Exercise Helps Manage Hip Arthritis Pain

shutterstock_269353049

(Reuters Health) – Water- or land-based exercise should provide some short-term benefit in pain management for hip osteoarthritis, though there are few well-designed trials testing it, according to a new review.

Americans develop three million new cases of osteoarthritis each year. Most vulnerable are those who are older, obese, have previous joint injuries, overuse, weak muscles or genetic risk factors.

“It is nice to finally have some hip-specific data, as hip and knee osteoarthritis are often grouped together and it is almost certain that there are differences between these groups of patients, as well as differences in those with multiple joint osteoarthritis,” said Dr. Amanda E. Nelson of the Thurston Arthritis Research Center at the University of North Carolina Medical Center in Chapel Hill, who was not part of the new study.

“However, the studies are still small and heterogeneous, and larger, longer-term studies of more specific interventions are certainly needed to provide more specific recommendations,” she said.

The review only considered pain, not joint function, which may also improve with physical activity, Nelson told Reuters Health by email.

The researchers, lead by Kay M. Crossley of La Trobe University in Bundoora, Australia, reviewed 19 studies of water-based or land-based exercise therapy or manual therapy for hip pain, 10 of which were designed specifically for hip osteoarthritis.

Four studies found short-term benefits, up to three months later, with water-based exercise compared to minimal pain management. Six found similar benefit for land-based exercise therapy in the short term, but there was no evidence for benefit in the medium or long term, up to one year after therapy.

shutterstock_303682499

Manual therapy, which includes joint manipulation, active stretching and massage, did not appear to provide additional benefit on its own or in combination with exercise, the researchers reported in the British Journal of Sports Medicine.

That’s not encouraging, said Dr. Kim Bennell of The University of Melbourne in Australia, who was also not part of the review. “However, the number of studies is relatively small and there was a lot of variation in the methods of the studies, so further research is needed in this area to confirm the results.”

Most doctors do not recommend exercise therapy, relying instead on pain-relieving drugs for osteoarthritis, despite agreement across guidelines and organizations that non-drug approaches are worthwhile, Nelson said.

“There are numerous potential barriers to recommendation and treatment including access to care, financial concerns, and the burden of managing multiple medical conditions in a short visit with a provider, among others,” she said. “Therefore, although the guidelines are in agreement, it is likely that the majority of patients are not receiving this recommendation from their providers, and that even fewer actually follow through on the recommendation if given.”

The 19 studies in the review all tested different type, frequency and duration of exercise, so the best sort of exercise, how much and how often to do it, remains to be determined, she said.

It would appear that a 12-week program with exercises generally including strengthening and range of motion three times per week is beneficial, Bennell told Reuters Health by email.

“Based on the overall body of work in physical activity, though, any regular physical activity is likely to be beneficial to most patients,” Nelson said. “It is safe to say that most adults do not get enough physical activity, and that this is even more of an issue among those with osteoarthritis.”

SOURCE: http://bit.ly/1Z1OiCu British Journal of Sports Medicine, online November 26, 2015.

Original Article HERE

Advertisements

‘Like an orchestra’: Pain management moving toward holistic approach

shutterstock_177445016

Logan resident Dawn Carter’s life changed in January 2015 following an accidental fall down a flight of stairs.

Originally diagnosed with just a concussion, complications from the injury now cause Carter to experience chronic nerve pain and migraines, in addition to seizures and memory loss.

“There is really nothing (my doctors) can do about my pain,” Carter said. “It hurts so bad (that) I feel like an electric eel is swimming throughout my body. It mainly starts in my wrist and works up my arms, up to my shoulders and down to my back.”

According to data gathered by the Institute of Medicine of the National Academies, 100 million Americans suffer from chronic pain conditions, affecting more people than coronary heart disease, diabetes and cancer combined.

