Health Matters

Arthritic Pain: Part One There are more than 100 kinds of arthritis, but we are only going to cover the most common in this multi-part series for the newsletter. We will be covering one type in each issue until the series is completed. Topics in other issues will cover osteoarthritis, gout, and rheumatoid arthritis. According to the 1990 Ontario Health Survey, one in five adults suffer from some form of arthritis. Indeed, the national figures are 19% of females above the age of 12 and 11% of males, making it the single-most prevalent chronic condition in the country (National Population Health Survey 1989-99). One in forty adults suffer long-term physical debilitation from it. The frequency and disability increases sharply with age. Women appear to be more vulnerable to the major forms of arthritis; the ratio for women compared to men for osteoarthritis is 2:1 and rheumatoid arthritis is 5:2. Unlike other chronic conditions, however, there appears to be no effective lifestyle changes that can prevent the disease. For the most part, the cause of arthritis is unknown, although genetic and certain environmental factors seem to play a role. Arthritis is simply defined as inflammation of one or more joints in the body. The inflammation can be a result of a mechanical injury such as a fracture, an infection such as gonorrhea, an autoimmune disorder such as lupus, or simple wear and tear on the joint that happens over time with usage. Signs and symptoms may vary. A physical examination of the joint may show a fluid collection around the joint called “an effusion.” If this has occurred the joint may appear somewhat swollen or puffy to the eye. The joint may be ender or sore when gently touched and may also be warm to the touch. When attempting to rotate the joint through it’s normal range of motion, it may be painful or difficult. There may also be crepitus, which is best described as a crunching when the joint is moved. This is caused by a decrease in production of synovial fluid in the joint. Synovial fluid is a viscous substance produced by the body to “lubricate” the joints. A physician may do x-rays, blood test, or remove fluid from the joint with a needle to determine the type of arthritis. The best treatment for arthritis is to eliminate the underlying cause of arthritis if possible (for example, septic arthritis). However most of the time the cause is not known or curable. Thus the treatments are aimed at reducing pain and discomfort, preventing further disability and increasing quality of life. Symptoms may be reduced with simple modifications in daily activities, providing rest and decreased stress to the joints. Medications such as Non-Steroidal Anti-Inflammatory Drugs (NSAIDS) are often prescribed to help the body keep down the inflammation to the affected joints. Recently a new man-made synthetic form of synovial fluid (Synvisc) has been developed. This substance is injected directly into the effected joints to increase the joint mobility. In severe cases and for certain types of arthritis, Corticosteroids, such as Cortisone and Prednisone and Cancer drugs, such as methotrexate are given to decrease inflammation and increase functioning of the effected joint. Shiatsu, massage, and acupuncture have also proven effective in some people, in reducing the pain associated with arthritis. For example, certain muscles in the foot, thigh and lower leg can tighten or shorten causing the knee to torque, compress and/or sheer upon weight-bearing. The former may result from weakness in either a muscle by the shin or in the instep of the foot which may cause one’s weight to shift to the inside of the foot. Compression may arise from tautness in the hamstrings or two muscles in the calf. If the muscles in the back of the thigh are too tight, they may prevent proper extension of the knee, resulting in sheering upon weight-bearing. By relieving tension in these muscles with acupuncture, massage therapy or shiatsu, one potential cause of arthritic pain is reduced and the joint is able to be used more freely and with less pain. * * * * * * * * * * * * * * * * * *

