If stiff and sore joints bother you only some of the time, you may not have seen a doctor for a diagnosis. But you’ve probably tried some arthritis remedy you heard from a neighbor or friend. And if you’re being treated for arthritis by a doctor, your pain is probably great enough that you’re even more likely to try something outside your conventional treatment.

While arthritis generally means stiff and painful joints, it is not one disease but more than 100. What’s helpful for degenerative osteoarthritis (the most common kind) may not be for rheumatoid arthritis, gout or other forms. And, in many cases, patients suffer persistent pain and activity limitations, regardless of treatment.

To deal with these problems, studies show, more than 60 percent of Americans with arthritis make use of complementary or alternative medicine. Surveys indicate that pain is the primary driver.

Complementary/alternative medicine (CAM) is the term generally used for products and practices that are not considered part of standard medical care. Some of these have been proven safe and effective; others have not.

Actually, the two most effective self help measures, weight loss and moderate exercise, are not considered complementary medicine. Both rank high on any conventional treatment plan based on ample evidence that they may be the most effective thing you can do for sore, aching joints.

Even moderate weight loss helps take pressure off weight bearing joints. But studies show that it also helps relieve symptoms from arthritis of the hand–probably because of metabolic changes.

Physical activity improves circulation, lubricates the joint and strengthens adjoining muscles. Without it, the stiffness, soreness and disability will only get worse. Exercise should be regular, though, and care should be taken not to over-stress or damage the affected joints.

YOGA AND TAI CHI are natural choices to complement whatever treatment is used, particularly for patients with osteoarthritis. Both involve simple, gentle movements that focus on strength, balance and flexibility. With origins in ancient eastern philosophy, they also stress the integration of mind and body in a way that should help mediate and control pain.

More than 75 studies in major medical journals have found yoga to be a safe and effective way to exercise with important psychological benefits.

One study of 17 patients with osteoarthritis of the fingers found that subjects receiving 60-minute group sessions of yoga had decreased pain and improved range of motion compared to control subjects. Grip strength and joint circumference were unchanged, however, after 10 weeks.

A review of five studies found that rheumatoid arthritis patients practicing tai chi reported improvement in disability, mood and vitality but no change in pain or functional ability. Results for fatigue and swollen joints were inconclusive.

Among osteoarthritis patients, a randomized, controlled study by researchers at Tufts Medical Center found that tai chi subjects showed greater improvement in pain, physical function, depression, self efficacy and health-related quality of life compared to a control group.

OTHER MIND-BODY TECHNIQUES such as meditation, biofeedback and relaxation therapy are frequently used to control pain, A 2002 review of research found that they could provide beneficial effects if added to conventional medical treatments. Subjects most likely to benefit were those with a shorter duration of pain.

ACUPUNCTURE is a traditional Chinese practice that has many advocates. The first large randomized, controlled study of acupuncture published in Annals of Internal Medicine [December 21, 2004] found that the procedure relieved pain and improved function of patients with osteoarthritis of the knee.

A more recent study [Arthritis Care and Research, September, 2010] found that patients with osteoarthritis of the knee treated with acupuncture had no greater benefits than those getting a sham acupuncture, or placebo. While subjects reported a small decrease in pain, it was no greater than that reported by the control group.

MAGNETS, in the form of patches, disks, shoe insoles, bracelets and mattress pads are widely marketed for pain control. While they are generally safe for most individuals, studies have provided no convincing scientific evidence that magnets are effective in relieving pain.

Some studies have suggested that magnets might provide some relief from osteoarthritis pain. More rigorous research is required before any conclusions can be made about the role of magnets in pain relief.

HYDROTHERAPY or mineral baths were widely used in the early part of the 20th century and still offer appeal to many patients. A 2008 Cochrane review of seven studies found positive findings from most studies but flaws in methodology that made it impossible to draw conclusions. Some improvements were noted in morning stiffness and grip strength.

