Why Exercise?
When you first discussed exercise with your health care provider, he or she probably did not spend a lot of time talking about the benefits of exercise. Throughout our lives we’ve heard that exercise is “good for you,” but if you’re living with arthritis, exercise is particularly important. Exercise has been shown to increase muscle strength, endurance and flexibility and reduce weight. It has also been shown to reduce joint pain and stiffness, and improve overall sense of well-being.

Types of Exercise
As you’ve likely discussed with your health care provider, there are three main types of exercise that benefit people living with arthritis. Range-of-motion exercises are designed to help with flexibility and joint movement. In range-of-motion exercises, you move your joint through its entire range. For example, this might include rotating your wrist 360 degrees. Range-of-motion exercises should be performed daily or every other day. Your doctor can demonstrate the correct movements. Strengthening exercises are designed to make your muscles stronger in order to support and protect your joints. Strengthening exercises are also done daily, but shouldn’t be done when symptoms are flaring. Strengthening exercises may include the use of small weights, or water exercises. Aerobic/Endurance exercises are done to help control weight and improve your overall health. These exercises are usually done three times a week, for 20 to 30 minutes at a time.

Hints for Maintaining Your Exercise Program
After you’ve worked with your doctor or physical therapist to design an appropriate exercise program, the most difficult part of all is taking what you’ve learned and applying it to your daily life. For most of us, this is easy to do for the first few weeks, but becomes more difficult as time goes on. Try the tips below to help stay on track.

* Start small. Don’t begin your exercise program expecting to work out like an Olympic athlete. While it’s good to start with enthusiasm, starting a program that is too advanced can lead to pain – and decrease your chances of maintaining the program.

* Stretch. Along the same lines, don’t jump into each exercise session at “full swing.” Give your muscles a chance to warm up by stretching and doing range-of-motion exercises.

* Make exercise part of your routine. Like brushing your teeth, taking your vitamins, or any of the things you do every day, exercise should be established as part of your daily program. Set aside time each day to complete your program. Don’t forget to allocate time for stretching and cooling down.

* Make exercise a priority. Too often we drop exercise from our list of “to do’s” when we get busy or tired. It’s difficult to make something a priority when most of the benefits are long-term rather than immediate, but if you make exercise a daily priority you’re guaranteed to see results in your overall health.

* Give yourself a break. “No pain, no gain” definitely does not apply to people living with arthritis. Sometimes, some joints will hurt more than others. If you find that a particular exercise causes pain or inflammation, talk with your doctor about adjusting your exercise program.

* Distract yourself! If you’ve been sticking with the same exercise routine for more than a few weeks, you may have begun to tire of its repetition. Look for distractions while you’re exercising. For example, range-of-motion exercises can easily be done in front of the TV while your favorite program is on.

* Make it a party! OK, “party” might be a bit of a stretch, but you can make exercise fun by doing it with other people. Check with your local Arthritis Foundation for classes in your area. Or invite a neighbor, friend, or your spouse to exercise with you, or even keep you company while you exercise.

Remember that these tips are provided to give you ideas. Experiment a little and find out what works best for you. If you can find a program that you enjoy and can stick to it, you’re sure to see long-term benefits in improved health.

Ayurveda: means “science of life.” This form of alternative therapy focuses on maintaining physical health and well-being so a person can pursue a greater spiritual development. The main emphasis is healthy living through a good diet, exercise, moderation and meditation. The practitioner is just an advisor. Each person must put the advice to use. The theory of this kind of therapy is centered at body energy. What the practitioners helps you achieve is a balance of energy within yourself and the forces around you. Most of the treatment has to do with your digestion and elimination systems. The idea is to purify the system by eliminating toxins, therefore restoring balance within the body.

Chinese Medicine: “Balancing Vital Energy.” This form of therapy also has to do with finding balance in the body. The Chinese describe it as the yin and yang energies. These two forces are often opposing, but need to be in balance for optimal health. The Chinese also believe in something called Qi, which loosely translated represents life itself. It is referred to as life flowing through our bodies. When the Qi is blocked somewhere in the body the person becomes sick and the practitioner must work with that person to unblock the Qi. To accomplish the unblocking and re-establish the balance between the yin and yang they prescribe acupuncture, acupressure and exercises called tai chi chuan and qi gong as well as other herbs and preparations.

