Strategies for Managing Arthritis and Chronic Pain

By: Gina Tantalo, RMT

Dr. Tammy Langedyk, B.Sc., D.C., D.Acu.

Goals for today

• Educate you about arthritis• Educate you about pain• Educate you about typical medical treatments• Educate you about complimentary treatments• Provide info on strategies to manage pain• Guide you through a typical exercise program,

that you might use in the future• EMPOWER YOU!

WHAT IS ARTHRITIS?

Arthro = JOINT itis = INFLAMMATION

Consists of more than 100 different conditions.

It leads to joint pain and impairment from loss of normal joint structure and function.

Types of Arthritis

• Mild forms – Tendinitis– Bursitis

• Mild-Moderate-Severe forms– Osteoarthritis***MOST COMMON***

• Severe forms (inflammatory)– Rheumatoid arthritis– Gout– Lupus Erythematosus

• Pain Syndromes– Fibromyalgia

What is Osteoarthritis?

The bones of joints are capped with cartilage. This is a tough elastic material that acts as a shock absorber and allows the joint to glide smoothly with low friction.

OA causes destruction of cartilage surfaces of the bone, where these boney ends grind together causing pain, loss of mobility, deformity and dysfunction.

In essence…OA is the inability of the body to repair the cartilage faster than it is degraded by a specific enzyme (metalloprotease, activated by IL-1, a pro-inflammatory product).

Other forms of Arthritis

• In many forms of arthritis it is the joint lining or synovium that becomes inflammed and thickened, producing extra lubricating fluid, containing inflammatory cells.

• These cells can damage the cartilage and the underlying bone

Normal vs Arthritic joint

Causes of Osteoarthritis (OA)

• Obesity (thought to be the number one modifiable risk factor)• Age • Congenital or Developmental joint deformity

(hip socket displaced)

• Genetic / Gender (female>male)

• Traumatic (injury causes loss of normal joint structure)

• Occupation (repetitive stress ie lifting)

• Sports/activities (wear and tear, if abnormal joints exposed to repetitive stress, or if normal joints subjected to high impact)

• Muscle weakness / ligament laxity

Where is OA most common?

• Hands (1st joints)

• Spine

• Knees

• Hips

• Thumb joint (1st MTP)

Did you know…There are over 100 joints connecting the body’s 206 bones

What are the Symptoms of Arthritis?

• Physical Findings– Gradual onset of localized joint pain– Joint may lock or “give way”– Stiffness in the morning or after rest (rarely exceeds 30 minutes)– Decreased range of motion– Pain increases with motion, relieved by rest– Changes in barometric pressure– Joints in fingers are enlarged– Pain upon palpation of the joint

• X-Ray findings– Decreased joint space– Osteophytes– Whitening or cysts on the surface of the bones

What is PAIN?

Cartilage has no blood or nerve supply. Thus, it does not feel pain, nor does it heal very well. The pain comes from the joint lining, surrounding muscles/ligaments/tendons and capsule.

• Pain is a necessary warning that tells us something is wrong…we need to modify our behaviour or physiology

• it is physiological or a physical response to an injury

• It is also a pyschological response

Perception of Pain

How pain messages travel

• Peripheral Nerves – pain receptors pick up information from the skin, muscles, joints, bones, organs and travel to the spine

• Spinal cord – pain message enters the dorsal horn of the spinal cord and the message travels up to the brain

• Brain – thalamus (sorting/switching station), sends message to – Physical sensation area, to identify where the pain is– Emotional feeling region, experiences suffering– Thinking region, assigns meaning to the pain

PAIN, a unique experience

• Affected by:– Emotional and psychological state– Memories of past pain– Upbringing (taught to “grin and bear it”)– Age– Sex– Beliefs and values– Social and cultural influences (man on the hook)– Attitude– ExpectationsFEAR and ANXIETY can increase intensity of painOn the other hand, ATHLETES can condition to endure pain

Chronic Pain

• PAIN becomes more of a learned experience and less of a physiological experience

• Chronic = Pain longer than 6 months• Can come/go, remain constant, can feel

– Tingling, jolting, burning, dull, aching, sharp• Can be from painful inflammation of joints• Can be from damaged nerves

If you have a mood disorder ie. depression or anxiety, you’re more likely to experience chronic pain- and to feel it more intensely. Ergo, treating mental health conditions can improve or eliminate chronic pain.