GLUCOSAMINE AND CHONDROITIN are substances naturally found in and around the cells of cartilage. Supplements, usually combining the two, are commonly isolated from shellfish and used as a complementary treatment for osteoarthritis based on the belief that these substances can strengthen cartilage.

The Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT) is the first large-scale study to test the effectiveness of these supplements in reducing the pain and diminishing the structural damage of osteoarthritis of the knee. Results from June of 2010 [Annals of Rheumatic Diseases] found that patients taking glucosamine (1,500 milligrams daily), chondroitin (1,200 milligrams daily) or both had similar results as those taking placebo. For a small subset of subjects with moderate to severe pain, however, the supplements did provide pain relief.

OTHER SUPPLEMENTS used as complementary treatment include fish oil, gamma linolenic acid (GLA), tumeric, ginger, valerian, feverfew and thunder god vine–all believed to have antiinflammatory properties. All have their advocates, but scientific evidence of their effectiveness is either weak or inconclusive.

One major reason not to use dietary supplements is that they are unregulated. You cannot be sure that what you’re getting is what the package claims. In many cases these supplements interact negatively or reduce the effectiveness of prescription medications.

Most doctors have no quarrel with complementary medicine. In fact, many recommend yoga, tai chi or certain dietary supplements in addition to conventional therapy. They prefer, however, to know about these self treatment measures so they can be sure the patient is not doing or taking anything that could be risky or work against the doctor’s treatment plan.

REFERENCES:

“Acupuncture not superior to sham acupuncture in knee osteoarthritis,” Arthritis Care Research News Alerts, September 3, 2010.

“Acupuncture relieves pain and improves function in knee osteoarthritis,” National Center for Complementary and Alternative Medicine, December 21, 2004.

D. Lonnie Anderson, Pharm.D., et al, “Prevalence and patterns of alternative medication use in a university hospital outpatient clinic serving rheumatology geriatric patients,” Pharmacotherapy, August, 2000.

Arthritis Care, “Complementary therapy,” last modified August 18, 2011.

Majid Artus, et al, “The use of CAM and conventional treatments among primary care consulters with chronic musculoskeletal pain,” BMC Family Practice, July 26, 2007.

Arthritis Foundation, “Alternative therapies.”

Sarah Brien, et al, “Homeopathy has clinical benefits in rheumatoid arthritis patients that are attributable to the consultation process but not the homeopathic remedy,” Rheumatology, 2011;50(6):1070-1082.

Allison Gandey, “Patients in pain more likely to choose alternative medicine,” Medscape Medical News, October 19, 2005 (Arthritis and Aging, October 15, 2005).

Martin Garfinkel, EdD, “Yoga as a complementary therapy,” Geriatrics and Aging, 2006;9(3):190-194.

“Glucosamine/chondroitin arthritis intervention trial (GAIT): primary and ancillary study results,” National Center for Complementary and Alternative Medicine, June, 2010.

Steffany Haaz, MFA, RYT, “Yoga for people with arthritis,”Johns Hopkins Arthritis Center, updated June 23, 2009.

Steffany Haaz, MFA, RYT, “Complementary and alternative medicine for patients with rheumatoid arthritis,” Johns Hopkins Arthritis Center, updated December 19, 2008.

Nancy A. Melville, “Chondroitin sulfate shows efficacy for hand osteoarthritis,” Medscape Medical news, September 8, 2011.

National Center for Complementary and Alternative Medicine, “Magnets for pain,”“Cat’s claw,”“Evening primrose oil,” “Feverfew,” “Ginger,”“Thunder god vine,”“Tai chi may benefit older adults with knee osteoarthritis.”

Richard S. Panush, M.D., MACP, MADCR, et al, “Patient information: complementary therapies for rheumatoid arthritis,” uptodate.com, last literature review version, January, 2012.

Vijitha de Silva, et al, “Evidence for the efficacy of complementary and alternative medicines in the management of osteoarthritis,” Rheumatology, 2011;50(5):911-920.

“Supplements for your condition,” Arthritis Today.

“Two-year study of knee osteoarthritis pain reports similar outcomes with glucosamine and chondroitin, celecoxib, and placebo,” National Center for Complementary and Alternative Medicine, June 4, 2010.

