‘Stepped’ Approach to Exercise Can Help With Arthritic Knees

‘Stepped’ Approach to Exercise Can Help With Arthritic Knees

Millions of Americans suffer from the pain of arthritic knees. But an innovative exercise regimen may help relieve discomfort and improve knee function, a new study finds.

The program is called STEP-KOA (short for stepped exercise program for patients with knee osteoarthritis). It starts with gentle exercises at home and, if needed, moves to phone consultation and in-person physical therapy.

“STEP-KOA could be an efficient way to deliver exercise and physical therapy services for people with knee osteoarthritis, since it reserves the more resource-intensive steps for people who do not make improvements earlier,” said lead author Kelli Allen. She’s a research health scientist at the Durham VA Medical Center in North Carolina.

“This could be important in health systems that are trying to maximize resources or when there is limited access to physical therapy,” Allen said.

For the study, researchers from the Veterans Affairs Health Care System randomly assigned more than 300 patients with painful knee osteoarthritis to either STEP-KOA or arthritis education. Osteoarthritis is the most common form of arthritis in the knee. It is a degenerative, “wear-and-tear” type of arthritis.

STEP-KOA starts with an internet-based exercise program. If it is not effective, the patient moves to step two, which included twice-monthly coaching phone calls for three months.

If pain still does not improve, the patient moves to step three, which included in-person physical therapy.

Participants in the arthritis education group were mailed educational materials every two weeks.

After nine months, 65% of patients in STEP-KOA progressed to step two, and 35% went on to step three.

Compared to participants who received education only, the stepped-care group had greater improvement in pain and function, the researchers reported.

This strategy could lower health care costs and tailor programs to patients’ needs, the study authors said.

However, a prominent orthopedic surgeon called this approach backwards.

It should start instead with physical therapy and move on to patients doing exercises on their own, said Dr. Jeffrey Schildhorn of Lenox Hill Hospital in New York City.

“It seemed like this study was designed for a style of medicine that I think very few of us would appreciate,” Schildhorn said. “It was almost like you’re preparing for a future where there are limited resources, and you try to do everything remotely, and you put the responsibility on the patient,” he added.

Schildhorn noted that 90 patients dropped out of the program, and only 10% remained at step one throughout the study.

Because each patient’s knee damage and perception of pain is unique, an effective program must be individually designed, he said.

“I think that it’s imperative that people who have mild to moderate disease try to do whatever they can on their own, with or without in-person physical therapy,” Schildhorn said.

The key is to keep the joint moving with gentle exercise. A multimodal approach that includes periodic check-ins with a therapist, being shown in person how to do the movements with follow-up by phone or video chat is a viable approach, he said.

But patients need to do their exercises at home every day, Schildhorn emphasized.

“Someone who goes to physical therapy three times a week probably doesn’t do as well as someone who goes three times a week and practices on their own. The majority of the value comes with daily in-home, stretching exercises,” Schildhorn said. “If you go to physical therapy two times a week, then do nothing the other five days, there’s zero value there.”

The report was published online Dec. 29 in the Annals of Internal Medicine.

More information

Learn more about knee osteoarthritis from the American Academy of Orthopaedic Surgeons.

SOURCES: Kelli Allen, PhD, research health scientist, Durham VA Medical Center, Durham, N.C., and associate director, Durham Center of Innovation to Accelerate Discovery and Practice Transformation; Jeffrey Schildhorn, MD, orthopedic surgeon, Lenox Hill Hospital, New York City; Annals of Internal Medicine, Dec. 29, 2020, online

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Which Exercise Regimen Works Best to Ease Lower Back Pain?

Which Exercise Regimen Works Best to Ease Lower Back Pain?

Chronic lower back pain can make the most routine tasks difficult. But a new study suggests patients can learn new, practical and less painful ways to move through individualized “motor skills training,” or MST.

A two-year study of nearly 150 patients found that MST appears to better relieve disability from lower back pain than a more common but less-tailored exercise regimen broadly focused on improving strength and flexibility.

