Fight Arthritis Pain Without Pills
Other methods also can help you conquer arthritis pain.
Relying on painkillers to fight arthritis pain can be difficult as we find that some drugs aren't as safe or effective as we thought, so many people explore alternative pain relief therapies.
Non-steroidal anti-inflammatory drugs (NSAIDs) got a bad name when the COX-2 inhibitors Vioxx and Bextra were pulled off the market: Studies had revealed they increased the risk of heart attacks and strokes. Although Celebrex and other NSAIDS like ibuprofen and naproxen are still available, they carry some risks of heart disease and of gastrointestinal bleeding.
Opioid drugs like morphine haven’t fared much better. Both doctors and patients are skittish about their risks for dependence and unsettling side effects, such as depression, constipation, nausea, drowsiness and breathing problems.
Still, worry doesn’t quell pain. And pain abounds. According to the National Center for Health Statistics, 76.2 million, or 26 percent of Americans, suffer chronic pain – and more than half of those suffer from arthritis. The question that plagues many of us is this: Can’t something be done for pain besides pills?
The answer, fortunately, is yes. No one’s saying that pills don’t have their place in managing your pain. But pain physicians are now leaning toward pills’ measured use in combination with an array of alternative therapies for arthritis pain relief – from electrical stimulation to meditation, from pain pumps to shoes.
Consider the following expert advice about innovative therapies that may offer relief.
1. Topical medications
What they are: Gels, creams and patches that are applied to the skin supply sodium channel blockers, such as lidocaine or prilocaine. Prescription NSAIDs that come in drops, gels, sprays or patches are also becoming popular.
How they work: Sodium channel blockers work by numbing nerve endings close to the skin. Topical NSAIDs work by reaching the joint fluid and decreasing inflammatory proteins like prostaglandins, says David N. Maine, MD, director of the Center for Interventional Pain Medicine at Mercy Medical Center in Baltimore. “They have a direct anti-inflammatory effect.”
Pain they work well for: Sodium channel blockers work best for nerve disorders like diabetic neuropathy or neuropathic pain. Topical NSAIDs help relieve the pain and inflammation common in arthritis.
Risks: Although studies don’t yet bear this out, physicians believe topicals may pose fewer cardiovascular and gastrointestinal risks than oral NSAIDs because the topicals are absorbed locally rather than throughout the body. Says Dr. Maine: “GI side effects are rare compared to oral nonsteroidals.” About 10 to 15 percent of patients have some reaction, usually skin related, including rashes, irritation or itching.
2. Transcutaneous electrical nerve stimulation (TENS)
What it is: TENS involves hooking up to a pocket-sized, portable machine that sends electrical current to painful spots, via wires attached to electrodes placed on the skin.
How it works: “Pain is carried on small fibers called C fibers,” says Girish Padmanabhan, clinical director of outpatient rehab at The George Washington University Hospital in Washington, D.C. “But other sensations are carried by larger fibers. The sensation of the current is transmitted through the larger fibers, which supersedes the smaller fibers,” essentially shutting out the pain. “The electrical current also stimulates the nervous system, possibly stimulating the brain to release endorphins and enkephalins, opiate-like substances that relieve pain.”
Pain it works well for: “TENS is effective in treating any kind of arthritis pain – in treating pain, period,” says Padmanabhan.
Risks: You can’t use it if you have a pacemaker, infection or open wounds.
3. The right shoes
What they are: Well, we all know what shoes are. But according to a 2010 study on 31 people with osteoarthritis at Rush Medical College in Chicago, researchers found that flat, flexible shoes like flip-flops and sneakers (Puma H-Street shoes were used in the study) reduced the force exerted on knee joints by 11 to 15 percent compared with clogs and special walking shoes.
How they work: “Higher [force] on the knee joints is associated with pain,” says lead author and rheumatologist Najia Shakoor, MD. “So, if you exert less [force], you should have less pain.”
Pain they work well for: Wearing flexible shoes may best relieve pain from osteoarthritis (OA) of the knee and perhaps the hip.
Risks: Despite the study findings, Dr. Shakoor hastens to say that flip-flops can cause other problems like plantar fasciitis, inflammation of the connective tissue along the bottom of the foot. And they can put people with osteoarthritis at greater risk for falls. “Flat, flexible, closed shoes with arch support are a good choice,” she adds.
4. Steroid injection
What it is: Steroids, or corticosteroids, such as cortisone, hydrocortisone and prednisone, are synthetic versions of the hormone cortisol, which reduces inflammation.
How it works: A doctor injects a steroid directly into a joint to calm inflammation, says Allen D. Boyd Jr., MD, chief of Adult Reconstructive Surgery and Total Joint Replacement at the University of Rochester Medical Center in New York.
