Examining the essentials

The main concern of most people who have joint pain is to continue to be active, and to be able to do the things they want to do, despite problems with their joints. This chapter will consider basic ways of dealing with the symptoms of OA. You may not think of these as treatments because they are everyday things that you can do for yourself, without the need to see a doctor. The chapter will also look at the evidence as to whether these ‘treatments’ work.

 

Physical activity to ease joint pain and increase mobility

As we saw in the first chapter, people who have OA have found out for themselves how important it is to keep active.

“One of the ladies in work said that her fingers went stiff and she couldn’t bend her fingers. And I said, ‘Yeah but the longer you keep them still the worse it is going to get. I find that if I move the pain goes away’. By dinnertime she came across and she said, ‘You’re right. I’ve got going and the pain’s gone.’”

Evidence from research confirms the importance of physical activity in helping to relieve pain and stiffness, and keep people independent

 

EXTRACTS FROM: The MOVE consensus

Published in Rheumatology 2005, volume 44, pages 67-73.

Drawn up by health professionals who work in the field of OA.

Supported by research on exercise for lower limb OA by Uthman and colleagues in The BMJ 2013;347:f5555

Research has shown that amongst people with knee OA, both muscle strengthening and aerobic exercise (physical activity that makes the heart beat faster) can reduce pain and improve the ability to do everyday tasks. Both home based exercises and hydro- therapy (exercising in warm water) are effective. Only a few studies have looked at the value of exercise in relation to OA in other joints.

Experts in OA have concluded that exercise is safe. Experts see both aerobic and muscle strengthening exercise as an essential part of the treatment of every patient with hip or knee OA. There are very few reasons why people with OA would be advised not to do aerobic or muscle strengthening exercises.

Research has shown that group and home-based exercises are equally effective. Patients, though, may have a preference for one over the other. Experts emphasise that it is important to keep up exercise routines in order to continue to get benefit.

Experts think that improving the strength and use of muscles around the knee and hip may play a role in preventing the progression of OA.

Which physical activities are suitable?

Physical activity can be the general sort that causes your heart rate to increase (aerobic exercise) – such as walking, cycling and swimming. Or it can be the sort that works on a particular joint in order to increase the strength of muscles and improve the range of movement, for example, exercises like straightening your knee while sitting in a chair, making a fist or flexing the wrist, moving the head from side to side. Both sorts are beneficial.

Walking, swimming and cycling are good forms of exercise for people with joint pain. Physical activity, particularly that which involves getting out and about with other people, helps not only with joint pain and other health problems, but also with a general feeling of wellbeing.

“I go to town with a friend who is, she’s ninety actually, and we do that. We go and have a coffee. It’s just you know have a look round, have a coffee and get the bus home, which is quite nice. So it is just a break, really.”

However, to be of benefit, physical activity has to be ongoing. If it stops, the good work it does, stops too. Sometimes though, it can be hard to stay motivated for all sorts of reasons. People have told researchers about the kinds of things they found help, or hinder, keeping up physically activity.

 

Things that help people to keep physically active:

• Doing activities that can be easily incorporated into everyday life. Walking is probably the easiest activity to build into everyday life. Some people are happy to walk for the sake of walking but others are not. If you are one of the latter then try increasing the amount of walking you do as a natural part of your everyday life, for example, taking the stairs rather than the lift, walking rather than using the car for local errands or getting off the bus one stop earlier.

“I don’t actually take physical exercise but I walk – it’s not that I wouldn’t go to the gym. Every morning, I walk down, maybe a quarter of a mile, to the bus. The simple reason for that is, there’s no buses when I go out in the morning, and it’s become a habit now that instead of catching the bus that’ll drop me right outside here, I’ll take the other one and I’ll walk down.”

British weather and living in a hilly area can make walking outdoors a challenge.

“I mean this is what the nurse said at the surgery. She lives round this area. ‘You’re in an awkward place. There’s not a lot of flat.’ But what I have done I’ll walk up as far as the post box and back. It’s a walk isn’t it?

Active housework, gardening and climbing stairs are also forms of exercise. Muscle strengthening and range of motion exercises can be done while watching TV, in bed, or while taking a bath.