W. Zhang, Ph.D., et al,/ “OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines,” Osteoarthritis and Cartilage, 2008;16:137-162.

2/28/2012

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Karen had been putting in quality time at the driving range and was eager to demonstrate her new golfing skills to her friends. Then her elbow started acting up.

Whether you play a sport or just enjoy working out, you undoubtedly know the feeling. Just when you think you’re approaching a new level of fitness or competence, your body starts objecting, First, it’s a small pain that you try to ignore. But it continues to get bigger. Eventually, symptoms could include stiffness, swelling and redness around the joint, particularly during and after using the joint or muscle.

In most cases, what you’re experiencing is tendinitis. Literally, this means inflammation of a tendon, one of the thick rope-like cords of tissue that attach muscle to bone. Tendinitis can occur anywhere a tendon exists–most commonly in the vicinity of the shoulder, elbow, knee, wrist or fingers. You may recognize the sport specific names–tennis or golf elbow, swimmer’s shoulder, jumper’s knee, rock climber’s fingers.

Achilles tendinitis (at the back of the heel) frequently occurs to persons age 35 to 45 who are not particularly athletic. Older persons are also vulnerable because tendons become less flexible with age and injury can occur with minimal exertion.

In sports, the pain is nearly always associated with overuse–training a bit longer or with a bit more intensity than your tendon is able to accommodate at this particular time. Tendinitis can also occur because of repetitive motions in occupations such as carpentry or carpet laying. And it can occur any time you ask your muscles to move in new ways or do more than they are accustomed to doing.

For a high level athlete, a diagnosis of tendinitis may come as a relief because it indicates no structural damage to the joint. But it should not be taken lightly because, without attention, the problem will get worse and could lead to more serious problems.

Self Treatment with RICE

The most important thing you can do for tendinitis, or any soft tissue injury, is to rest the injured joint or muscle–something the competitive athlete does not want to think about.

After the first few days, though, rest means relative rest rather than complete immobilization, which can promote stiffness. The patient is advised, rather, to continue some kind of activity but at a lower level of intensity and with care taken to prevent damaging the most injured tissues. An alternate activity may also be advised–swimming to avoid stressing lower limb tendinitis, for example.

Ice is another basic part of self treatment. The ice or cold pack should be placed on the injured area to reduce swelling, pain and muscle spasm. It should be applied to the injured area for 20 minutes at a time several times a day while inflammation and swelling exist.

Later, for more chronic conditions, deep heat, such as from ultrasound, can ease pain and increase blood flow.

Compression (with wraps or compressive bandages) and elevation (keeping the affected limb above the level of the heart) are the other components of the traditional self treatment known as RICE (rest, ice, compression, elevation).

With prompt self treatment and a gradual return to former activities, the symptoms of tendinitis should clear fairly quickly. It’s important not to let the problem linger or recur, however, because it could lead to a more serious degenerative condition known as tendinosis.

Muscles and tendons become stronger through a gradual process of being broken down and then being rebuilt to adapt to a higher load. That is what training is all about. But when the process is rushed–when new injuries occur before old ones have a chance to heal, the result is a chronic degenerative injury of “failed healing.” That is tendinosis.

Based on research findings of the last 15 years, it’s now believed that failed healing rather than inflammation is the most frequent cause of tendon pain (even in cases commonly referred to as tendinitis). And, as a result, strategies for treatment are changing.

Many athletes pop aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen or naproxen at the first sign of tendon pain. That’s a practice that’s not very safe and, according to studies, not very effective, either, if failed healing rather than inflammation is causing the pain. Some studies, in fact, suggest that NSAIDs may even contribute to the development of tendinosis by shutting down inflammation in the early stages when it could be a positive factor in the healing process.

The same is true for cortisone injections. The injections are designed to reduce inflammation, but if no inflammation is present, there is no benefit, and repeat injections can weaken tissue. Cortisone is capable of dissolving scar tissue, however, so it is considered a useful option in some cases of tendon pain.