Low Back Pain Treatment Second only to arthritis/rheumatism, non-arthritic back pain is most prevalent, chronic health condition in Canada, affecting 15% of females and 13% of males over the age of 12 (Statistics Canada, Health Statistics Division, Health Reports, 12:3 (April 2001)). Deep, dull ache. Sharp twinges. Stabbing pain. Electrical-like shocks down the leg. Slouching. A feeling of being twisted or bent forward or to the side. Difficulty sitting, standing, walking or finding a comfortable sleeping position. Those are some of the associated signs and symptoms which many of us will experience (if only in part) at some time during our lives. Indeed, the cumulative percentage increase since 1994/95 in the occurrence of low-back pain was the highest of any medical condition in Canada at 16% for women and 14% for men. While the goal of all treatments are naturally the same – increasing range of motion and/or eliminating or reducing discomfort –, the type and direction of therapy will necessarily depend upon the cause(s) of pain. For instance, the type of intervention required for flank pain from a kidney infection or lumbago from cystitis will differ from that for a herniated intervertebral disc which will differ from soft-tissue strain due to a trauma or from chronic, repetitive use. Thus, as the treatments vary, so too will the practitioners who provide each. It is in regard to soft-tissue sources of pain that acupuncture, shiatsu, and registered massage therapy are particularly beneficial, including muscular contributions to disc protrusion. Given that pain medication is the most widely used (by 65% of Canadians over 12 years old) but that it may not eliminate the cause, manual therapies are all the more important . A better understanding of this can be afforded by a brief overview of some aspects of the functional anatomy of low back pain. From the shoulder to the hip and on down to the foot, this includes networks of muscles/tendons, ligaments, bones, cartilage and fascia, all of which will work together in different patterns depending upon the position of one’s body at the time. Naturally, one of the principal factors will be gravity, determining which muscles are used to induce movement and stabilize different joints. Those muscles will affect not only the low back directly via their attachments to the vertebrae but also indirectly via the ribs, the pelvis and the sacrum most notably . Probably the most common source of soft-tissue pain in the above regard is the lateral paraspinals, those muscles which feel like bands which parallel the spine for almost its entire length. They help to extend the back and also aid flexion by anchoring the ribcage. In a sense they can be likened to the main pillars of a tent. Given that humans are bi-peds, one can easily imagine just how important they are at keeping us erect. One can test this by standing up straight with one’s fingers over either side of the low back and the thumbs pointing downwards. After standing naturally and feeling them in a soft tone, start to lean forward very slowly. Within a fraction of a second (and a few degrees), they will start to tighten. That happens to each of all day while we are active or even sitting in a chair while leaning forward. Supporting the lateral paraspinals is connective tissue called, “fascia.” If the reader has ever de-boned a chicken breast and saw a layer of silver tissue on the surface of the meat, that is fascia. By encapsulating those muscles, as they tighten and bulk out, it adds tension to them. Within the analogy of the tent, it would be part of the canvass. As with any tent there is the need for guy-wires. Other muscles in the buttocks, shoulder and around the abdomen so act, again in different (and sometimes seemingly paradoxical) combinations. For instance, the lat’ of the right arm acts with the glut’ (maximus) of the left to put a cross-tension in the fascia. Naturally, in this example, the position of the upper arm and upper leg will have an impact on the low back as they serve as the distal attachments for those muscles, respectively. Yet another common source of pain is a 3-layer muscle which attaches the 12th rib to the lumbar vertebrae to the hip crest then back to the 12th rib. Should one have one leg longer than the other and/or tend to stand on one leg more than the other, tightness can develop in this muscle (the quadratus lumborum) as well as one of the smaller gluteals. The action is to stabilize the low back but in a side-bending motion. The act of weight-bearing in one leg will also cause tension to potentially develop in many muscles of the thigh, both on the inside (the adductors) and the front and side (the quad’s and lateral hamstring). They (along with their accompanying fascia — the fascia lata) serve several functions related to the position of the pelvis and hip but generally here, stabilization too. For the purpose of this article, some muscles on the front of the body can also lead to low back pain by pulling the head and neck forward; rounding the shoulders and internally rotating the arms; tilting the pelvis forward; and causing a sheering action on the lumbar spine. As one’s upper body weight shifts forward, the lateral paraspinals and other erector spinae muscles work to anchor the ribcage and prevent one from falling forward. Whatever the cause (postural habits, repetitive strain at work, or congenital factors from birth), the chronic use of specific muscles over time can lead to their shortening and biomechanical distortions which become almost self-sustaining if not addressed. Acupuncture, registered massage therapy and shiatsu all have the effect of helping to lengthen contracted muscles and thereby help return joints to their normal range of motion. Acupuncture (either with hair-thin needles or a laser) has the added benefit of being able to address tightness in the very deep and small muscles which attach the vertebrae to each other. Finally, with each being whole-body treatments, the entire pattern of distortion can be addressed, something which is essential for long-term relief. When combined with supervised stretching and exercises where suitable, the benefits of treatment are sustained and the number of required treatments reduced.

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