By Elissa Lee and Albert Jiang, Contributing Writers
Thomas, 72, was once an avid hiker. Throughout his 50s and 60s he had frequented the sandy trails of Crystal Cove for strenuous and beautiful day-hikes. The retired post office clerk had been struggling with osteoarthritis in his knees for decades, but now the pain in his knees flared so badly that he found himself spending more time indoors – in bed, in the armchair next to his television especially after an unusually rainy California winter.
One morning, after Thomas finished his business on the toilet, he put down his newspaper and prepared to stand up when he realized – he couldn’t. He tried to pull his feet under him to ready himself when he felt his knees increase in stiffness, and then, the pain came on. It was a radiating ache he knew all too well, but now the intensity was excruciating, and for the first time, made Thomas more fearful than annoyed.
As Thomas recounted this incident for me at our first physical therapy session together, he confided in me that the feeling of frustration and embarrassment outweighed the bodily sensations of pain and stiffness in that moment. He called for Lois, his wife, and luckily she was able to pull him into standing. The ordeal, though it was a scenario they had heard about, unsettled both Thomas and Lois. Lois urged Thomas to see a doctor, and they both quietly anticipated an impending knee replacement. After a consultation with their orthopedic specialist, Thomas was encouraged to try the more conservative approach of physical therapy before considering a total knee replacement, and a week later he landed in our rehabilitation clinic.
“They tell me it’s nearly bone on bone”, bemoaned Thomas as he sat on the treatment table. The recent imaging showed significant cartilage degeneration in both of his knees. While he was disturbed by the visualization of his bones grinding together, he was looking forward to trying physical therapy.
What is arthritis?
Arthritis encapsulates many joint disorders, but the most common forms are osteoarthritis (OA) and rheumatoid arthritis (RA). OA, also known as the “wear and tear” arthritis, is a degenerative joint disease in which joint cartilage breaks down over time. RA is an autoimmune disease in which one’s immune system attacks affected joints.
Arthritis affects nearly a quarter of all adults in the United States, and there is great variability in how it may impact day-to-day life. For some, it could be so severe it is the barrier that keeps us from doing what we love (and need to do) everyday; for others, it is a limiting factor for mobility on top of everything else. Arthritis can affect any joint, but the ones that give older adults the most problems are the knees, hands, wrists, and hips. Prevalence has increased — with knee osteoarthritis doubling since the mid-20th century.
As we continued in the session together, it became clearer to Thomas how his arthritis was starting to rule his life. The pain he experienced was debilitating and prevented him from his most treasured pastimes (e.g. hiking) and daily necessities (e.g. toileting). He couldn’t kneel down to play with his grandchildren at their level (picking them up was out of the question). Thomas began to notice that he was adopting a more sedentary lifestyle. “I’m frustrated that I can’t get out and even walk without fear. I just don’t feel like myself anymore.”
In our practice, we’ve seen many patients like Thomas, who have felt that their arthritis was becoming a limiting factor in everyday activities. Here are a few tips to get you started:
- Consult a medical provider: We recommend seeing a medical provider, especially as it comes to pain medication treatment. It can also be helpful to modify your diet to incorporate foods that are less inflammatory, as well as decrease your BMI – which will alleviate the weight on your joints, particularly on the knees.
- Scale your movement with monitoring and modification – motion is lotion: To start, it’s important to understand the relationship between movement and pain. Are there particular triggers that cause your pain to flare? Oftentimes, it can be as a result of overworking the joint, cold weather, stress, or an infection.
Monitor your symptoms by keeping a log to find any patterns in your pain. This can also help you understand that it might just be that the “workload” is too much for your joint in the current moment, but it doesn’t mean it always will be, or there isn’t preparation you can do to alleviate the load. For example, if you know that cold weather triggers pain for you, keep some extra blankets close by or even an electric heating pad ready when that drafty winter morning hits.
As you monitor your symptoms it can be helpful to differentiate between when the joint is acutely inflamed or injured as opposed to in chronic pain. It makes sense to not want to move when your body feels pain – in fear of causing more pain. Recent research in the field of pain neuroscience, however, has aided us in further understanding the connection between chronic pain and our brain. When you have an injury to your knee, the body sends a signal to the brain to register it as a pain – serving as a warning signal for us to restrict movement in that area to promote recovery. However, in the case of chronic pain, it can continue to light up the neural pathway long after the injury and inflammation has abated.
During an acute flare-up, let the joint rest, apply ice or heat, and take NSAIDs or other pain medications.
If the joint feels more stiff and the pain more chronic, it feels counterintuitive, but can actually be good to move – with modification. “I have arthritis every time I get out of bed, so I don’t get up” – is what we hear a lot of our patients say. We have them apply heat to the area, take a hot shower, and do some gentle movement to warm the joint up – this will bring blood flow to the area, improve circulation, release endorphins, and override some of the pain signals. Try some lower-impact exercise alternatives, such as gentle stretching to start. Many of our patients will move their joints around slowly, sit at the edge of the bed to warm up their joints before “fully loading” and standing up. Assistive devices such as walkers, canes, or trekking poles can help to reduce the load on your joints as well.
Warming up makes movement much more tolerable, and can build your confidence to move with little or no pain.
It takes time and practice
As you monitor your symptoms, build your movement practices, you are also building the muscles around your joints, maintaining bone strength, keeping weight down, and improving energy, balance, and mood – all of these will in turn keep your joint healthy and the pain away.
Initially, Thomas learned about strategies for managing symptoms of arthritis and how to modify and scale the activity and load he was putting on his body throughout the day. By discussing his daily routine, we were able to identify potential triggers, like ascending and descending the two flights of stairs in his home- a seemingly innocuous task. We discussed how to scale down and appropriately pace these activities of daily living to allow for his body to recover and relieve some of the stresses that were inciting inflammation.
After ten sessions over a few months, Thomas was able to manage his pain more effectively and return to the trails he had missed. A few weeks after his last physical therapy session, he called the clinic, excited to report that he was able to comfortably get on a low stool and help his grandson build a train track. He was happy not to kneel.
This article was written with the support of a journalism fellowship from The Gerontological Society of America, The Journalists Network on Generations and the The Silver Century Foundation.
Elissa S. Lee is a health care reporter, chronic care researcher, occupational therapist and a consultant. She holds a doctorate in occupational therapy from USC and a bachelor’s degree from UC Berkeley. Albert Jiang is a physical therapist in the Bay Area. He has a doctorate in physical therapy, and as an avid hiker, climber, and runner, he enjoys helping patients take the next step in incorporating healthy movement into their lives.
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