The best treatment for tendinosis is gentle stretching and strengthening, but patience is required since tendons heal more slowly than muscles. In most cases, it’s best to have the help of a physical therapist who has experience working with tendinosis.

Eccentric exercise may be helpful as part of the physical therapy program. This is exercise that forces a muscle to lengthen as it contracts. Walking downhill, for example, is eccentric, while walking uphill or riding a bike is concentric exercise.

Animal studies have found that lack of nitric oxide delays tendon healing. As a result, some experts have proposed the use of topical glyceryl trinitrate, a prodrug of nitric oxide. Some studies have found that patients using eccentric exercise plus glyceryl trinitrate had less pain and greater range of motion.

Blood platelets play a role in the healing process. As a result, some doctors advocate introducing platelets into the tendon–either by

• causing the tendon to bleed by needling or poking it or

• giving the tendon injections of blood or platelet-rich plasma taken from the patient.

The idea, in both cases, is to stimulate the body’s own healing mechanisms.

In the past, many athletes dealt with tendinitis by “toughing it out.” Pain, though, is never to be taken lightly. A better approach is correcting any problems of technique or gait that may have caused the problem, then having the patience to see that thorough healing takes place.

04/18/2012

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Ellen loved seafood and had eaten shrimp dishes frequently. This time it was different: her lips started tingling and then swelling, and soon she was finding it difficult to swallow or breathe. Fortunately, her friends acted quickly to get her to the emergency room where she discovered she was having an allergic reaction to the shrimp dip she had eaten.

Nearly everyone has some negative reaction to some foods on some occasions. The food may cause gas, cramping, an upset stomach or a headache. The rational response is to try to avoid that food at least in the quantity that brought on the reaction.

Allergies are generally much more serious and, as in Ellen’s case, can be life threatening. It’s important to know the difference between being allergic to a food and having a food intolerance or sensitivity.

A FOOD ALLERGY is an autoimmune reaction. The body’s immune system mistakenly identifies a protein or other substance in the food as an invader and over-reacts, producing antibodies to fight it.

The first time the food is eaten, the person notices no reaction, but the immune system produces imunoglobulin E (IgE) antibodies to fight it. The next time the food is encountered, these antibodies trigger the release of other chemicals such as histamine to attack what is perceived as an invader.

Histamine is a powerful chemical. In the skin, it produces hives or a rash; in the gastrointestinal tract, cramping, pain and diarrhea. The most severe reaction, often occurring within seconds, is anaphylaxis: constriction of the airways, a swollen throat, rapid pulse, lightheadedness and shock, with a dramatic drop in blood pressure. Without emergency medical attention, the person can die within minutes.

About 90 percent of allergies are to eight foods: peanuts, tree nuts, eggs, fish, shellfish, milk, soy products and wheat. Food manufacturers are required to report clearly on the label the possibility of even trace amounts of these foods.

An allergy typically develops early in life, but many children outgrow their allergies to milk, eggs, soy and wheat. Peanut, tree nut and seafood allergies are more likely to be lifelong. As in Ellen’s case, it’s also possible for an allergy to develop in adult life.

About six to eight percent of children and three to four percent of adults have some kind of food allergy. Exposure to even a small amount of the food can trigger a reaction, and there is no way to predict how severe symptoms will be. Some individuals have suffered severe allergic reactions simply by walking past a restaurant where shellfish is being prepared.

Since there is no cure, the only course is to avoid the food in any amount. A person with a food allergy must:

• be careful to read food labels,

• inquire about ingredients and food preparation when eating away from home, and

• carry epinephrine for use in emergencies.

For a child, of course, this strategy is difficult and requires the help of responsible adults.

A FOOD INTOLERANCE, by contrast, is a reaction of the digestive system. While symptoms (such as stomach pain, cramping and diarrhea) may be similar to those of an allergy, they usually come on more gradually and are rarely life threatening.

One of the most common, lactose intolerance, affects about 10 percent of Americans. It occurs because the person lacks the enzyme, lactase, needed to digest lactose, the main sugar in milk and most milk products.