Fortunately, treatment options for both chronic and acute forms of pain have evolved from the over-simplified, pharmaceutical heavy days of the 1970s, said Dr. Brian Richardson, who specializes in pain management at Logan’s Southwest Spine and Pain Center.

As pain management evolves, so too does the form it takes. The new standard of care in pain management is that of the holistic approach, or the treatment of a patient’s pain with the combined help of general practitioners, physical therapists and psychologists.

“The way I like to describe treatment to my patients is that it’s like an orchestra,” Richardson said. “Say you’re watching “Les Miserables” live onstage, but the only instrument in the score is a trombone. Alone, that might not be very pleasant. But if you’ve got cellos, violins, saxophones and clarinets, it’s going to sound a lot better and be a much more pleasant experience. It’s the same concept with pain management. Now, we’re using multiple tools to help diagnose, address and fix a problem.”

The physical, mental, social approach

shutterstock_178866611

Physical therapist Swen Sandberg, who has been rehabilitating outpatients through Intermountain Healthcare at Logan Regional Hospital since 2013, said pain management has been working towards the “biopsychosocial” model of treatment over the past few years.

Often abbreviated as BPS, the approach gives equal weight to the physical, mental and social aspects of any given disease.

Sandberg said research studies have shown the effectiveness of the BPS style, with patients showing better recovery results when cared for holistically instead of by a single entity. The results are shifting the way pain management is being approached and introducing an increase in collaboration between medical professionals.

Sandberg predicted that within 10 years, insurance companies will start to provide better reimbursement to patients that are exploring the holistic style of care as opposed to consulting with just a single medical professional.

“The research is backing it up,” Sandberg explained. “It’s the model that Intermountain Healthcare is working towards as well. You can see that it’s the direction that health care is going.”

Richardson said although collaboration with other doctors may sometimes be challenging to coordinate because of varying schedules, he echoed that the increase of experience and evidence confirms it as the new medical standard for pain treatments.

“Not only is the approach important, but it’s absolutely critical,” Richardson said of his regular communication with other doctors. “It’s no longer just giving patients a painkiller. When you look at one modality versus someone also using physical therapy and working through coping skills with a psychologist, that type of multi-modal approach has by far and away been proven to be the most successful.”

Restoring function

Richardson said one of the most common misconceptions regarding treatment for pain is the assumption that doctors will simply prescribe pain medication, but medication isn’t the core of treatment. Instead, the focus lies first on diagnosing the problem itself and then exploring ways to restore function in pained areas.

“Communication with the patient about what the goal is for treatment is before we begin,” Richardson said. “From there, we can manage expectations and work together on the same page.”

While short-term pain relief may be a priority depending on the needs of the individual patient, not all patients may need to be prescribed medication depending on their treatment plan. Richardson used the example of an 80-year-old woman slipping in her bathtub and suffering a compression fracture. In this case, a low dose analgesic may be prescribed to help relax the pain, but the patient would receive an MRI and a back brace first, while also meeting with a physical therapist. A procedure may be recommended if the fracture doesn’t heal naturally from there.

However, if pain medication is in the best interests of the patient, Richardson said enough is prescribed to meet the patient’s needs.

Every 30 days, Richardson would meet with the patient to determine how the treatment is progressing before processing a refill on any prescription.

“It’s rare that you have people with legitimate pain problems that don’t stick with the prescribed regimen,” Richardson explained. “It’s much more common to see people that want to get better.”

Sandberg, the physical therapist, said treatment is on a spectrum between restoring function and pain control. Working towards one end may be able to provide for a solution on the other end, however.

“Very rarely does a patient present without some form of pain,” Sandberg explained. “As therapists, what we do is try to address what’s causing the pain. Sometimes, unless you reduce stress on the joint or the structure, it won’t get better no matter how many pills you take. But other times if we can reduce the pain enough, we can work towards ways to restore that function.”