Osteoarthritis Pain Cycle

Pain

Avoidanceof

Motion

IncreaseMuscle

Tightness

Loss of Range ofMotion

Managing Pain

• Start with your doctor to properly diagnose• Immediate control may require use of NSAID’s

or anti-inflammatories • See a therapist who can devise an exercise

program specifically for you (muscle wasting, strengthening and ROM)

• You might require a brace/orthotic to keep joints properly aligned

• You may need to seek counseling

You become the master of your domain

Medications

• Control the Symptoms (pain, stiffness & swelling) – Painkillers & NSAID’s– Take days to weeks to begin– Make one feel better, do not affect condition

• Control the Disease– Primarily for inflammatory arthritis– Prevent joint damage that lead to deformities– Take six weeks to six months to work

Pain Reliever/NSAID’sPain Reliever…the goal is reduce your pain.– Tylenol (drug of choice 1000mg)

Anti-inflammatory…minimize day-to-day inflammation(which can damage cartilage/bone)it may take up to 2 to 4 weekstake even when you feel good

1. Cortisone2. NSAID’s -Non-Steroidal Anti-inflammatory drugs– (ASA)Aspirin, (Ibuprofen)Advil, Motrin, Aleve– (Cox-2 Inhibitors) Celebrex– (meloxicam) Mobicox– Pennsaid - Topical NSAID

Linaments – most try to distract the body Tiger Balm - Capsaicin (effectively stops pain signals from being transmitted)

COX Inhibitors

Medication Side-Effects

• Tylenol – liver– Clotting

• NSAIDS – gastrointestinal bleeding– Indigestion – Constipation– liver and kidney effectCox-2 Inhibitors (Celebrex)– Not recommended heart/stroke risk– Good NSAID for stomach /ulcers

• Pennsaid– Topical NSAID for knees specifically

Medical Treatments

Injections• Corticosteroid Injections

– Improve function– Decrease swelling– -ve weaken cartilage, deplete bone minerals

• Hyalgan – hyaluronic acid supplementation injection into the joint– Cochrane 2005 beneficial for knee in decrease of pain and

increase of function

Surgical Techniques• Debridement (scraping)• Osteotomy (bone cut to change alignment)• Partial/Total joint replacement

Complimentary Techniquesto Relieve Pain

• Rest• Energy conservation• Sleep • Relaxation• Exercise

If properly done, you’ll have more energy and less pain to do the things that are important to you.

Complimentary Treatmentof Chronic Pain

Persistent, severe pain from arthritis requires a combination of therapeutic strategies, no one pill or management technique is enough to provide non-stop pain relief safely.

1. Exercises (ROM, stretch, strength, endurance, body awareness)

2. Physical Therapy (chiropractic, massage, physio, TENS, heat/ice, acupuncture)

3. Sleep4. Nutrition5. Self Care6. Dealing with Emotions

Why Exercise

BENEFITS OF EXERCISE

• POTENTIAL BENEFITS: Randomized, controlled trials clearly show that regular moderate-level exercise does not exacerbate osteoarthritis pain or accelerate the pathological process of osteoarthritis. Furthermore, these studies strongly indicate that increasing the level of physical activity in osteoarthritis patients reduces pain and morbidity.

Why exercise

Osteoarthritis exercises can be an effective treatment for joint pain. Exercise can help:

• Control weight

• Keep joints flexible

• Increase muscle strength

• Strengthen bones and ligaments

• Improve mood and overall outlook

CONTRAINDICATIONSAbsolute contraindications :

uncontrolled arrhythmias third degree heart block recent electrocardiographic changes unstable angina acute myocardial infarction acute congestive heart failure

Relative contraindications :cardiomyopathy valvular heart disease poorly controlled blood pressure uncontrolled metabolic disease

ANY HEART CONDITION

Cross Training: secret of champions

• Range-of-Motion (ROM) Exercises– Maintain or restore normal joint movement and relieve stiffness

• Stretching exercises– Help maintain or restore normal flexibility to joints muscles and tendons