Naturopathic Medicine: This form of therapy centers around the body healing itself by living a healthy lifestyle and giving the body what it needs to function properly. It focuses on the person and not the disease and also working with the patient to prevent disease. The doctor plays the part of a teacher, with the patient educating themselves on healthy habits. Some of the focus is on removing poisons and bad habits and encouraging things like exercise, positive attitudes and bringing balance into ones life. One of the key areas the practitioners focus on is nutrition. Modern naturopathic physicians study a variety of disciplines including, nutrition, manipulation, herbal medicine, hydrotherapy and counseling. This type of practitioner is not equipped to provide all the treatment you will need for arthritis. It is truly a complementary form of medicine; therefore you also will need a medical doctor to treat you as well.

Osteopathic Medicine: Today osteopathic doctors go through almost the identical education process as regular MDs. They can do surgery and write prescriptions and they can also specialize in other fields of medicine just as a regular MD. The big difference between a regular MD and an Osteopathic doctor is the Osteopathic doctor looks at the musculoskeletal system as the core of the problem. They feel that if they can help the patient get their bones and muscles in good working order that other problems will resolve themselves. They use manipulation of the entire bone structures of the body. Some other forms of therapy used include massage, relaxation, diet changes and also exercise.

Chiropractic: This form of alternative therapy is widely used. It is the third largest health-care profession. Millions of people each year seek the help of a chiropractor for the relief of back and neck pain. Many people find themselves going to a Chiropractor after an accident or injury. It is also a form of therapy that many people with musculoskeletal problems find relief from their discomfort. The focus of treatment is to realign the spine. Chiropractors feel if there are problems with the alignment of the spine (subluxation specifically) this causes pain and sometimes immobility and loss of function. By aligning the spine they feel the patient will benefit by a reduction in pain and an increase in overall mobility.

There are two different kinds of Chiropractors “straights” and “mixers.” Traditional or “straights” concentrate on just doing spinal manipulations. “Mixers” use several different approaches to treatment. Some include, electrical stimulation, ultrasound, herbal and vitamin therapies, and nutritional counseling. These practitioners may also have other certifications including massage therapy and physical therapy or work closely with practitioners that provide these complimentary services. “Mixers” use more of a comprehensive approach that involves more than just spinal manipulations. People with arthritis should use caution when seeking help from a chiropractor. Manipulating weak, diseased joints can cause more damage to the joint.

Mind-Body Connection: There are many therapies that are practiced by individuals for pain relief and stress reduction. Most people use these with other forms of conventional therapy. It has been well documented that negative emotions such as stress, depression and anxiety can increase symptoms and result in more pain and loss of function. The mind-body connection and how it can be used to help a person get control over symptoms and their life is an accepted form of therapy. This fact was proven a few decades ago when researchers used a placebo on a group of patients. In a controlled study some patients were given the real medicine and others were give a sugar pill or placebo. It was proven in several research studies that about 30 percent of the people in the studies responded the same whether they got the medication or the placebo. From this research they concluded that there was something to the mind, body connection and how a patients physical well-being was affected by their mental health. Because of these studies and others like them the whole field of mind-body therapy immerged. Some of the more common forms of mind-body therapies follow.

Biofeedback: This is a method where electronic monitors are used to teach the patients how to lower muscle tension and reduce pain. It is performed at a clinic initially and then as the patients become familiar with the process they can do it at home. Basically an electrical monitor is used to detect tension at a specific area of the body. The patient is lead through a series of relaxation exercises focusing on that area of the body to help relieve the tension. The monitor is used to help the patient or clinician detect a change in how the muscle is reacting to the relaxation techniques. This form of therapy takes concentrated work on the part of the patient. The results come over time as the patients become more in tune with their bodies and can focus on certain areas of the body. It also requires a place where the patient can go and not be interrupted and can feel safe.

Meditation: People who practice meditation find it helps relieve tension, pain, stress and depression. It is a form of therapy that develops an inner calmness when practiced regularly. Meditation is not a form of therapy that can be learned and applied overnight. It takes practice, focus and belief in the process. Usually the longer a person practices the more effective the outcome.

Hypnosis: There is self-hypnosis and being hypnotized by a professional. This form of therapy has been used for several conditions: weight reduction, smoking cessation, pain reduction and a number of other problems. The way it works is through different techniques that alter your consciousness and help you focus your attention. This is another form of therapy that you have to believe in or it will not work for you.

Other forms of mind-body therapy used are visualization, guided imagery, relaxation, deep breathing, progressive muscle relaxation, tai chi and yoga to name a few. In addition to the mind-body aspect of treating symptoms there are other specific forms of therapy that I want to mention.