Sandberg said that many of his patients are on some form of pain medication, but the majority of his modalities aren’t related to pain medication. Instead, he may use ultrasounds or electrical stimulation on the affected areas to retrain the nerves to induce a proper pain response, or provide stretching or traction to joints and tendons to invoke chemical responses that help to relieve the pain.

Sometimes, techniques as simple as changing posture can help relieve pain without turning to medication.

Ending the stigma

Both Sandberg and Richardson acknowledge that there is a certain stigma surrounding chronic pain conditions that may cause patients to not enter treatment. For some, it may be a case of affordability, although Sandberg said that many physical therapy patients may be able to seek treatment for low or no cost regardless of their insurance status. For others, it may be a doubt that doctors really believe their claims of pain.

“Anybody would be frustrated if they got the response, ‘There’s nothing wrong with you,’” Sandberg said. “Sometimes there is a stigma that you may be faking it, but for doctors that notion is completely unacceptable. That can’t exist in the medical community. Pain is taken at face value. Just because there isn’t visible damage now doesn’t mean that there wasn’t damage at some point.”

Richardson said advances in pain management clinics over the past 15 years alone are countering the old notions of simply receiving pain pills.

“We’re committed to finding out what is causing pain and why,” Richardson said. “It can sometimes be a challenge, but once they come through the door and realize what we’re trying to accomplish, that perception changes rapidly.”

Acute vs. chronic pain

Pain takes many forms, which means that professionals like Richardson and Sandberg treat patients on an individual basis to best suit their needs.

“Sometimes the pain is an acute pain, which is here and now,” Richardson said. “For example, you may have a patient who has tweaked their spine tossing a bale of hay and now has nerve pain. If we can treat these conditions quickly enough, we may be able to phase out that pain completely. But with chronic conditions, expectations may need to be reevaluated. Sometimes pain just can’t be cured — there may not be one thing to fix that will stop it from coming back.”

For chronic patients, the involvement of a psychologist can be beneficial, helping patients to learn effective coping strategies regarding the control of their pain. In the cases of psychosomatic pain, which is pain that is caused by the brain’s misinterpretations of nervous system responses, psychologists can also help to reduce the pain or eliminate it entirely.

Sandberg said chronic pain is often the result of a previous injury where the problem is a maladaptive nerve response instead of lingering damage, in which the nerves are unable to register pain in the correct fashion.

“These people may still be in pain because their nervous system hasn’t been able to register the pain response appropriately,” he explained. “To help, we retrain the nervous system through modalities like exercise or electrical stimulation.”

Sandberg said his first sessions with chronic pain patients are often educational, defining the difference between acceptable levels of pain and non-acceptable ones.

“For many, pain is associated with discomfort,” he said. “But there can be different levels of pain that can be improved upon through therapy. For chronic pain patients, the pain may never completely improve, but the function can make progress.”

Exploring alternatives

Aside from the patient’s prescribed regimen, some patients may also choose to supplement their care with other forms of therapy. Richardson said it isn’t uncommon for patients to ask about options such as chiropractic care, massage therapy and acupuncture. Richardson said he encourages proactivity in his patients, noting it as a sign of the patient’s desire to reach to the heart of the problem.

“If someone is willing to explore other functions in addition to their treatment, that means they’re obviously interested in getting better,” he said.

Sandberg said these alternative care options should be weighed on a cost-to-benefit ratio.

“Is it worth the cost? Does it help, or do you feel like it helps?” he said. “Things like herbal medicine or foot zoning may not have as much evidence that they’re helpful, but if the patient is feeling better, we never discourage that. The mind is a powerful thing when it comes to pain control. If you believe that it’s helpful, then it’s helpful.”

Sandberg also encourages patients to explore the options as long as it doesn’t conflict with their current treatment.

“I think proactive searching is important,” he said. “It shows good coping skills. Those patients seem to do really well. If I have a patient that comes in and hasn’t tried anything on their own, I might refer them to a psychologist.”

Original Article Here by Clayton Gefre