Physical and Complementary Therapies

Despite the variety of medications available for arthritis, physical therapy remains a cornerstone of traditional treatment. In addition, many people with arthritis try various complementary therapies to alleviate pain and other symptoms. Options abound in both these areas and, when carefully chosen, such nonmedical therapies can help you maintain and improve joint function.

Physical therapists focus on restoring or maintaining physical function by designing an inpidualized treatment program for you. The physical therapist first will thoroughly evaluate your pain, functional ability, strength, and endurance levels, then will provide advice about ways to ease pressure on your joints while building muscles to support them. Physical therapy can take place at a hospital or outpatient clinic, in the therapist's office, or in your home. Some activities can be done alone; others require the therapist's assistance.

You are likely to have much less guidance when it comes to deciding on whether to use complementary therapies, and which ones. Such therapies literally run the gamut from A to Z — from acupuncture to zinc supplements. And they're popular: One widely cited 1997 paper estimated that one in four people with arthritis used some type of complementary therapy. Although hundreds of such therapies exist, only a few have actually proved to be effective when evaluated in rigorous studies.

To become a wise consumer of complementary therapies, become a skeptical one. Don't buy into any treatment that promises a cure. And be sure to ask questions about complementary therapies: Do the claims rely only on testimonials from people who have tried the treatment, rather than on scientific studies? Are the promises extravagant? Do proponents advise not telling your doctor about the treatment? Do they suggest stopping medical treatment? Are the ingredients unidentified or "secret"? If you answer any of these questions "yes," your best response to trying a therapy is an emphatic "no."

Finally, if you are contemplating any physical or complementary treatment, you should first discuss it with your doctor to make sure it will support, rather than hinder, your arthritis management plan.

Heat and cold therapy

In the 19th and early 20th centuries, wealthy Europeans embraced hydrotherapy (warm baths) and sought cures at exotic spas for real and imagined ailments. Most resorts claimed that the health benefits were from minerals in the water. The therapeutic value actually lay mostly in the water's temperature. Heat raises the pain threshold and relaxes muscles.

Hydrotherapy remains a standard part of the physical therapist's practice, and its techniques can be used at home. A bathtub equipped with water jets or a hot tub can closely duplicate the warm-water massage of whirlpool baths used by professionals. Of course, oversized tubs are expensive luxuries. For most people, the bathtub works nearly as well. A 15–20 minute soak in a warm bath exposes the body to warmth and allows the weight-bearing muscles to relax.

A warm shower can relieve the morning stiffness of ankylosing spondylitis and may help lessen the stiffness caused by other kinds of arthritis. People can upgrade their showers with an adjustable shower-head massager that's inexpensive and easy to install. It should deliver a steady fine spray or a pulsing stream, usually with a few options in between. Therapists also recommend taking a warm shower or bath before exercising to relax joints and muscles. Dress warmly after a shower or bath to prolong the benefit.

A heating pad is another good idea, but keep in mind that moist heat penetrates more deeply. Although you can purchase hot packs and moist/dry heating pads, a homemade hot pack works just as well. Heat a damp folded towel in a microwave oven (usually for about 10–60 seconds, depending on the oven and the towel's thickness) or in an oven set at 300 degrees (for 5–10 minutes — again, this depends on the oven and towel thickness). To prevent burns, always test the heated towel on the inside of your arm before applying to a joint: It should feel comfortably warm, not hot. To be extra safe, wrap the heated, moist towel in a thin, dry one before placing it on the skin.

Sometimes therapists recommend a paraffin bath. You dip your hands or feet into wax melted in an electric appliance that maintains a safe temperature. After the wax hardens, the therapist wraps the treated area in a plastic sheet and blanket to retain the heat. Treatments generally take about 20 minutes, after which the wax is peeled off. Paraffin bath kits are also available for home use, but it's important to talk with your physical therapist for recommendations and cautions before purchasing one, to avoid burning yourself.

Cold has analgesic effects similar to those of heat: An ice pack on the joint relieves pain, especially after an injury. Gel-filled cold packs are inexpensive and available in different sizes and shapes. Keep two or more in the freezer so you'll have cold therapy available instantly. Ice chips in a plastic bag also work well. Cold packs should be applied for 15–20 minutes and can be reapplied hourly or as needed. Coolant sprays, available from pharmacies, may also be used. Cooling is a temporary measure to relieve pain; too much may induce muscle stiffness and painful circulatory disturbances.

Exercise

Even the healthiest people find it difficult to maintain an exercise regimen. But those with arthritis commonly discover that if they don't exercise regularly, they'll pay the price in pain, stiffness, and fatigue. Regular exercise not only helps maintain joint function, but also relieves stiffness and decreases pain and fatigue. Feeling tired may be partly the result of inflammation and medications, but it's also caused by muscle weakness and poor stamina. If a muscle isn't used, it can lose 3% of its function every day and 30% of its bulk in just a week.

Work with your physician or physical therapist to develop your own exercise program. Most likely this will involve exercises with three goals.

