). The fluid has a vital role to play in both the inflow and outflow of substances to and from the joint:
The ancient Indian medicine system called Ayurvedic medicine would say this is because of congestion. Whereas traditional Chinese medicine will say that this blockage has led to qi stagnating. Osteopaths call areas of congestion and stagnation, lesions. A lesion is a compromised area of the body where cellular function is impaired. Toxins will build up in tissue that is in a state of a lesion, as dead cells and the waste products are not getting drained away. ANY substance can be a toxin if it has a poisonous effect. In the example of a farmers field, if irrigation is not functioning, the field will yield a bad crop.
WHAT ROLE DOES FLUID DYNAMICS PLAY IN OSTEOARTHRITIS?
Without an efficient synovial fluid transport system controlling the incoming and outgoing of substances, the synovial fluid will become stagnant. Debris from day-to-day joint usage will accumulate, and inflammatory swelling will build up. Frequently a blockage in the synovial fluid goes unnoticed, is asymptomatic. Even when the lack of fluid motility hinders the physiological functioning of the joint. Barriers to fluid movement may be occurring to you right now. Unbeknown to you, these barriers could be stopping smooth-flowing operations in their tracks at this very moment. This impairment of joint regeneration will lead to earlier development of structural changes we all refer to as osteoarthritis. There are signs that joints with osteoarthritis have been affected by a blockage or blockages that have been impairing the joint’s ability to irrigate (absorb and excrete).
HOW INCREASING THE FLOW OF FLUID TO AN ARTHRITIC JOINT REDUCES JOINT PAIN.
It is common knowledge that blood flow is good for our joints. With physiotherapy being even more specific and saying that it is lymph flow that helps to reduce swelling within joints: “enhancement of lymph flow attenuates joint tissue damage” (Shi, 2014). Now it seems that there is a 3rd player. Interstitial fluid. If we do any of the following movements/exercises, then we will hit three birds with one stone as they all promote arterial and venous blood flow and compress and stretch the space between our tissues, which in essence pumps fluid from one area to the next, rhythmically.
Established by Dr Andrew Spina, this slow rhythmic motion is fantastic for getting fluid to flow into and out of our joints
Delayed Onset Joint Soreness is like DOMS
If you scored 2 or less, in the table above.
1: Over the last few weeks have you been using the joint to complete a repetitive task?