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Joint Venture

Degenerative joint disease can cause debilitating pain, loss of mobility, and function, even severe disability. But what if you’re just starting to suffer from a little wear and tear? Here’s how to work with your joints — not against them.

Listening to the familiar breakfast-cereal sounds of stretch class, I couldn’t help but wonder if my own snap-crackle-popping joints were normal and healthy, or an early sign of painful, arthritic changes. And, of course, that’s partly why I was there: I’d been warned about the need for slow, easy stretching during rehabilitation three years ago after breaking both wrists in a dirt-bike accident.

“Flirt with the movement gently and lovingly, rather than challenging it,” advised my practitioner, Dr. Lainey Niemiec. “Listen to your joints now,” she cautioned, “or you’ll be hearing from them later.”

Welcome to the world of the over-30. Even with the best intentions of staying flexible and strong, you too may someday find your joints complaining on a fairly regular basis. One thing most experts agree on is that if you’re just beginning to have joint pain, this is the time to take action. By developing good habits now, you may be able to avoid or reduce more serious joint problems down the road.

Signs and Symptoms

The first thing most people worry about when their joints start giving them trouble is arthritis. The word “arthritis” simply means “joint inflammation,” but that doesn’t begin to explain the many forms it can take. The wear-and-tear form of arthritis – the type athletes and healthy active people have to watch out for as they age – is called osteoarthritis (OA) or degenerative joint disease. The most common out of 100 different types of arthritis, this form alone affects 35 million Americans and is expected to affect 40 million by the year 2020. It accounts for more than half the total hip replacements and 85 percent of the total knee replacements done in the United States.

No one knows the exact causes of OA, but the likely suspects include age, obesity, heredity, injury, overuse and an inflammation-promoting diet. Any joint can be affected, but usually it’s the hips, knees, lower back, neck and sometimes the fingers and toes. Wrists, elbows, shoulders, ankles and jaws are usually only affected after an injury. Your risks increase with age, rising two- to tenfold from age 30 to 65. Before age 50, more men than women have generalized symptoms. After 50, more women have symptoms, specifically of the hand, foot and knee. For knees, the greatest risk factors are obesity and injury.

Symptoms may come up suddenly or over time, may affect one joint or many, and may start as a dull ache that becomes more frequent and more severe. Later stages can be sharp, stabbing pain.

In the early stages of OA, the surface of the cartilage may weaken and lose its elasticity. Over time, your joints can degenerate further until eventually the bones rub together. If you reach that point, using your joints will cause serious pain and discomfort.

While symptom-reducing treatments abound, a “cure” for OA is unlikely to be forthcoming. That’s why it’s so important to protect and care for your joints early on.

The Hip Bone’s Connected

To understand your joints, you have to look beyond them. In other words, if you have pain in one of your joints – let’s say your hip – the real problem may or may not originate there. “To reverse chronic pain,” says William James Brooks, DO, “you need to address all the anatomic as well as functional connections between the top of your head and the bottom of your feet.”

Brooks gives the example of a pitcher who has a sore leg, which throws off his motion, so he ends up with shoulder or elbow pain. Brooks says the usual procedure is to focus on the pitching arm, but that won’t help if you don’t address the connection with the impaired leg.

Brooks was the first manipulative-medicine specialist ever invited onto the staff of a major MD academic institution, the University of Arizona, where he was assistant professor of clinical surgery and also the chief consulting physician for rehabilitation for the Wildcats Athletic Teams. As one of the country’s leading practitioners of osteopathic manipulative medicine now practicing in Kansas City, Brooks treats the patients with complex joint problems – problems that other doctors have given up on in frustration.

“If you have a joint problem due to a specific damaged structure like a broken bone or a ligament that’s been ripped to shreds,” says Brooks, “mainstream medicine is well trained to find and define that. But all too often, people have aches and pains that, sometimes, even after thousands of dollars worth of fancy tests and consultations, nobody can find the answer to.”

Because these kinds of functional joint issues rarely show up on tests, the usual treatments rarely help. Ignore them, though, and you may end up with the more serious structural problems modern medicine can fix – with injections, surgeries and other invasive procedures. The idea is not to let it get that far. Brooks says this makes prevention and good biomechanical habits all the more important.

Boost Your Biomechanics

Most damage to joints results from everyday mistakes in movement. When habits of posture and movement rely too heavily on any one joint, it can wear out prematurely. “Optimal biomechanics depends on spreading the burdens of posture and movement, as much as possible, throughout the entire musculoskeletal system,” says Brooks.

How you walk, sit, stand, answer the phone and roll out of bed can all have an enormous effect on joint health, but the specifics have to be adapted and modified to the individual. Brooks says the typical bullet list of things to do can be misleading.

For example, one person’s answer to the common problem of low back or knee pain may be as easy as a simple change of shoes or some cushy inserts. A recent study analyzing the body mechanics of walking in stilettos, chunky shoes and barefoot found women twisted and turned more on their knee joints in both the wide and narrow high heels than when walking barefoot. Over time, this extra stress could lead to joint damage.