Increase range of motion. These exercises aim to increase the mobility and flexibility of your joints. To increase your range of motion, move a joint as far as it can go and then try to push a little farther. These exercises can be done any time, even when your joints are painful or swollen, as long as you do them gently. For several examples of range-of-motion exercises you can do at home, see Figure 11.

Figure 11: Range-of-motion exercises for arthritis

Hand

Range-of-motion exercises for arthritis: Hand

Open your hand, holding fingers straight. Bend the middle finger joints. Next, touch your finger-tips to the tops of your palm. Open your hand. Repeat 10 times with each hand. Next, reach your thumb across your hand to touch the base of your little finger. Stretch your thumb back out. Repeat 10 times.

Knee

Range-of-motion exercises for arthritis: Knee

Sit in a chair that is high enough for you to swing your legs. Keep your thighs on the seat and straighten out one leg. Hold for a few seconds. Then bend your knee and bring your foot as far back as possible. Repeat with the other leg. Repeat 10 times.

Shoulder

Range-of-motion exercises for arthritis: Shoulder

Lie on your back with your hands at your sides. Raise one arm slowly over your head, keeping your arm close to your ear and your elbow straight. Return your arm to your side. Repeat with the other arm. Repeat 10 times.

Hip

Range-of-motion exercises for arthritis: Hip

Lie on your back, legs straight and about 6 inches apart. Point your toes toward the ceiling. Slide one leg out to the side and then back to its original position. Try to keep your toes pointed up the whole time. Repeat 10 times with each leg.

Strengthen your muscles. An excellent way to provide aching joints with more support is to strengthen the muscles surrounding them. Strengthening exercises use resistance to build muscles. You can use your own body weight as resistance. One example: Sit in a chair. Now lean forward and stand by pushing up with your thigh muscles (try to use your arms only for balance). Stand a moment, then sit back down, using your thigh muscles. This simple exercise will help ease the strain on your knees by building up your thigh muscles. Avoid these exercises during arthritis flare-ups.

Build endurance. Aerobic activities such as walking, swimming, and bicycling can all build your heart and lung function, which in turn increases endurance and overall health. Just be careful to pick activities with low impact on your joints. If you have arthritis, you should avoid high-impact activities such as jogging. If you're having a flare-up of symptoms, wait until it subsides before doing endurance exercises.

Joint protection strategies

When you have arthritis, it's important to pay attention to your body's signals. Overuse of arthritic joints can lead to pain, swelling, and additional joint damage. A physical or occupational therapist can teach you how to conserve energy, protect your joints, accomplish daily tasks more easily, and adapt to lifestyle disruptions. Many of these strategies are simple common sense.

Keep moving. Avoid holding one position for too long. When working at a desk, for example, get up and stretch every 15 minutes. Do the same while sitting at home reading or watching television.

Avoid stress. Avoid positions or movements that put extra stress on joints. For example, opening a tight lid can be difficult if you have hand arthritis. One solution is to set the jar on a cloth, lean on the jar with your palm, and turn the lid using a shoulder motion. Better yet, purchase a jar opener that grips the lid, leaving both hands free to turn the jar.

Discover your strength. Use your strongest joints and muscles. To protect finger and wrist joints, push open heavy doors with the side of the arm or shoulder. To reduce hip or knee stress on stairs, lead with the stronger leg going up and the weaker leg going down.

Plan ahead. Simplify life as much as possible. Eliminate unnecessary activities (for example, buy clothing that doesn't need ironing). Organize work and storage areas; store frequently used items within easy reach. Keep duplicate household items in several places; for example, stock the kitchen and all bathrooms with cleaning supplies.

Use labor-saving items. In the kitchen, use electric can openers and mixers. In the bathroom, cut down on scrubbing by using automatic toilet bowl cleaners and spray-on mildew remover in showers or tubs.

Use adaptive aids. Numerous devices on the market can help you avoid unnecessary bending, stooping, or reaching. Long-handled grippers, for example, are designed to grasp and retrieve out-of-reach objects. People with limited movement might have an easier time getting dressed by using long-handled hooks to put on socks and long-handled shoe horns. Also helpful are shoes that slip on or fasten with Velcro, pre-tied neckties, and garments with Velcro fasteners, zippers, or hooks and eyes instead of buttons. Rubber grips are available to help you get a better handle on faucets, pens, toothbrushes, and silverware. Pharmacies, medical supply stores, and online vendors stock a variety of aids for people with arthritis.

Make home modifications. Using casters on furniture can make housecleaning easier. A grab bar mounted over the tub is a necessity for many people, as is a suction mat in the tub to prevent falls. Putting a bathing stool in the tub or shower is a good idea for people who have arthritis in the lower extremities.

Ask for help. Maintaining independence is essential to self-esteem, but independence at all costs is a recipe for disaster. Achieve a balance by educating family members and friends about the disease and the limitations it imposes and enlisting their support. Ask for help with specific tasks.

Other physical therapies

A variety of other physical therapies have been suggested for the pain of arthritis, but the scientific evidence for their effectiveness is scant. If you choose to explore such therapies and find them useful, be sure to continue your conventional therapy and visit your physician regularly.