Massage in its many different forms has shown to be beneficial in treating symptoms. When looking for a massage therapist you might want to educate yourself on the different techniques used in massage. These are a few of the more common types: reflexology, craniosacral, deep tissue, trigger point, myofascial release and acupressure. Each one of these techniques concentrates on a specific area of the body or amount of pressure used. This is one form of therapy that people either get good results or no results and it usually only takes one or two session to find out if it will benefit you. Educate yourself and find out what kind of training your therapist has before you schedule an appointment. The information you collect can mean the difference between helping you and causing more damage to your joints.

Other segments of alternative therapy are diet, supplements, herbs, teas and things like bee venom, magnets and copper bracelets. I am not going to elaborate on these forms of therapy because the benefits derived from them are controversial and lack scientific explanation. There are articles written about these forms of therapy if you have an interest and want to investigate them.

In closing one thing I would like to emphasize is that each person with arthritis needs to find his/her own unique remedies. Even though some 22 million people have osteoarthritis, each one of them needs to find the right treatment program for themselves. That program may include several different treatment modes, combining conventional with alternative. Just as each person is an individual, his or her approach to treating illness should also be tailored specifically for that individual.

Over the last 47 years of battling with rheumatoid arthritis I have used many different forms of therapy in my treatment program. One treatment plan will not last forever so we all must constantly be educating ourselves about new therapies whether they are conventional or alternative.

It is especially important to pay attention to this disease, not only because it can be disabling, but also because probably the most important single lifestyle factor that prevents major fatal diseases is exercise. It is crucial that we keep our joints in as good condition as possible, so that we can be as active as we choose in order to maintain healthy cardiovascular systems and many other vital systems in our bodies.

Injuries, overuse, excessive weight or pressure on the joints, or biochemical changes in the joint cartilage can trigger the process that causes deterioration of the cartilage, the lubricated cushion that keeps the joints working smoothly and freely. If old cartilage is degraded faster than new cartilage is formed, the result is deterioration. In early stages, not enough proteoglycans, glucosaminoglycans and collagen are produced to rebuild cartilage. As the cartilage thins and loses its elasticity, it becomes more prone to damage due to excessive use and injury. Then inflammation can occur. Bone exposure from loss of cartilage causes minute fractures and over-growth of bone with sharp edges within the joint. This then leads to pain, stiffness, swelling and deformity.

Conventional medical therapy such as non-steroidal anti-inflammatory drugs (NSAIDS) can reduce pain and inflammation, but they do not slow the deterioration of the joints, and in fact they cause more degradation of the cartilage if they are used regularly for a long time.

As with other chronic disease, it would make the most sense to prevent these changes from happening, and after they begin to occur, to provide the best support for the cartilage to repair itself.

One important support is proper exercise. Since there is no blood circulation in the cartilage, the cells can only get nourishment by a sponge-like action that comes from squeezing and releasing the cartilage through weight-bearing or other force-producing exercise. The pressure on the joint also has to be not excessive or too repetitive; therefore, obesity and activities that are too repetitive can cause harm. For example, running on hard pavement without properly cushioned shoe soles more than 10 miles per week could cause repetitive injury. Other similar excessive wear on joints could do the same.

What are some of the biochemical factors that promote cartilage deterioration? Dr. Sutter points out that free radical damage is being implicated increasingly in this disease, and research has shown that antioxidant nutrients do protect against degradation of cartilage.

If this is so, then all the other preventive measures that prevent free radical generation, applicable in most other degenerative diseases, could be applied here. Avoiding excess chemical and radiation exposure, avoiding high-fat foods and fried foods, managing and decreasing stress, improving detoxification ability, reducing allergic reactions, preventing diabetes and insulin resistance, and minimizing the use of prescription and non-prescription drugs, all are things that can reduce free radical damage. Eating foods high in antioxidants, such as colored fruits and vegetables, and taking antioxidant supplements also helps quench free radicals.

Also, any nutrient that prevents inflammation could slow or reverse the inflammatory stage of this cartilage deterioration. Foods high in ogega-3 fatty acids such as fish and vegetables, certain nuts and flax oil, and foods low in saturated fat could reduce tendencies for inflammation.

Drs. Alan Gaby, M.D., and Jonathan V. Wright, M.D., have found in their experience that some people are sensitive to foods in the nightshade family such as potatoes, peppers, tomatoes, eggplant, etc., and that they improve in arthritis symptoms when avoiding them.