If your shoes are straining your back or knees, try wearing a different style for a few weeks and see if that helps. Or invest in some insoles. Insoles can relieve pressure and stress on joints, decreasing wear and tear.

Then again, the problem may have nothing to do with your shoes. To get relief, you may need a full range of biomechanical changes supervised by a skilled practitioner.

Pick Your Treatments

For joint pain, doctors almost always recommend non-steroidal anti-inflammatory drugs (NSAIDs), which can be anything from aspirin, ibuprofen or naproxen to the new, much-hyped COX-2 inhibitors, such as Celebrex, Vioxx and Bextra. In the United States alone, doctors write more than 100 million prescriptions for NSAIDs annually. While NSAIDs may be great for managing pain, they come with a high risk of gastrointestinal problems such as nausea, vomiting, stomach-lining irritation, ulcers and kidney problems.

A study using capsule endoscopy announced at the Digestive Disease Week 2003 conference in Orlando, Fla., concluded that the problem of NSAID side effects was even more serious than previously thought. Switching to Celebrex and some of the other COX-2 inhibitors was supposed to lessen the problem, but these drugs haven’t lived up to their earlier promise, according to a study published in the December 2002 New England Journal of Medicine.

Even worse, the largest study ever done looking at joint-disease modification, published in the journal Arthritis & Rheumatism, found that people using 25 mg of Vioxx lost 0.27 mm of cartilage in just one year. That number was expected to be 0.1 mm.

“Somehow, this study flew under the radar,” says Jason Theodosakis, MD, MS, MPH, coauthor of The Arthritis Cure (St. Martin’s Press 2004). The information is unlikely to be broadcast by pharmaceutical companies, he explains: “It could affect the billions of dollars in sales of the COX-2 inhibitors if people knew they might be destroying cartilage while they’re trying to relieve their pain.”

Joint-Soothing Supplements

Many doctors now recommend supplements for joint health, particularly glucosamine and chondroitin. Glucosamine supplements have been shown to reduce pain and improve joint function. Chondroitin sulfate supplements have been shown to actually diminish cartilage-destroying enzymes. Previously controversial for their lack of substantial evidence, glucosamine and chondroitin, says Theodosakis, now have almost 40 controlled trials behind them. A member of the steering oversight committee for the ongoing $16 million National Institutes of Health (NIH) trial on glucosamine and chondroitin, Theodosakis says the best thing about these two nutrients is they have no known side effects. He points to a recent two-year study showing disease modification with oral chondroitin and a new review of the literature for glucosamine and chondroitin recently published in the Archives of Internal Medicine.

Although not everyone experiences pain relief with glucosamine and chondroitin, Theodosakis says, the NIH trial found evidence that the breakdown of the joints as an organ is not linked to pain. “Just as they can completely numb the pain with narcotics or anti-inflammatory drugs as the joint destruction accelerates,” says Theodosakis, “we now know, from three years’ worth of studies, that people with no significant pain relief from using glucosamine and chondroitin can still slow the progression of the cartilage loss. This has been determined by quantitative x-rays.”

Theodosakis warns against using these supplements in topical form, though. “There is no theoretical basis for it,” he says, “and to date, no supportive research of any value.” One topical treatment that has proven helpful in relieving pain is capsaicin cream, which contains the same alkaloid that makes chili peppers hot. Commercial capsaicin preparations include Zostrix, Capzasin-P, Capsalgel and Salonpas-Hot.

Research on two other supplements for joints originated in Europe and continues in the United States. One is a prescription systemic enzyme formula from Germany called Plogenzym (Wobenzym is the over-the-counter version available in the United States). Another is avocado soybean unsaponifiable (ASU), an oil extract used for OA in France. S-Adenosylmethionine (SAMe) has about equal effects to NSAIDs, but less than glucosamine and chondroitin, according to an Agency for Healthcare Research and Quality (AHRQ) review study in the United States. Over the past few years, studies in Wales (see Good to Know, page 18 of the printed version) have also shown cod liver oil to be surprisingly effective in reducing the joint inflammation and pain associated with arthritis.

Bodywork

If your joints need therapy, bodywork such as manipulative medicine, physical therapy and chiropractic all have a lot to offer, assuming your therapist is up on the latest techniques. A pre-packaged, one-size-fits-all approach won’t do. Most therapists will try to address posture and alignment, but the best ones also address movement.

“The musculoskeletal system creates both posture and movement,” Brooks explains, “and it creates them as a whole musculoskeletal phenomenon. If you neglect either posture or movement, you probably won’t get any lasting effect.”

Therapies such as massage and Rolfing can help by releasing tight, contracted muscles so they put less stress on arthritic joints. But again, finding the right practitioner is as important as the technique. Try to find someone who has had success in working with joint pain and who is willing to be gentle.

Lainey Niemiec, DC, FIACA, the carefree, Arizona-based practitioner of sports rehabilitation, chiropractic and acupuncture who rehabilitated my wrists, finds the success of any therapy depends on what patients do between visits. “If you continue with the same habits that overburden your joints,” Niemiec says, “you’ll have to keep going back for treatments.”