Lacking the enzyme, the body uses bacteria in the intestine to break down lactose, and this process results in gas and the symptoms of bloating, abdominal pain and, in some cases, diarrhea.

There is a big difference, often misunderstood, between cow’s milk allergy and intolerance to cow’s milk, which is ordinarily due to lactose intolerance.

Persons with lactose intolerance can usually control their disorder by consuming smaller quantities of milk products or by taking lactase supplements. Persons with a milk allergy must avoid milk products, even in small amounts.

Another common food intolerance involves a negative reaction to additives such as monosodium glutamate, food colorings, preservatives or sulfites. Sulfites, which can also occur naturally in foods or generated as part of the winemaking process, can cause serious breathing problems in susceptible individuals.

Foods containing naturally occurring substances such as salicylates can trigger symptoms in some persons. Salicylates are found in many fruits, vegetables, nuts, coffee, beer and wine as well as in drugs such as aspirin.

Hereditary fructose intolerance occurs when a person lacks the enzyme necessary to break down fructose, a naturally occurring or man-made fruit sugar. Serious symptoms, including convulsions, jaundice and excessive sleepiness, can be seen soon after a child starts eating solid food or infant formula.

Celiac disease or gluten intolerance has some similarities to an allergy since it involves an immune system reaction. This is a unique reaction, however, that does not involve the production of IgE antibodies.

In susceptible persons, many of whom have a family history of the disorder, gluten causes an immune reaction that damages the lining of the small intestine, affecting its ability to absorb nutrients properly. A major ingredient of wheat, barley, rye and possibly oats, gluten is difficult to avoid, but that is what persons with this disorder must do.

In addition to abdominal pain, bloating and other symptoms, persons with celiac disease become malnourished and often have unexplained weight loss.

Both food allergies and food intolerances can be difficult to diagnose. Although a severe allergic reaction such as

Ellen’s is impossible to miss, the offending food may not be the main ingredient of the dish.

With a food intolerance, it can take 48 hours or longer for the symptoms to appear, and severity may vary according to how much of the offending food is consumed.

There is also a lot of misleading information circulating informally by word of mouth or the media. If you have questions about your reaction to certain foods, it’s best to talk to your doctor.

02/28/2012

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Nearly everyone knows how heartburn feels. The searing sensation in the chest, the sore throat and bitter mouth taste are no fun, but they are no big worry as long as they go away within a short time and don’t return any time soon.

Heartburn happens because the sphincter muscle or valve at the bottom of the food tube (esophagus) fails to close properly, letting the acidic contents of the stomach wash back up briefly. This is sometimes called acid indigestion or acid reflux. The burning sensation indicates that the lining of the food tube is being irritated.

When heartburn happens occasionally, most Americans simply take an antacid or other remedy and consider changes in their eating habits. When the symptoms continue to occur frequently despite these measures, it’s probably time to see a doctor. Symptoms recurring more than twice a week or interfering with daily activities qualify for the diagnosis, gastroesophageal reflux disease (GERD),

GERD can occur at any age. In fact, it’s estimated that 35 percent of babies have GERD at birth. Although healthy and happy, these infants spit up or vomit frequently–a problem that usually resolves by their first birthday.

In children and even in some adults, GERD is characterized not by heartburn but by a persistent dry cough, asthma symptoms or trouble swallowing. Young children may be irritable and arch their backs during or shortly after feeding.

Cause Is Often Unclear

Infants with GERD probably have a gastrointestinal system that is not yet fully developed. In adults, causes are still unclear. Weakening of the sphincter muscle can occur as a result of smoking. And the problem often develops because of crowding and pressure on the stomach during pregnancy or in people who are obese.

Some individuals develop GERD because of an anatomical abnormality known as a hiatal hernia. Normally, the diaphragm helps the sphincter function, but, with a hiatal hernia, the stomach and sphincter are pushed above the diaphragm.