• Activities that are part of a person’s usual lifestyle. Different people have different feelings about what is right for them. Some people would not, for example, see gyms and fitness centres as the kind of place they would go to, whereas others feel quite at home there.
• Social support and having fun. Doing exercise with someone else is usually more enjoyable, and having someone take an interest gives encouragement.

“He (GP) showed me in the surgery what exercises to do. And I’ve got a daughter who is a fitness fanatic. So, you know, she said, ‘Are you doing those exercises?’ I’ve been okay with them.”

Many people attending group activity sessions say that the social interaction is as important as the exercise.

• Local facilities and opportunities. Having opportunities for

physical activity close to home, particularly if they are led by someone who is experienced in working with people who have joint problems, makes it easier to keep going.

“ . . . Different people have different feelings about what is right for them. . . “

 

Things that can get in the way of people keeping active:

• Worry about making a joint problem worse. Exercising a joint helps to strengthen the muscles around the joint, and increase its range of movement. So, exercise helps to ease a joint problem not make it worse.

“Movement does tend to relieve the pain. There are times when we’ve gone out for a very long walk and I’ve thought, ‘I’m going to suffer for this.’ But actually, sometimes it’s better. I think that’s a bit odd because you’ve used the musculature an awful lot and you’d have thought that’s going to exacerbate the problem. But it doesn’t; it seems to be the opposite.”

The sound of bones clicking or grating, when doing neck exercises for example, is not unusual. Such noises seem loud because the joints are near the ears but they are not an indication that the joint is being damaged.

Some people who have OA think pain is an indicator of harm and worry about masking it with medicines when exercising. Experts think that in a long term condition, such as OA, pain is not a sign of doing harm to a joint, They also think that using a pain relieving medicine, like paracetamol, before undertaking physical activity is a good idea, if it makes exercising more comfortable.

• Worry about overdoing exercise. Prolonged and extremely strenuous use of a joint can be harmful. If you have not been very active for a while it is important to build up slowly. It is usual to experience some aches and pains after exercise, but gradually these fade. From experience, you will learn to pace yourself, that is, to find your own optimal balance between doing too much and doing too little.

“I tire a little bit more quickly than I used to. I’m not 18 anymore – accepting that you are physically unable to do the things you used to do. In the garden I have seats around so that I can sit down any time – I do about a quarter of an hour’s work and five minutes sitting .”

Most health professionals think that under-exercising is a bigger problem than over-exercising.

• Fear of falling. Falls amongst older people, particularly the very old, are not uncommon. So, having a fear of falling is understandable. Research has shown that one of the ways of preventing falls is by improving muscle strength and balance, through being physically active, particularly walking.

Walking aids can help by giving people the confidence to move about, and this in turn will help prevent falls. Muscle strengthening exercises can be done while sitting down.

• Having other health problems in addition to OA. People who have several health problems often find their own way to continue to be active. Where there is concern that exercising to help ease OA symptoms may make another medical condition worse, a physiotherapist or a GP can tailor advice about exercise to meet specific needs.

 

Getting started

If it is some time since you have done very much physical activity, perhaps start by joining a gentle walking group. As a result of a national programme to encourage walking, many local authorities have organised such groups. Water based exercise sessions are also suitable because water supports the body, making it easier to move. Some arthritis support groups hire hydrotherapy pools at a local hospital; some swimming pools have special sessions for older people to exercise under the guidance of an instructor.

 

HYDROTHERAPY

Hydrotherapy involves doing exercises in a pool where the water is maintained close to body temperature. Some hospitals have their own small pools with steps and handrails to enable those who have restricted movement to get in and out easily. Some public pools also offer hydrotherapy. The warmth and the support of the water relaxes muscles and eases pain, making exercise easier.

‘I feel a great warmth throughout my body after I have been in the pool, which alleviates the pain in my spine’

The Telford and Wrekin Arthritis Support Group hires the hydrotherapy pool at its local hospital weekly, and pays for a physiotherapist to attend every two weeks to advise on exercise programmes. Volunteers from the support group are specially trained to supervise the sessions and offer help with exercising if so desired.

Those who use the pool say that they experience an improvement in their mobility and relief from pain and stiffness.

