Putting arthritis on hold

Zoomer | March 22nd, 2006

Helen Klassen slips into the pool and feels relief. Swimming laps four or five days a week at the community pool in Cranbrook, B.C., has given her back her life. It’s the one place where she feels no pain.

Over the past year and a half, she has come to crave the water and the way it makes her body feel. At 63 years old, Klassen has suffered with osteoarthritis for 25 years. For more than half of that, she went undiagnosed because of her grin-and-bear-it attitude and the belief that she was just feeling the effects of aging.

It wasn’t until after being asked by the B.C. Arthritis Society to facilitate a conference and subsequently being offered the chance to join its board of directors that she began to learn that the symptoms she had been experiencing for years were anything but normal.

“As I got involved and learned more and more about the disease, I began to realize that there was something going on in my body,” explains Klassen. “I finally went to my family doctor and he said that, yes, osteoarthritis was showing up in the X-rays of my hands.” She was referred to a rheumatologist when the disease spread to her knees.

There are more than00 forms of arthritis, with osteoarthritis (OA) being the most common and affecting three million Canadians. “By age 65, approximately 60 per cent of us will have symptoms of osteoarthritis,” according to Dianne Mosher, MD, Howard Stein, MD, and Gunnar Kraag, MD, authors of Living Well With Arthritis. OA occurs when cartilage, the elastic material covering the ends of bones which allows them to move smoothly over each other, deteriorates and becomes thin. Bones begin to thicken, and small pieces of bone can break off and float around to other soft tissues in the joint leading to pain and swelling. Eventually, the bones may begin to rub against each other, which is as painful as it sounds.

A COX-2 controversy

For Klassen, like many Canadians, initially the answer to the pain was drugs. “I started with all the recommended things. At one point, I was prescribed so many Aspirin that my ears would ring. I still have ringing in my ears today because of it,” she says.

Eventually, the OA moved to so many places in her body that she was forced to literally crawl up and down the stairs of her house, often in tears. Her rheumatologist prescribed non-steroidal anti-inflammatory drugs (NSAIDs), but none of them worked. To make matters worse, she had to take another drug just to counteract the effects the NSAIDs were having on her stomach lining. Finally, in 1999, Vioxx came on the market, and it seemed to be the answer to her prayers. Vioxx was one of a new class of NSAIDs called COX-2 inhibitors, which didn’t pose a risk of stomach ulcers and gastric hemorrhaging.

“The beauty of Vioxx was that I took it when I needed it,” says Klassen. “And it worked.”

In September 2004, Merck Frosst, the company that manufactured Vioxx, pulled it from the market after a clinical trial revealed there was an increased risk of cardiovascular events, including heart attack and stroke after 18 months of taking Vioxx compared to a placebo. Since the announcement, Bextra, another COX-2 inhibitor, has been pulled from the Canadian market. Currently, Celebrex is the only COX-2 available, but new usage restrictions have been imposed by Health Canada based on ongoing studies into the cardiovascular safety of the drug.

“The big thing with COX-2s is that they were very well tolerated by a lot of people,” explains Dr. Arthur Bookman, a rheumatologist and associate professor of medicine at the University of Toronto. “I think people felt a lot better taking something where they didn’t think a major ulcer catastrophe was in the background.”

It’s also important to note that studies have indicated all anti-inflammatories, including over-the-counter products such as ibuprofen, actually increase the risk for heart attack for those at risk. The only exceptions, according to Bookman, are Naprosyn and Aspirin. “Any person who has a risk of heart attack shouldn’t take routine anti-inflammatories except for Naproysn or Aspirin,” he says.

Finding a refuge in water

Klassen struggled with what to do once she couldn’t take Vioxx (she had tried Celebrex but it didn’t help her pain). The OA was everywhere in her body: her neck, shoulders, arms, fingers, thumbs, hips, knees, ankles, heels and toes. “There were times when I would wake up in the night because the pain would be so excruciating. It would just be burning – like a furnace,” she says. It was an invitation by her grandchildren to join them at the community pool that was the turning point for Klassen. “At first, I thought, I don’t want people to see this ugly, fat body. But then I realized my grandkids don’t care what I look like and, once I’m in the water, people can only see my head,” she laughs.