Pain it works well for: “A steroid injection will make almost anyone [with inflammatory joint pain] feel better for days or months or longer,” says Dr. Boyd. “It’s good for anyone with inflammatory arthritis and can be used across the board, including for juvenile arthritis (JA).”
Risks: You can repeat a steroid shot two to three times a year, Dr. Boyd says. More than that may make the ligaments and tendons more fragile, and they can rupture. And there is some small risk of infection with any injection.
5. Hyaluronic acid injection
What it is: Hyaluronic acid (Synvisc, Hyalgan, Supartz) is a slippery, viscous fluid that is a component of natural cartilage, says Dr. Boyd.
How it works: Hyaluronic acid injection may help damaged cartilage by increasing its nutrition and overall health. “There have been claims that it can help cartilage regenerate,” Dr. Boyd says. “But the science for that is a lot softer. And the effectiveness [of the injections] varies from patient to patient.” Patients get a single injection, or one injection a week for three to five weeks, depending on which hyaluronic acid product is used. If the treatment is helpful, patients can repeat it once a year.
Pain it works well for: It’s suitable only for damaged cartilage in the knee joints, but probably not for JA, Dr. Boyd says, “and some studies show only limited benefits.”
Risks: There’s a small risk of allergic reaction or infection.
6. Exercise/physical therapy
What it is: Physical therapy is a treatment that uses exercises designed to improve posture, strength, function, range of motion and to reduce pain. It boosts energy and mood as well.
How it works: A patient who is new to exercise might begin a program of strengthening, stretching and aerobics by seeing a physical therapist twice a week for 12 weeks. “We ask patients to work toward exercising two to three times a week for 30 to 40 minutes each time,” says Padmanabhan.
Pain it works well for: Exercise works for any kind of arthritis, including OA, rheumatoid arthritis (RA) and ankylosing spondylitis.
Risks: Overdoing exercise is always a risk. Don’t exercise through pain. High-impact activities like running and jumping may worsen joint health and increase your risk of injury, so be sure to check with your doctor or physical therapist before trying them. You may be better to stick with low-impact sports like swimming, water aerobics and cycling.
What it is: You can apply heat with heating pads, warm compresses, heat patches, warm baths or even hot wax. Cold therapy can arrive in a cold pack, ice pack or frozen vegetable packs.
How it works: “Muscle spasms can cause basic constriction of blood flow,” says Padmanabhan. “Heat works by increasing the blood flow to the [painful] area. It also relaxes the muscles.” Cold sensations travel along large nerve fibers, superseding pain sensations that travel along smaller fibers. Cold also reduces swelling and inflammation by constricting the blood vessels.
Pain it works well for: “Heat works better [than cold] for osteoarthritis pain,” say Padmanabhan. Apply heat two or three times a day for 15 minutes at a time. Heated paraffin wax baths can be helpful for patients with RA, especially their hands – as long as they’re not having a flare. Cold works best for inflammation caused by injuries like sprains, strains and pulled muscles and ligaments. Apply cold packs two to four times a day for 15 minutes at a time until pain and swelling lessen.
Risks: Heat can aggravate an acute injury like a muscle sprain or strain, making the swelling and inflammation worse. And overdoing either heat or cold can cause burns; never apply to bare skin.
8. Trigger point injection
What it is: A physician injects anesthesia such as lidocaine, or anesthesia plus a corticosteroid, into muscle.
How it works: “Trigger points are bundles of muscle that are painful,” says Mehul J. Desai, MD, director of Pain Medicine and Non-Operative Spine Services at The George Washington University Hospital in Washington, D.C. “Putting a needle into the trigger point allows the muscle tissue to go back to its normal structure. An injection can [relieve pain] for weeks or months.” Stretching and exercising the muscle afterward helps the injection’s effect last longer.
Pain it works well for: It can work for any kind of muscle pain caused by arthritis but not for fibromyalgia, says Dr. Desai.
Risks: You shouldn’t have the injections more than three to four times a year. Too many create scar tissue, which can change the muscle’s ability to contract, ultimately causing more pain.
What it is: Meditation is the practice of developing a deep concentration or focus. Tanya Edwards, MD, director of the Center for Integrative Medicine, Wellness Institute at the Cleveland Clinic, defines meditation as an array of mind-body and relaxation techniques – meditation, breath work, progressive relaxation, guided imagery – that help to lessen pain.
How it works: According to Dr. Edwards, stress produces chemicals in the body that increase inflammation. “With relaxation techniques, you have stress reduction and therefore decreased inflammation and less pain,” she says. Meditation also relaxes muscles that tense up with pain. Dr. Edwards suggests meditating for 20 minutes once or twice a day. For moments of acute pain, she also recommends “meditation minutes.” For example, take four to five deep breaths, counting to 10 with each inhalation and exhalation. “Just doing that four to five times a day can decrease depression and improve outlook,” she says.