I have found in my practice that several people were sensitive to other foods that, when eliminated, made the arthritis symptoms disappeared, in this case often the food was orange juice. It can be useful to do an elimination diet to try to detect which specific foods may be causing flare-ups of pain and inflammation for that particular person.

Dr. Sutter lists many nutrient supplements that can decrease free radicals, reduce inflammation, and supply building blocks for the cartilage cells to use to make new cartilage.

Glucosamine sulfate and chondroitin sulfate supply material for making more glucosaminoglycans, proteogllycans and synovial fluid, for building new cartilage. Vitamins E and C are important antioxidants that prevent free radical damage. Niacinamide helps to reduce inflammation by slowing the synthesis of nitric oxide (NO), which is a potent trigger for the degradation of cartilage. N-acetylcysteine, a nutrient also produced by the body, helps to reduce inflammation and increase production of the body’s own antioxidant, glutathione. Selenium assists vitamin E in antioxidant activity. Zinc, copper and manganese are needed for production of the body’s own antioxidant, superoxide dismutase (SOD).

Human studies have shown effectiveness in reducing symptoms of osteoarthritis with these aforementioned supplements. Several herbs have also been found in human studies to reduce symptoms, probably by reducing inflammation. These are ginger and turmeric (common kitchen spices), and boswellia serrata, a traditional Ayurvedic anti-inflammatory herb related to frankincense.

The amounts of the supplements our recommends are as follows: (Note: Caution should be exercised if turmeric or ginger is used in combination with drugs that prevent blood clotting, and niacinamide in these doses recommended should be done under a physician’s supervision, possibly with blood tests for liver function.)

Glucosamine sulfate — 500 milligrams three times daily.
Chondroitin sulfate — 400 milligrams two to three times daily.
Vitamin E — 400 to 800 IU per day.
Vitamin E — 500 milligrams three times daily.
Niacinamide — 500 milligrams two to three times daily.
N-acetylcysteine — 200 milligrams two to three times daily.
Selenium — 200 to 400 micrograms per day.
Zinc — 5 milligrams three times daily.
Copper — 2 milligrams per day.
Manganese — 20 milligrams per day.
Boswellia standardized extract — equivalent to 150 milligrams boswellic acids three times daily
Turmeric standardized extract — equivalent to 150 milligrams curcuminoids three times daily
Ginger standardized extract — equivalent to 10 milligrams gingerols three times daily

There are several homeopathic remedies that also have been useful in osteoarthritis.

Physical therapy can be useful in designing the proper exercise and activities to do for a person suffering from arthritis.

There is much we can do by way of natural therapies that can prevent or reduce osteoarthritis and its pain and inflammation, a disease for which it was once thought there was nothing that could be done for it.

Several medical therapies and life-style activities changes now exist for the treatment of osteoarthritis. However, at this point, their use is based solely on treating the symptoms of osteoarthritis, including pain, swelling from inflammation and reduced joint movement. Among the medicines employed, corticosteroids can be administered directly into the affected joint. Corticosteroids remain the most potent anti-inflammatory drugs employed in the therapy of osteoarthritis. There are reasons to minimize the use of injectable corticosteroids or oral formulations as these drugs have significant side-effects when employed for long periods of time. Aspirin and aspirin-like drugs were developed to reduce inflammation and so they are very useful in the medical therapy of osteoarthritis. This class of drugs, the non-steroidal anti-inflammatory drugs (NSAIDs) target a class of molecules called prostaglandins which are very much involved in the inflammatory processes accompanying osteoarthritis. NSAIDs inhibit an enzyme, called cyclooxygenase, which is required for the production of prostaglandins. However, the same enzyme is also required for normal function of the gastrointestinal mucosa, which lines the stomach and for normal kidney function. Long-term use of NSAIDs can result in gastrointestinal bleeding. It was for this reason that a new class of NSAIDs were developed, which reduce cyclooxygenase only at sites of inflammation and spare the normal cyclooxygenase. These so-called COX-II inhibitors are now widely employed for the medical therapy of osteoarthritis.

Naturally occurring substances such as glucosamine, chondroitin sulfate and hyaluronic acid has been used for treating patients with osteoarthritis with varying results. Nutritional supplements such as glucosamine and chondroitin sulfate may be more efficacious in maintaining cartilage health in symptom-free individuals than in restoring function in patients with osteoarthritis.