“Our findings suggest that motor skill training in functional activities is an effective and efficient treatment that results in important short-term and long-term improvement in function in people with chronic low back pain,” said study lead author Linda Van Dillen. She’s a professor of physical therapy at Washington University in St. Louis School of Medicine.

Lower back pain is incredibly common, and the No. 1 cause of disability, according to Van Dillen. It is the most frequent cause of chronic pain among American adults.

Van Dillen notes that at least 60% to 80% of adults will experience lower back pain, and “almost half of them will have had a major episode by age 30.”

Yet there is no accepted standard of care for chronic lower back pain patients, nor a clear sense of what type of exercise intervention might work best, researchers said.

To get a better handle on the issue, Van Dillen’s team focused on a pool of patients diagnosed with what is known as “non-specific” lower back pain. That means they have tension, stiffness and/or soreness in the lower back area for which there is no clear cause.

Before the study began in December 2013, all participants had struggled with lower back pain for at least a year.

Participants, who ranged in age from 18 to 60, were randomly divided into two groups. One group received “strength and flexibility treatment for the trunk and lower limbs” — a common exercise intervention, according to Van Dillen.

The other group took part in MST, which teaches patients new ways to carry out everyday tasks rendered difficult by back pain.

MST aims to zero in on each patient’s personal posture and movements throughout an entire day, and then to tailor pain-free movement strategies to their specific routines.

Both groups received six weeks of training for one hour per week. Half of each group also received three “booster” treatment sessions six months later. Disability questionnaires were completed at the outset, and at six months and one year out.

While both groups’ ability to perform daily functions without pain improved, the MST group achieved “significantly” better gains (meaning lower disability scores) over the study period.

MST patients were more satisfied with their care and less likely to use drugs for back pain. They were also less fearful of addressing work-related needs, and less likely to avoid normal daily activities, the study found.

Six months out, MST patients had fewer acute back pain flare-ups and were more likely to keep up with their exercises. And after a year, when their back pain flared up, it was less severe, researchers said.

Dr. Daniel Park, an associate professor of orthopedic surgery at Oakland University William Beaumont School of Medicine in Rochester, Mich., reviewed the findings.

He said it remains to be seen just how much better MST is compared to more common interventions.

While Park said the findings appear to be statistically significant and support the benefit of therapy on back pain, he stopped short of saying the researchers had shown “meaningful improvement.”

“I think any structured therapy can be beneficial, because you want the muscles moving and working to help with back pain,” Park said. “We used to think rest and relaxation was better. But studies show only short-term rest is beneficial, and actually if you rest too long, you can have worse outcomes.”

As a result, he added, many doctors advise patients to rest for the short term and then to begin exercising to help the muscles.

The findings were published Dec. 28 online in JAMA Neurology.

More information

Learn more about lower back pain at the U.S. National Institute of Neurological Disorders and Stroke.

SOURCES: Linda Van Dillen, PT, PhD, professor, physical therapy and orthopedic surgery, Washington University School of Medicine in St. Louis, Mo.; Daniel Park, MD, associate professor, orthopedic spine surgery, Oakland University William Beaumont School of Medicine, Rochester, Mich., director, minimally invasive orthopedic spine surgery, William Beaumont Hospital-Royal Oak, Rochester, Mich.; JAMA Neurology, Dec. 28, 2020, online

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How to Talk to Your Doctor About Arthritis Pain

How to Talk to Your Doctor About Arthritis Pain

SUNDAY, Dec. 20, 2020 (HealthDay News) – Chronic pain can be excruciating, debilitating and hard to describe.

Yet the best way to get the right treatment for the exact pain you’re experiencing is to put those symptoms into words, so your doctor can pinpoint a diagnosis and help you find relief.

The Arthritis Foundation created a guide with suggestions for communicating your discomfort. Included are questions ranging from, “What does the pain feel like?” to “How does the pain affect your life?” and specific details to share.