Foods that are often linked to acid reflux or GERD include citrus fruits, chocolate, drinks containing caffeine or alcohol, onions and garlic, mint flavorings, spicy foods and tomato-based foods such as pasta sauce, salsa, chili and pizza.

Even if you feel you can live with the symptoms, it’s important to seek treatment for GERD. Constant irritation by stomach acid can cause the esophagus to develop ulcers or bleed. Scar tissue can form, making it increasingly difficult to swallow. And, in some cases, persons with GERD go on to develop Barrett’s esophagus or esophageal cancer.

Barrett’s esophagus involves dysplasia or changes in cells of the esophagus that are sometimes pre-cancerous. It’s reasonable to assume that persons with long-standing, severe symptoms of GERD are most at risk of developing both Barrett’s esophagus and esophageal cancer. And such patients are usually singled out for screening.

A recent study published in the Archives of Surgery [July, 2011] called this practice into question. Among 769 patients taking medication for treatment of GERD, those with severe symptoms had significantly lower rates of esophageal cancer than those with mild symptoms or none at all. This finding explained previous results showing that 95 percent of patients diagnosed with cancer were unaware of the presence of Barrett’s esophagus and thus had not been recommended for screening.

While most individuals can manage occasional heartburn through lifestyle changes and use of over-the-counter medications, many patients with gastroesophageal reflux disease need stronger prescription medications as well as lifestyle changes. In most cases, the disease is best managed by a gastroenterologist who has specialized diagnostic tools and experience.

Lifestyle measures that should be started even before occasional heartburn turns into GERD include:

• weight loss,

Generally, acidic and spicy foods are the culprits, but fatty, greasy foods such as french fries can also trigger heartburn.

• avoiding cigarette smoke,

• eating smaller meals,

• not eating a snack just before bedtime or lying down right after a meal;

• wearing clothing that fits loosely around the waist so as not to put pressure on the abdomen;

• sleeping on your left side;

• elevating the head of your bed six to nine inches with wood or cement blocks (raising your head with pillows will not help); and

• avoiding foods and drinks that trigger heartburn.

Generally, acidic and spicy foods such as oranges, vinegar, tomatoes and grapefruit are culprits, but fatty, greasy foods such as french fries also trigger heartburn in some persons. Carbonated and caffeinated drinks may also bring on acid reflux.

Initial over-the-counter heartburn treatments include antacids such as Maalox, Mylanta, Gelusil, Rolaids and Tums. These are designed to neutralize stomach acids, and overuse can cause diarrhea or constipation.

H-2 receptor blockers such as Tagamet HB, Pepcid AC, Axid AR and Zantac 25, 75 or 150 reduce stomach acid. These provide longer term relief but don’t act as quickly.

Proton pump inhibitors such as Prevacid and Prilosec block the production of acid, allowing damaged tissue in the esophagus time to heal.

Both H-2 receptor blockers and proton pump inhibitors are available in stronger prescription strength formulations. A doctor’s supervision is needed since proton pump inhibitors can lead to loss of bone density in some persons and may decrease the effectiveness of blood thinners such as Plavix.

Other medications, known as prokinetic agents, may be prescribed to tighten the sphincter muscle and help the stomach empty more rapidly.

When lifestyle changes and medications fail to stop symptoms, more invasive measures may be necessary. One surgical procedure, known as Nissen fundoplication, involves tightening the sphincter at the lower end of the esophagus by wrapping the very top of the stomach around it.

Another surgical procedure places stitches in the stomach near the weakened sphincter, creating a barrier to keep stomach acid from backing up. For a third option, scar tissue can be created through electrode energy to help strengthen the barrier. Both of these are used primarily for patients with severe, longstanding symptoms who are not considered good candidates for Nissen fundoplication.

If you suffer acid reflux on a regular basis, with symptoms that keep you awake or impair your productivity at work, it’s best to do something about it. Seeing a doctor is the first step toward relief.

04/18/2012

For more information, sample newsletters or to get on our mailing list contact:

        Community Relations
        West River Regional Medical Center
        1000 Highway 12
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