After analyzing a client’s posture and movement, Niemiec often recommends several modalities for joint problems, including acupuncture. She agrees with Brooks that the way to long-term joint health is mobilization. “Acupuncture is one of the things we can use to support healing,” Niemiec says, “both during an acute phase when a joint needs to be rested, and after a condition has become chronic.”

Acupuncture stimulates the nerves to make changes in the tissue cells, and it triggers the release of endorphins, the body’s natural painkillers. “At first, people are a little scared of the needles,” Niemiec says, “but they don’t really hurt after the initial little pinch. Then, after experiencing relief, often for the first time in years, most people are sold on it.”

When I went to Niemiec’s office for therapy six months after the accident, my wrist bones had already begun to knit. But after removing the splints, I had so little mobility I couldn’t even wave hello. From an acupuncture perspective, the trauma impeded the qi (life energy) on the meridians (energy pathways) running through my arms. “Imagine a train running on a track,” Niemiec explains, “and the injury as a brick falling on the track. Acupuncture removes that impedance, allowing the body to create a clean track again so the train can get to the next stop, which is the next acupuncture point.”

I went back three times a week for half-hour acupuncture sessions. Niemiec inserted the tiny disposable needles along the meridians in my hands, wrists and forearms. I actually found it somewhat relaxing, and, after two months, 95 percent of my mobility had returned.

The stiffness in my wrists is an example of how the body tries to immobilize an injured area by laying down an auxiliary architecture in and around the soft tissues of the joint, just as we do with casts, splints or braces. “The body tries to heal itself in spite of itself,” Niemiec says. “It’s as if the body tries to build a picket fence around the injured area to protect it while it heals.” If we don’t heal quickly, though, we’re left with blockages or chronic immobilization that can cause other problems.

Stretching and Strength Training

The right physical activity performed properly can strengthen muscles and joints and actually reduce your risk of joint disease or minimize its effects. New research concludes that, in the long run, inactivity inevitably leads to secondary problems that can affect joints, including loss of muscle tone, muscle weakness, joint contracture, lack of endurance and poor body mechanics.

For healthy joints, experts recommend varying your exercises to include strength training, range-of-motion work and aerobic or cardiovascular conditioning. There’s no evidence that any one sport or type of exercise automatically leads to arthritis in healthy joints, as long as you use proper techniques, wear appropriate gear and avoid high-intensity, acute, direct joint impact and twisting. When injuries do occur, you can prevent permanent damage by allowing the affected area to heal fully before jumping back in.

A study reported in the International Journal of Sports Medicine shows that resistance training may increase range of motion of a number of joints in inactive older people, possibly by improving muscle strength. Strengthening the quadriceps can also help prevent knee problems. A recent review reported in the Annals of Internal Medicine said that a relatively small increase in strength (20 percent for men and 25 percent for women) can lead to a 20 to 30 percent decrease in risk. Another study published in the journal Nursing Research showed improvement in the functional health status of the knee joint with an eight-week isokinetic muscle-strength-training program (resistance mode with a set maximum RPM).

If you have a serious joint problem, though, you should check with your doctor before starting any exercise program, because you may worsen it. “It’s as if you already have a log jam,” Brooks explains. “You don’t want to add more logs until you clear the jam.” Brooks says that’s how acute problems become chronic.

There are several gentle exercise approaches that have shown promise in helping joint-sensitive people increase strength and balance without undue risk. The ancient Chinese practice of tai chi is an exercise almost anyone can do safely, almost anywhere at any time, and with no special equipment or clothing. In the Eastern tradition of improving the flow of qi, tai chi takes the joints slowly through their range of motion with a series of gentle postures and focused concentration. A recent University of Arizona opinion paper on mind-body alternatives for rheumatic diseases concluded that because stress and pain are closely related, the psychological as well as physical focus of tai chi can bring relief.

Yoga has been shown to help joints in several clinical trials, including two small studies published in the journal Rheumatic Diseases Clinics of North America. Another study at Stanford University showed that yoga was an effective complementary treatment for musculoskeletal diseases. Only two months of yoga reduced pain by 46.7 percent in patients with knee arthritis, according to a new study published in abstract form in the journal Osteoarthritis and Cartilage. The study’s author, University of Pennsylvania rheumatologist Sharon L. Kolasinski, says, “We are really just at the beginning of finding out the ways in which things like yoga might benefit people with arthritis.”

Pilates (pronounced pih-lah-teez) training develops the body through 500 controlled movements requiring five special pieces of equipment and a padded mat. The classic piece of equipment, the Reformer, has pulleys and cables that you push or pull with your hands or feet. Positioning bars, supports and hand-holds help you stretch farther and into positions unreachable on the mat alone. Physical therapists often use Pilates training to help patients prevent or recover from injuries.

Joint problems can affect each person differently, so you may end up trying several things to find what works for you. If your joints feel great, treating them well can go a long way to helping them stay that way. If you’re beginning to feel a few twinges, don’t wait for them to get worse. Listen to your joints speaking – before they start creaking – and you may be able to keep an open, friendly conversation going well into your old age.

Kathy Summers is a freelance health and fitness writer.

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