Pain it works well for: “It works on any kind of pain,” Dr. Edwards says. Numerous studies have found that regular meditation practice reduces the brain’s response to pain.
10. Nerve block
What it is: A doctor injects a local anesthetic, or a mixture of local anesthetic plus a steroid, into a nerve. Nerve blocks are used to block pain and also to help physicians pinpoint where certain pain is coming from.
How it works: “The anesthetic stops the conduction [of signals] along the nerve, and the steroids help [calm] the inflammatory tissue,” Dr. Desai says.
Pain it works well for: “A block is most commonly used when pain is in the spine and going down into the arm or leg,” says Dr. Desai.
Risks: Infection and bleeding are possibilities. And it’s possible that a physician could target a wrong nerve, which could lead to problems with movement or feeling in areas affected by that nerve.
What it is: Acupuncture is an ancient Chinese therapy that involves placing tiny needles along meridians in the body to release trapped energy, or chi.
How it works: “Placing the needles increases the production of endorphins, morphine-like substances that are natural pain relievers,” says Dr. Edwards. “It also may increase the blood flow to the area, which helps get rid of by-products like lactic acid that cause pain.”
Pain it works well for: “It’s appropriate for any kind of arthritis pain – almost any kind of pain,” Dr. Edwards says.
Risks: If you are on blood thinners, there’s an increased risk of bleeding, and if you are getting chemotherapy, you may have an increased risk of infection.
12. Peripheral nerve stimulation
What it is: A physician implants a trial electrode just under the skin along a painful peripheral nerve (any nerve outside the brain and spinal cord) that receives electrical signals from a small battery-operated generator. If your pain is relieved after a week-long trial, the electrode as well as a small generator are permanently placed.
How it works: The therapy works much the way TENS does. “An electrical current stimulates large fast fibers [whose messages] get to the spinal cord before [those] from the thin fibers that carry pain,” says Dr. Desai.
Pain it works well for: “Although it’s most commonly used for nerve injuries, it’s also used for low back pain [such as that] caused by osteoarthritis,” Dr. Desai says. “The relief can last perpetually.”
Risks: It’s possible to have infection and further nerve injury, says Dr. Desai, “but it’s a low-risk procedure.”
13. Pain pump
What it is: After a short trial, a doctor implants a small pump programmed to deliver varying amounts of pain medication, such as morphine or baclofen (a muscle relaxant), through a catheter threaded into a space around the spinal cord.
How it works: The pump delivers narcotic medication directly to a painful area so that a patient has fewer systemwide side effects than she would with oral narcotics, says Dr. Desai.
Pain it works well for: “It’s used increasingly for low-back pain that could be caused by osteoarthritis or spinal arthritis,” says Dr. Desai.
Risks: As with any surgery, there are risks of infection and bleeding. And it’s possible that the catheter could get blocked, although that’s rare. The battery also has to be replaced every five to seven years. In some whose pumps have delivered medication to a joint, such as a shoulder joint, patients have developed chondrolysis, a rare condition in which cartilage dies.
14. Facet joint denervation
What it is: A physician uses radiofrequency heat energy to destroy painful nerves that supply the facet joints, or the paired joints at the back of the spine.
How it works: The doctor delivers radio waves through a needle inserted next to the nerve. The injury to the nerve interrupts pain signals. “The nerve typically comes back in three to 12 months,” Dr. Desai says. “If you have arthritis, it’s likely you would have pain again.”
Pain it works well for: According to Dr. Desai, this therapy is very useful for patients with OA in the facet joints. “The therapy can be used for multiple kinds of arthritis. It’s typically used for back pain,” he adds.
Risks: In rare instances, you can have numbness, infection, bleeding or a temporary increase in pain. Or the procedure may not work at all.
15. Deep brain stimulation
What it is: This invasive therapy is used only when all else fails. A neurosurgeon implants an electrode in a part of the brain such as the thalamus. A wire from the electrode is placed under the skin of the head, neck and shoulder, connecting to a generator, which is usually implanted under the skin on the chest.
How it works: “The continual impulses disrupt [pain] messages that the thalamus would otherwise send to the cortex to be interpreted [as pain],” says Dr. Maine.
Pain it works well for: It has been used for chronic low-back and leg pain, nerve pain and stroke-related pain. It’s also been used for central pain – pain caused by damage or dysfunction of the central nervous system – but not very effectively, says Dr. Maine. Although some physicians have used it for arthritis pain, that’s not its primary use. “It’s just being established for use in pain cases,” says Dr. Maine.
Risks: “There’s a possibility of brain injury,” Dr. Maine says. “It’s much more invasive than other methods – and physicians don’t understand clearly how it works. It’s a last resort.”
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