When describing what the pain feels like, be as specific as possible. If you describe it as aching or dull, that may point to muscle strains or arthritis. A description of shooting, tingling or burning might point to nerve pain as the cause. Sharp or stabbing pain might suggest injuries to a bone, muscle or ligament. Throbbing could be a headache, abscess or gout. Tightness may be a muscle spasm.

Where does it hurt? Is it in one location or does it travel? Is it steady or does it come and go? Try to be precise about location. For example, someone might describe a shoulder pain as deep in the joint or on the muscle surface.

Rate the intensity of your pain on a scale of 0 to 10, with 0 being pain-free and 10 being unimaginable. This can help a doctor determine the type or dosage of pain medicine you may need.

“Some patients come in the door with an eight on the pain scale, and they’re functional. Other patients walk in with a three and they’re disabled,” said Dr. Thelma Wright, medical director of the Pain Management Center at the University of Maryland Rehabilitation and Orthopedics Institute. “Function is huge.”

Keep a journal tracking when you hurt and if it’s worse at certain times of day.

“If I notice that a patient has higher pain scores in the morning versus in the evening, I may tailor my medication management to that,” Wright said.

Does anything ease your pain? In your journal, make note of what you’ve tried and what helped or hurt. Options could include heat or ice, rest or over-the-counter pain medicine.

Be aware that it could take a while to find relief. Being able to communicate your pain will help get you closer to a solution.

“It’s a trial-and-error process,” Wright said. “You might go through several medications before you get the best combination.”

More information

Johns Hopkins Medicine offers more information on chronic pain.

SOURCE: Arthritis Foundation, news release, Dec. 14, 2020

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A ‘Stunning’ Alternative Rx for Arthritic Joints?

A ‘Stunning’ Alternative Rx for Arthritic Joints?

THURSDAY, Nov. 19, 2020 (HealthDay News) — A procedure that “stuns” pain-sensing nerves might offer relief to people with severe arthritis of the hip or shoulder, a small, preliminary study suggests.

The procedure is a form of radiofrequency ablation, where doctors use needles to send a low-grade electrical current to nerves that are transmitting pain signals from the arthritic joint to the brain. The current heats and damages the nerve fibers, rendering them unable to deliver those pain messages.

In the United States, a number of ablation devices are cleared for treating low back pain and knee osteoarthritis.

At this point, the procedure is slowly becoming a more established treatment, said Dr. Felix Gonzalez, a radiologist at Emory University School of Medicine in Atlanta.

But whether ablation can help patients with severe hip or shoulder arthritis is unclear.

To find out, Gonzalez and his colleagues treated 23 patients whose hip or shoulder pain had become so bad that anti-inflammatory painkillers and cortisone injections — two standard treatments — were no longer helping.

Before undergoing ablation, and again three months later, patients answered standard questionnaires gauging their pain and daily function.

In the end, the study found, patients with shoulder arthritis reported an 85% drop in their pain ratings, on average. Among hip arthritis patients, pain declined by an average of 70%.

Gonzalez called the results “promising” and said, in his experience, there have been no major complications from the procedure, such as bleeding or infections — though those are potential risks.

And before the ablation is done, Gonzalez explained, patients go through what is basically a trial run. They are given an injection of numbing medication near the nerves believed to be generating the pain signals. If the pain abates, that means targeting the same nerves with ablation will likely work, too — longer term.

It’s too soon, however, to judge the effectiveness of the approach for shoulder and hip pain, according to Dr. Rajat Bhatt, a rheumatologist who was not involved in the study.

None of the study patients received a placebo (inactive treatment) to serve as a comparison, said Bhatt, of Prime Rheumatology in Katy, Texas. So it’s possible at least some of the pain relief came from the fact that patients received a novel therapy.

“With pain, there’s generally a large placebo effect,” Bhatt pointed out.

Larger studies, with a comparison group, are still needed, he said.

