Transcript ARTHRITISOTHER SELF CARE OTHER METHODS FOR

Strategies for Managing Arthritis
and Chronic Pain
By:
Gina Tantalo, RMT
Dr. Tammy Langedyk, B.Sc., D.C., D.Acu.
Goals for today
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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)
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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?
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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
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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
– Expectations
FEAR and ANXIETY can increase intensity of pain
On 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
Avoidance
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Motion
Increase
Muscle
Tightness
Loss of
Range of
Motion
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’s
Pain 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 weeks
take even when you feel good
1. Cortisone
2. 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 effect
Cox-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 Techniques
to Relieve Pain
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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 Treatment
of 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. Sleep
4. Nutrition
5. Self Care
6. 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
CONTRAINDICATIONS
Absolute 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
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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 peas
10-10-10 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
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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 Supplementation
Anti-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 Supplementation
Cartilage 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
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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
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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
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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
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www.balancedhealthcare.ca
www.arthritis.ca
http://www.arthritis.org/
http://www.americanarthritis.org/portal/load
er.php
• http://www.adeeva.com/
Core Strength
List of Stretching/ROM for OA