For example, a technique called diathermy (deep heat) uses electromagnetic waves of different frequencies to deliver heat deep to the tissues. Microwave and ultrasound are the most common wave frequencies used in physical therapy, chiefly to relieve muscle spasm. Microwaves relax muscles, while ultrasound penetrates deeper to reach other soft tissues as well. Diathermy should not be used on actively inflamed joints, and people with pacemakers cannot be treated with microwaves (although ultrasound is safe for such people). Whether diathermy is useful for people with inflammatory arthritis is controversial.

Doctors sometimes recommend transcutaneous electrical nerve stimulation (TENS) for people with chronic pain. TENS works by stimulating large nerve fibers, which theoretically blocks transmission of pain signals from small fibers. Some people with chronic pain from rheumatoid arthritis or osteoarthritis find TENS quite effective. The TENS device consists of a battery pack and electrodes that attach near the painful joint. The battery generates a very low electrical current to the electrodes, producing a pleasant tingling, vibrating, or massaging sensation.

Diet

The idea that a diet, supplement, or vitamin pill could prevent or cure arthritis is very appealing, but as yet there's no scientific evidence of an effective dietary solution for most types of arthritis. Gout, which can be triggered by certain foods, is the notable exception (see "Treating gout").

However, it is important to keep two issues in mind when it comes to diet. The first is that it's important to eat in a way that helps you to maintain a healthy weight, because excess pounds only increase the stress on your joints. To maintain a healthy weight, exercise regularly and eat a diet low in saturated and trans fats and high in vegetables and lean proteins.

Second, there is some evidence that omega-3 fats, found in cold-water fish such as salmon, herring, sardines, and mackerel, may help reduce inflammation. And some early studies have found that consuming such fats on a regular basis can reduce morning stiffness and joint tenderness in people with rheumatoid arthritis. But it's too soon to know whether these results will hold up over time, or whether people can continue the diet without gaining weight — which would just create other problems. Even so, it may be wise to increase your consumption of omega-3 fats, if only because this type of diet is a good way to reduce your risk of heart disease.

Acupuncture

Many Americans undergo acupuncture treatments to help relieve pain, including the pain of arthritis. Acupuncture, which involves the application of tiny sterile needles to the skin, has been a staple of Chinese medicine for 2,000 years. Acupuncture is based on the belief that qi, or life force, flows along 14 meridians (channels) within the body. A blockage of qi is said to cause illness, while stimulating certain areas along the meridians with fine needles releases qi and restores health. Acupuncture seems to work by releasing endorphins, a natural morphine-like chemical in the nervous system.

Although some people with arthritis find acupuncture treatments relieve their symptoms, results from studies have been inconsistent. However, a randomized controlled study of 570 people with osteoarthritis, published in the Annals of Internal Medicine in 2004, found improvement in both joint function and pain relief with acupuncture therapy compared with sham therapy ("fake" acupuncture that participants believed was real). There is no proof that acupuncture reduces inflammation in joints. If you do choose to try acupuncture, talk with your doctor first and find a licensed acupuncturist.

Glucosamine and chondroitin

Glucosamine and chondroitin are both chemical components of cartilage, which has raised the hope that supplements containing synthetic versions of these substances might help stop joint destruction and ease arthritis pain. And over the years, some people who have osteoarthritis have claimed to have less pain and stiffness when regularly taking such products.

A major study designed to answer a key question — whether these supplements relieve pain — concluded that the answer may depend on the severity of pain you experience. The Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), reported in the New England Journal of Medicine in 2006, involved more than 1,500 people with osteoarthritis of the knee. Participants were randomly assigned to take glucosamine hydrochloride alone, chondroitin alone, a glucosamine-chondroitin combination, or the COX-2 inhibitor celecoxib (Celebrex). The study found that, on the whole, glucosamine and chondroitin supplements — either taken alone or in combination — provided no more pain relief than a placebo, but that celecoxib did. But the study also revealed that a certain subgroup of people — those with moderate to severe pain — did experience greater pain relief by taking the glucosamine-chondroitin combination than those taking a placebo.

To complicate matters further, the GAIT study used glucosamine hydrochloride, which is a different formulation from the glucosamine sulfite that other studies have found effective in relieving osteoarthritis pain. Meanwhile, the answer to a second key question — whether taking glucosamine and chondroitin supplements will slow the process of cartilage destruction in the joints (as earlier studies have suggested) — won't be known until the GAIT researchers complete that portion of the study.

At this point, if you're wondering whether you should take glucosamine and chondroitin supplements, the answer is: It depends. If you are experiencing moderate to severe osteoarthritis pain, try the glucosamine-chondroitin combination for two to three months. If you find it eases your pain, keep using it. If not, you might as well save your money. As always, if you choose to take these or any other alternative preparations, be sure to inform your physician.

Source: from Harvard Health Publications, Copyright © 2008 Harvard University. All rights reserved. Harvard Medical School does not endorse products.
Used with permission of StayWell.
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