Gonzalez is scheduled to present the findings at the annual meeting of the Radiological Society of North America, being held online Nov. 29 to Dec. 5. Studies reported at meetings are generally considered preliminary until they are published in a peer-reviewed journal.

Osteoarthritis is exceedingly common, affecting more than 32.5 million Americans, according to the U.S. Centers for Disease Control and Prevention.

The condition arises when the cartilage cushioning the joint breaks down over time, leading to pain, stiffness and decreased range of motion.

People with osteoarthritis often take over-the-counter painkillers, such as ibuprofen (Advil, Motrin) and naproxen (Aleve). But besides being only moderately effective, the drugs are not without risks: Prolonged use is linked to increased risks of heart disease and kidney damage.

Corticosteroid injections, which reduce inflammation, are the next option. But their effectiveness wanes over time, Bhatt said, and there are long-term safety issues, including a risk of cartilage damage.

Beyond that, Gonzalez said, there are essentially two options for more severe pain: joint replacement surgery or opioid painkillers.

“But not everyone is a candidate for surgery, because of health reasons,” Gonzalez said. “And some patients don’t want it.”

Opioids, meanwhile, carry their own well-documented problems, including the potential for addiction.

“So we need something to fill the gap,” Gonzalez said.

Ablation stands as an additional therapy, he said, but it’s not a “cure.” For one, it addresses pain — not the underlying joint damage of arthritis. And the pain is not banished forever: The nerve fibers eventually grow back.

When ablation is used for knee osteoarthritis, Gonzalez said, the pain relief typically lasts 6 months or more — and up to two years in some patients. The procedure can be repeated.

In this early study, patients were only followed for three months. So it’s not clear how long the pain relief will last, Gonzalez said.

And while ablation is coming into wider use for certain pain conditions, people may not be able to find it locally. Gonzalez said some of his patients come from hours away to get the treatment.

More information

The Arthritis Foundation has more on osteoarthritis.

SOURCES: Felix Gonzalez, MD, assistant professor, department of radiology and imaging sciences, Emory University School of Medicine, Atlanta; Rajat Bhatt, MD, Prime Rheumatology, Katy, Texas; presentation, Radiological Society of North America virtual annual meeting, Nov. 29 to Dec. 5, 2020

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‘Tough Guy’ Mentality Keeps Athletes in Denial About Pain

‘Tough Guy’ Mentality Keeps Athletes in Denial About Pain

FRIDAY, Oct. 23, 2020 (HealthDay News) — A culture of toughness and resilience is encouraged among elite college rowers, but it can keep them from reporting injuries, a new study finds.

There’s an overall myth among athletes that admitting pain is a sign of weakness and failure, the researchers said.

Irish and Australian rowers in this study felt compromised by lower back pain, which is common in the sport, the study authors said. But many felt that the sporting culture didn’t allow them to be open and honest about their pain for fear of exclusion.

Also, many felt they had to keep competing and training even when in pain. This might have increased the risk of poor outcomes from their pain, and poor emotional and mental experiences they had, according to the report.

Rowers who have lower back pain can feel isolated and it can affect their lives beyond sport, the researchers noted.

“This study presents a powerful message that athletes fear being judged as weak when they have pain and injury. They feel isolated and excluded when injured. They feel that there is a culture within sport that values them only when they are physically healthy. This leads athletes to hide their pain and injury, which is likely to lead to poorer outcomes,” said researcher Dr. Fiona Wilson. She’s an associate professor of physiotherapy at the School of Medicine at Trinity College, Dublin.

“Our findings will impact not just rowers but any athlete who has experienced pain and injury, allowing their perspective to be considered,” Wilson said in a college news release. “This will lead to the design of more tailored injury management programs and will also crucially create a sporting environment where an athlete’s physical health and welfare is at the core.”

The report was published online Oct. 9 in the British Journal of Sports Medicine.

More information

For more on lower back pain, head to the U.S. National Institute of Neurological Disorders and Stroke.

SOURCE: Trinity College Dublin, news release, Oct. 9, 2020

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