At first, Klassen would just float, but she soon realized when she was in the water, there was no pain. Gradually, over the course of the summer, she worked up the courage to try to swim a lap. She got only halfway on the first try. But she kept trying, and soon she could do one full length, then two, then 10 and eventually she was swimming 40 laps, a full kilometre! At the same time, she’d started rethinking her diet. Her doctor had suggested that losing weight would help her with the pain and progression of her OA.

Many years ago, she had been an international trainer for Weight Watchers, and she believed in the program. Now overweight, she was embarrassed to go back to a place where she had once been a slim and trim instructor. “But I swallowed my pride and went back because I knew it was the best program for me,” she says.

Klassen learned to eat only until she was full. She banished processed foods from her diet but kept healthy carbs. Gradually, as she swam more and ate less, the weight came off. Today, she is 91 pounds lighter. Klassen swims 80 laps of the pool (two kilometres) four or five days a week. “As my body felt better, I wanted to keep going back to the pool,” she explains. “I found that I’d still get a flare of pain now and then but instead of it knocking me down for a week or two, it would only knock me down for a day.”

The role exercise and weight loss play

While exercise and eating healthily may not be an easy route when it comes to controlling pain, it is the magic bullet according to experts. “Weight reduction will retard the progression of OA of the knees. A 10-pound weight loss now can cut the amount of OA years later by as much as 50 per cent,” explains Bookman. Adding regular exercise to your life if you’ve never done it before can be difficult. But the rewards are worth it. “Muscle strengthening will actually control pain much more. People who exercise have far less pain,” says Bookman. “People with strong muscles around their joints have far less pain than those with weak muscles.”

Enlisting the services of a physiotherapist can be crucial to learning what to do, how often and to help you stay motivated. Karen Gordon is a physiotherapist at The Arthritis Society in Ottawa who provides one-on-one consultations. “Another important benefit is increasing aerobic endurance, which counteracts the fatigue that is a symptom of arthritis. It gives people more energy to get their daily tasks done,” she says.

So which exercises are best? “In general, for anyone with arthritis, we recommend low-impact exercise like swimming, pool exercises, walking, bicycling, cross-country skiing, tai chi or just getting back out on the golf course, mowing the lawn, walking the dog. It all counts,” says Gordon.

To get results, you need to do a minimum of 30 minutes of exercise a day. But the 30 minutes can be broken down into two sets of 15 or three sets of 10. If you haven’t exercised in years, start with five minutes and build on it. “Anything is better than nothing,” she says. If you’re planning to hit the gym to get your workout, Gordon recommends those with OA in their hips, knees and feet try an elliptical trainer, bicycle or rowing machine rather than a treadmill. And get instruction from the personal trainers on staff about how to use the weights and machines properly to avoid injury. If you’re more inclined to work out at home, a physiotherapist can teach you simple routines using light weights, elastic bands and ankle weights.

One thing to avoid though is any activity that aggravates your arthritis. Running, jumping and contact sports may be too hard on many people with the disease. Find something that you enjoy and do it in moderation. Also keep in mind the two-hour pain rule. It’s normal to feel sore after exercising as long as any pain in your joints lasts for less than two hours. If it persists longer than two hours or stretches into the next day, you’ve overdone it and you need to reduce the intensity or the quantity of the exercise.

Getting the help you need

For Klassen, being taken seriously by her doctor played a huge role in her can-do approach to her health. “I educated myself,” she says. “And we need to take an active role in helping educate our doctors.” Bookman agrees that for too long, the symptoms of arthritis have been shrugged off as simply something to deal with in old age.