‘I have missed two sessions at the pool and have noticed that I have had more pains in my legs.’

Exercising in a group in this way has the added bonus of social contact.

‘I enjoy the company because I get lonely and down when I don’t see anybody. I always think I walk out better than when I walk in.’

(April 2007)

 

Many social centres for older people offer group activities such as keep fit or a gentle exercise called Tai Chi. Those who take the classes adapt their instruction according to what people feel able to do. So if you don’t feel able to do an activity standing up, then you can do it sitting down. Organisers know that some people worry about going along to a session for the first time – particularly if they are on their own – and those leading a group ensure that one or two of the regulars take care of someone new.

 

The best kind of footwear

There is a strong medical opinion that shoes which have a thick shock-absorbing sole, very low heels, wide fronts (so that toes can splay out when walking) deep soft uppers, and which fasten, are most suitable. Trainers are a type of shoe that fits this description. Several shoe manufacturers make shoes with these features. It is also possible to buy cushioned insoles to put into ordinary shoes.

Some companies sell insoles which are moulded to realign the feet and thus influence posture. This they claim will relieve pain from arthritis. However, their suitability depends on the foot being out of line in the first place. If the foot is not out of line then the padding could potentially make a back or leg problem worse. Only try these if you can get advice, from a physiotherapist or podiatrist (chiropodist), about their suitability for you.

 

Using warmth to relieve pain, and cold to relieve swelling

Warmth has been used for thousands of years to relieve pain and stiffness. A warm bath or shower is part of some people’s daily routine for managing OA. There are also different sorts of heat packs on the market. Some wheat or gel filled pads can be warmed in the microwave or on a radiator, while others warm up by themselves on exposure to air. They can be wrapped around an affected joint, or a hand/foot can be placed inside. Some are reusable.

“I’ve got a knee pad. You stick it in the microwave, you warm it and you pop it on the knee. Obviously what it’s doing it’s masking the pain.”

People who attend hospital clinics with hand pain may be offered heat treatment with a wax bath prior to exercise. Wax baths can be prepared at home but are fiddly and time consuming to set up, unless an electrical wax bath with a heat control is used. Warm water can work just as well; and washing up incorporates warmth and exercise for the hands.

Packs like wheat/gel pads can be made warm or cold. Cold can relieve swelling and thus help ease pain. An ice pack (or bag of frozen vegetables) can be applied over the joint for up to twenty minutes every couple of hours. Do not apply ice directly to the skin as it can cause an ice burn – wrap the pack in a tea towel. Some people use heat and cold alternately. By a process of trial and error you can find out what works best for you.

 

Body weight and joint pain

There is evidence that for those who have knee OA being overweight can make the joint damage worse. If your doctor thinks that your weight is affecting your health, for example, making your joint problem worse, then he or she will probably raise the matter with you. Ask about any local support to lose weight that the NHS or local authority offer.

Many people would like to be thinner than they are. Sometimes this is because people feel better about themselves if they have a slimmer body shape, and sometimes it is for health reasons.

“My son and daughter-in-law said they were going to a slimming club, so I said I’ll tag along, it’s worth a try. And I’ve lost half a stone in four weeks and I can honestly say I haven’t been hungry. But the weight had to go because I’d put on so much.”

For some people though, losing weight can be a bit of a struggle. Trying to do it just by eating less does not work as well as combining dieting with increased levels of activity. Those who have OA in their knees can be in the vicious circle of finding it difficult to get their weight down because it is painful to move, and being overweight making their joint pain worse. If this applies to you, taking painkillers before doing physical activity can help you break out of the circle.

The good news is that after losing some weight your knees are likely to become less painful, so you may no longer need to take painkillers before exercising.

“One and a half stone weight loss has made such a difference to my mobility and energy levels! At the moment I am feeling very positive – aches and pains are almost a thing of the past. “

 

Using distraction and relaxation to reduce pain

The source of pain in OA is not well understood. How people experience any pain is complex and involves not just physical changes to the body but also how people are feeling in themselves, and what other things are going on in their lives.

“And if you’re feeling interested and happy, and the sun’s shining then you don’t focus on the pain so much. If you retreat into yourself, I suppose it must be more intense because there’s nothing else for you to think about. Any distraction lessens what’s happening to you, doesn’t it? Something else takes your attention.”