• Strengthening exercises– Increases the muscles ability to provide support and stability to a joint

• Endurance exercises– Use large muscles of your body in rhythmic and continuous movement

ie swim, bike, dancing, walking

• Body awareness exercises– Help promote balance, posture and breathing ie yoga, tai chi

ROM Exercises

• Do these at least once per day. • Do each exercise 3 to 10 times. • Move slowly. Do not bounce. • Breathe while you exercise. Count out loud. • Begin exercises slowly, doing each exercise a few

times only and gradually build up to more. • Try to achieve full range of motion by moving until you

feel a slight stretch, but don't force a movement. • Don't try to help others do their exercises by moving

their arms or legs. • STOP exercising if you have severe pain.

Examples of ROM Exercises

• Ankle Alphabet

• Knee Raises

• Neck Rotation

• Finger Stretches

Stretching Exercises

• Perform daily or every other day

• Hold stretch position for 15 to 30 seconds• Exercise when pain and stiffness are minimal

(i.e., prior to bedtime). • Warm up (shower or heating pad). • Relax prior to.• Perform movements slowly and within a

comfortable zone. Breathe during each stretch. • Modify the stretching exercises to avoid pain or

when the joint is inflamed

Examples of Stretching

• Neck stretch

• Wrist stretch

• Knee to Chest– Knees– Back– Buttock

• Hamstring Stretch

Strengthening Exercises

• Perform 3 times per week

• If the joint you’re moving has arthritis but isn’t painful, repeat the exercise 10 times.

• If still pain-free gradually increase: 3 sets of 10

• If it is slightly swollen, mild pain 1 set of 15

• If hot swollen, and painful STOP

Isometric Exercises• Contract the muscle without moving the

joint

Isotonic Exercises

• Contract muscle against mild resistance while moving the joint through it’s range of motion

Endurance Exercises

• Helps us to increase circulation to our heart, lungs and blood vessels.

Body Awareness Exercises

• as their name indicates, help promote balance, posture and breathing through a variety of therapeutic techniques and recreational activities, including yoga and tai chi.

Chiropractic/Physical Therapy

• use a combination of non-invasive treatments. Including passive stretching, traction, use of TENS and ultrasound for pain control and inflammation. Recommend therapeutic exercise and provide nutritional, dietary and lifestyle counseling for long-term health.

Medical Acupuncture

• Contemporary Medical Acupuncture is a medical adaptation of Chinese acupuncture methods, based on current concepts of nerves, muscles, joints and release of the body’s natural chemicals.

• As in traditional acupuncture, it involves insertion of solid needles at relevant points on the body in combination with electrical stimulation.

• Acupuncture can be very effective for treating both acute injuries and chronic conditions.

• Works by reducing inflammation, endorphin release (pain control) and re-programming pain.

Heat & Ice

• Heat – recommended for muscle pain, promotes blood circulation, with nourishes and detoxifies muscles– Moist heat towels, hot packs, bath or shower– 15-20 minutes– 3 times each day

• Cold – soothes excited nerve cells and reduces swelling in an inflammed joint be constricting blood flow

- Cold Therapy Ice packs, 2 lb bag of frozen peas10-10-10 RULE: 10 min ice on -10 min ice off -10 min ice on

Massage Therapy

• Widely used for pain relief. Relieve muscle ache and tension by increasing blood flow.

Sleep

• Getting a good night’s sleep can be almost impossible when you’re in pain.

STEP 1 establish a new pattern (set alarm, wake up regardless)

STEP 2 don’t go to bed until you’re tired, if you can’t fall asleep in 20 to 30 min, get up

• Don’t do anything that doesn’t relax you ie TV• Good pillow and mattress• Keep heat at 64 to 66 degrees• Don’t use medications• Satin sheets or pj’s• Sleep on side• Keep room quiet

Nutrition• Weight control (burden on joints)

• General sense of well-being

• Avoid pro-inflammatory foods – red meat– night shade veggies (potatoes, tomatoes, egg plant, peppers)

• Consume anti-inflammatory foods Omega 3 & 6– Fish oils (Salmon, trout), nuts (almond, walnut), flax and

sunflower seeds and oil, soybeans

• Consume Anti-oxidants

– Fruits and veggies (especially high in Vit C = bright colours)

– Cherries, blueberries, apples, oranges, avocado, spinach, sweet potatoes, broccoli.