“Doctors dismiss arthritis as being minor, and it’s not,” says Bookman. “There is disability associated with it, waking high blood pressure, drugs with side effects that result in ulcers and high blood pressure, depression, self-image problems, not to mention living with constant pain and fatigue.

When it comes to treatment, Bookman suggests you look for a doctor or rheumatologist who will provide more than drugs. “No one just walks out of my office with a prescription. I don’t think they ever should walk out of any doctor’s office with just a prescription,” says Bookman. “There needs to be a whole treatment package: advice on exercise, physical therapy for reinforcement of exercise, advice about diet and weight reduction and lifestyle changes. If you can’t get that information from your doctor, ask for a referral to a physiotherapist, an occupational therapist or The Arthritis Society.”

What works and what doesn’t

Another benefit to recruiting the services of a physiotherapist is the option to get assisted devices including raised toilet seats, canes, crutches, walkers, devices for the kitchen to help you manage daily tasks, and splints for wrists and hands. If you require custom splints or orthotics, they can refer you to an occupational therapist who can fit you properly.

Resting your body by splinting the offending joint can go a long way to providing pain relief. Listening to your body is key too. When you start to feel pain or fatigue, take a break and let yourself do so without guilt. Pace yourself. “If things are challenging today, it’s okay,” says Klassen. “Because you know tomorrow you’ll get it done. It’s okay to rest. I had to learn that and it didn’t happen overnight.”

Topical NSAIDs such as Pennsaid can be rubbed on the joint and have been shown to be as effective as oral pills in reducing pain and swelling, and they don’t have nearly the same side effects. “Topical cream goes through the skin to the joint,” says Bookman. “It’s a systemic medication but it concentrates locally where the joint is.”

As important as weight loss in terms of pain reduction and retarding progression of OA is diagnosing the disease early and getting medical treatment. “The earlier you catch it, the more you can do about it in most cases,” explains Bookman. “There is clinical evidence that if you have OA in the back or knees and it’s picked up early and you lose weight and tone up muscles, you can probably retard the progression.”

When it comes to the myriad of remedies, creams and supplements touted as the next big thing for treating arthritis pain, few actually help. According to Bookman, glucosamine and chondroitin sulphate have been disproven as having any effect on arthritis. Copper bracelets? Pitch them. Topical creams that provide heat? They just make your skin burn so you don’t feel your joint pain as much, he explains.

Coming to terms with arthritis

When Klassen was first diagnosed, her reaction was denial. Once she accepted the diagnosis, she decided to take her health into her own hands. Since she began swimming and lost weight, her quality of life has improved dramatically. Now she realizes that her own mother probably suffered with OA for years.

“We didn’t know that that’s what it was in those years,” says Klassen. “We just thought, ‘Come on, you’re a tough old gal. You just have to grin and bear it and move on.’ That attitude is still prevalent today and we need to dissolve it and let people know that there are treatments available and they don’t have to suffer.”

While she admits its hard getting in the pool that first time, the benefits will quickly become apparent.

“Now when I go swimming, I know how comfortable I’ll feel and how soothing it will be. I know how great my body is going to be and how great it’s going to feel to be pain free.”

Tips to take control

Make exercise a daily habit. Schedule your day around it, instead of fitting it into your day.

Lose weight if you are carrying extra pounds. “Anyone with arthritis in weight-bearing joints – hips, knees, big toes or spine – can benefit from weight loss,” says Karen Gordon.

Ask for help. Contact The Arthritis Society in your province or go to www.arthritis.ca. They have a self-referral system and only require that you have your diagnosis confirmed by your physician. Access the wealth of experts available to you.</li.

Ask your doctor what medications are safe for you. If you have no history of cardiovascular problems, a Cox-2 inhibitor might be fine. But if you are taking any medication, even over-the-counter products, remember there is an increased risk of ulcers and bleeding. Take medications after meals or with something to protect your stomach.</li.

Get educated about the disease and take action.