The development and continuous refinement of prostheses for joint replacement surgery for osteoarthritis of the knee and other joints has been instrumental in improving the quality of life for individuals for whom medical therapy is no longer feasible. While it has been argued that knee replacement surgery is underutilized, it is an intervention that is not without problems. It is a significant cost to health insurers and in many cases, the original replacement must be revised over time adding additional costs to our health delivery system.

People should be aware of how life-style modifications affect their chance of developing osteoarthritis. Physical exercise may be a risk factor for developing osteoarthritis, but in and of itself does not appear to accelerate minor damage to the cartilage. Thus, a well-designed and carefully monitored physical exercise program should be maintained to provide muscle tone support and to promote cardiovascular fitness. Prior participation and regular participation in sports resulting in the potential for repetitive trauma may play more of a role than the proposal to maintain a moderate physical exercise program. Normal symptom-free individuals should not avoid physical exercise in an attempt to forestall the development of osteoarthritis. In certain families, however, where individuals have the potential to develop precocious forms of osteoarthritis as a result of a genetic disorder in the joint cartilage, physical exercise may play a greater role in the progression of disease activity. In these individuals, a diagnosis of increased risk for developing osteoarthritis based on the results of genetic testing could provide needed information allowing for a more prudent physical exercise plan to be developed for these individuals.

We are certainly aware of the fact that individuals sustaining major injury to the knee such as rupture of the meniscus or anterior cruciate ligament may proceed to develop osteoarthritis in the absence of any other risk factors. Surgical repair of the knee damage and physical rehabilitation is commonly employed to prevent such an outcome.

What about weight reduction? While obesity has clearly been determined to be a risk factor for developing knee osteoarthritis, unlike the other risk factors previously mentioned (physical exercise and/or trauma), recent studies by Cooper and colleagues now suggest that only obesity defined a body mass index (BMI) of 22.7-25.4 or greater was associated with progression of osteoarthritis of the knee as measured by x-ray analysis. A weight-reduction plan should be designed for individuals who have an x-ray diagnosis of knee osteoarthritis in its early stages. This life-style change becomes important as attempts are made to medically regulate the progression of osteoarthritis over time.

The importance of developing strategies for preventing osteoarthritis cannot be underestimated. A recent paper in the science journal, Arthritis and Rheumatism by Cyrus Cooper and colleagues indicated that the World Health Organization considers knee osteoarthritis to be a global burden as knee osteoarthritis is the fourth most important cause of disability in women and the eighth most important in men. The pain and stiffness in the knee joint developing as a consequence of changes in the articular cartilage which covers the skeletal joints is undoubtedly a cause of the significant morbidity associated with the condition.

What happens in the knee and other peripheral joints such as the hip and shoulder to cause osteoarthritis? In the general population on a background of risk factors such as over-weight, trauma or significant damage as a result of repetitive physical activity, the joint undergoes changes in the metabolism of the cartilage, which sits on top of the skeletal long bones. This articular cartilage is responsible for ensuring that the joint can withstand significant levels of compressive loading over many years of use.

Changes in the metabolism of the cartilage alters the way in which joint loads are transmitted to the underlying bone. Eventually, the cartilage fragments and breaks down. At that point, the underlying bone fails to properly function as a “shock absorber.” That is why osteoarthritis has been called a “wear and tear” disease. In reality, the fraying of cartilage is accompanied by attempts to repair the damage by cartilage cells, but the inbalance caused by inflammation in the joint that accompanies the breakdown of cartilage prevents repair from occurring properly. Eventually, the cartilage is no longer functional and the joint must be replaced by a prosthesis.

Experimental therapies designed to be eventually employed for the treatment of osteoarthritis in man are targeted at restoring normal joint function. Some experimental therapies being tested in animal models of osteoarthritis are designed to inhibit the chemical mediators, called cytokines, that stimulate inflammation, while other experimental strategies are focusing on the enzymes that destroy the cartilage itself. Still another tactic is related to stimulating cartilage repair by employing principles of gene therapy. In that strategy, the genes responsible for stimulating cartilage growth and/or repair are transferred to the affected joint where the proteins encoded by these genes are produced at a stable rate. Cartilage cell transplantation has also been experimentally tested in animals and current trials in man are currently underway. Many of these experimental studies appear to reduce the progression of osteoarthritis experimentally induced in animals. Hopefully, in the not to distant future, some of these experimental therapies will reach the marketplace and join the already established armamentarium of medical therapies now employed for treating osteoarthritis.

to be continued..