Natural SupplementationAnti-Inflammation

• Aspirin and related drugs can have undesirable side effects such as stomach irritation, intestinal ulcers, intestinal bleeding

• A number of herbal agents also block the production of PG-2 in the body, reducing the pain and inflammation, without the side effects.

• Curcumin (derived from the spice turmeric) has been shown to be effective in clinical trials involving patients with rheumatoid arthritis.

• Boswellia has been used successfully in studies with osteoarthritis and rheumatoid arthritis patients.

• White Willow Bark Extract has been shown to be effective in the management of various forms of arthritis, back pain and other joint inflammatory conditions.

• Ginger ingredients have been shown to be helpful in various arthritic condition and muscle inflammatory states.

• MSM (Methyl Sulfonyl Methane) helps control the low-grade background swelling and pain of osteoarthritis

Natural SupplementationCartilage Health

• Glucosamine Sulfate– Our bodies produce glucosamine sulfate naturally to make joint

cartilage– As we age our body slows down its production of glucosamine

sulfate– The good news is that studies conducted over the past 20 years

have shown that supplementation with a pharmaceutical and pure grade of glucosamine sulfate can help the body rebuild and repair joint cartilage.

– Clinical studies have proven that supplementation with glucosamine sulfate is an effective part of the management of osteo and degenerative arthritis, as well as in cartilage injuries, reducing pain and stiffness to a marked degree in many cases.

– 2006 study in NEJM showed Glucosamine sulfate was better than hydrochloride

– 1500mg/d for 6 to 8 weeks• Cautions

– seafood allergy– diabetics

Natural Supplementation

• Chondroitin (Shark cartilage)

– chondroitin sulfate is too large a molecule to be absorbed from the intestinal tract to the bloodstream, showing only 0-13% bioavailability. Do not waste your money.

• Calcium (1000-1200mg/day)• Vitamin D (200-400IU/day)

– Evidence OA progresses faster in people with low Vit D

– Milk has 100IU/glass

Self-Care

Effect of Mental State on Chronic Pain

• Depression is very common in patients with chronic/recurring musculoskeletal pain

• Depression is commonly misdiagnosed or never considered

• Professional care required for diagnosis and treatment of Depression

Dealing with Emotions

Short of death, a diagnosis like chronic illness elicits a strong emotional response.

• Depression

• Anxiety

• Feelings of helplessness and isolation

Stress and it’s Role in Pain

• During periods of emotional stress naturally occurring predicaments of musculoskeletal symptoms can become highly magnified and prolonged

• Attempt to avoid/minimize/escape emotionally stressful situations

• Seek professional help to cope with stress if necessary

Good Health Requires a Positive Attitude

• Focus on abilities instead of disabilities • Focus on strengths instead of weaknesses • Modify activities into small manageable tasks • Make fitness and nutrition part of daily routine • Minimize and manage stress • Balance rest and activity

Conclusion

• Pain is one of the hallmark symptoms of arthritis. • We understand how pain works, but it’s never

the same experience for any two people.• Relief requires a combination of strategies, not

just one “magic pill”.• You need to empower yourself with all of the

information and discover what works for you.• You are your own Arthritis Self-Manager.• Develop support system of family, friends, and

health professionals.

Exercise Program

• Warm up– Breathing– Neck circles– Shoulder circles– Reach up and out (sun salutations)– QL stretch– Seated flexion for LB– March on spot– Ankle circles/alphabet– Wrist/hand circles (squeeze and release)

Stretch & Strength

• AB hollow• Pelvic tilt• Hip flexion – 3” above, sits bones• Foot dorsi/plantar flexion• Hip hikes• Lumbar rotation• Figure 4• Mid back reach• Pec stretch• Trap stretch• Levator stretch• Wrist flex/ext stretch

Resources for Arthritis

• www.balancedhealthcare.ca

• www.arthritis.ca

• http://www.arthritis.org/

• http://www.americanarthritis.org/portal/loader.php

• http://www.adeeva.com/

Core Strength

List of Stretching/ROM for OA