When anxious or stressed it is common for people to tense their muscles – particularly in the neck, shoulders and back – often without realising that they are doing so. Pain feels worse when muscles are tense, so learning to relax muscles can help ease pain.

One way to do this is by deep slow breathing. Breathe in through the nose, hold the breath briefly and then let the breath out slowly though pursed lips. Another way is to learn muscle relaxation techniques. The Expert Patients Programme teaches relaxation (see page 52) or you can buy/borrow DVDs to learn to do this. It may take some time before relaxing comes naturally.

 

Can eating certain foods help?

Quite simply we don’t know! There are lots of claims made for foods that cure arthritis.

“There was a big piece in the newspaper the other day, on the medical page, about rose hip syrup. Well, I used to give that to my boys when they were little, and they took it off the market because they said it rotted their teeth. Now they put all this in the paper about this is good for your arthritis.”

It is often not clear whether such claims refer to OA or to rheumatoid arthritis. Many people with joint pain are interested in the question of whether certain foods can make a difference. Nearly all the research that has been done on this topic has looked at individual constituents of foods, such as particular vitamins or fatty acids. There is very little research on whether or not OA can be affected by a diet rich in the foods in which such constituents are found naturally.

Often the research studies have not been well designed, and so the findings are open to dispute. Diet is an area where further research is needed before it can be said if a particular diet is likely to help ease the symptoms of OA, and/or affect the underlying joint problem.

There is a lack of scientific evidence that either cod liver oil or honey is beneficial for OA.

Food supplements and herbal remedies can interact with prescribed medicines. Pharmacists have information on the active ingredient in herbal and other such remedies and can advise whether they could present a problem to someone taking other medicines.

 

What about glucosamine and chondroitin?

Some of the food constituents that have been tested are thought of as drugs in some countries, but as food supplements in others. In the UK they are classified as food supplements and this means they can be bought from health food shops.

Glucosamine and chondroitin are two such substances. They are involved in producing certain types of proteins and fats in the human body that, in turn, form part of the tissue in a joint. There is no evidence that either substance can alter the structure of a joint or help to relieve pain.

Some doctors have prescribed glucosamine in the past. The National Institute of Health and Care Excellence (NICE) has advised doctors not to prescribe glucosamine (chloride or sulphate) because they could find no evidence that it helped joint pain.

Since there is no evidence that chondroitin is helpful for joint pain, NICE do not recommend trying combined preparations.

 

Do elastic bandages, collars and knee straps help?

Some people use elastic bandages on a painful wrist, knee or ankle to help ease the pain and protect the joint. However, doctors, nurses and physiotherapists advise against the regular use of bandages or neck collars, as this will cause muscles to become weak, which will make movement more difficult.

There is also a strap which can be put around a knee. Advertisements claim it will relieve knee pain by pushing up the kneecap, thereby bringing the knee into line with the rest of the leg. Whether the knee strap could possibly help depends on whether the pain is caused by the knee being out of line in the first place. However, it is unlikely to do any harm if you think it is worth a try.

 

Courses in self-management

In many areas of the country there are self-management courses that are part of the NHS Expert Patient Programme. The course involves six 2½ hour group sessions. They are led by tutors who themselves have long term illnesses, and who have been specially trained to deliver the course. The tutors cover many topics including the following:

• Dealing with pain and extreme tiredness
• Coping with feelings of depression
• Relaxation techniques and exercise
• Healthy eating
• Communicating with family, friends and professionals
• Meeting other members of the group and having an opportunity to talk over experiences and share ideas can also be a boost.

Things to remember

1. Both general physical activity and specific exercises for joints are an essential part of managing OA. Build up slowly and take rests when needed, but try to be physically active every day.
2. If you normally exercise regularly then keep it going.
3. Pain when exercising is not an indicator that a joint is being damaged. Using a painkiller like paracetamol may make doing physical activity more comfortable.
4. When trying to lose weight it is better to combine eating less with being physically more active.
5. There are many ways to manage joint pain and stiffness, such as applying warmth, relaxation and distraction. Different approaches can be combined. Keep a record of the things you try.

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