Following up on the previous blog post covering Fibromyalgia, we will be covering another rheumatic condition, rheumatoid arthritis (RA). Not the most common condition treated by Osteopaths but an important one non-the less.
What is it?
Rheumatoid arthritis is what is known as a chronic condition and is categorised as being a sero positive spondyloarthropathy (geeky way of saying an autoimmune condition that causes your body to produce an inflammatory response against substances that are naturally present).
RA causes pain, swelling and stiffness in the joints and effects both sides of the body at the same time (bilaterally) for example; if RA affects somebody’s wrists then it will affect both wrists not just one. People suffering with RA commonly suffer from stiffness in the morning which lasts longer than 1 hour and begins to improve with movement. Early stage RA often affects the wrist and fingers before other joints, however other joints such as the knees can be affected too.
Osteoarthritis (OA) (The most common form of arthritis caused by wear and tear of the joints) also causes joint pain and stiffness but generally doesn’t have much swelling and symptoms progress slowly. Rheumatoid arthritis however causes symptoms to present relatively rapidly over several weeks or months.
Patients suffering some RA, experience flair ups and periods of remission where their symptoms disappear for a length of time. It is experienced in women more than men and people who smoke are further susceptible to the condition if already genetically predisposed.
What happens in the joints affected by rheumatoid arthritis and osteoarthritis?
Inflammation! Inflammation takes place around the synovium of the joint which makes the joint go red and feel swollen and hot. The pain experienced is due to cells of the body’s immune response, irritating small nerve that supply the joint. Additionally, the swelling from the inflammation causes the capsule around the joint (which is like a protective sack that offers protection and stability for the joint) to stretch, which also triggers a pain response.
OA on the other hand occurs when there is a disruption of the normal cartilage structure and the maintenance of the cartilage. OA effects not only the articular cartilage but also the other periarticular tissues around the cartilage. The cause of OA is a complex blend of hereditary and environmental factors which cause physical and chemical disruption in the joint. The effects of which are commonly pain and the inability of the joint to function healthily.
Osteopathy, exercise & diet
Osteopathy can help both RA and OA using articulation and massage techniques. Treatment is specific to the patient but often involves gently articulating the joint and stretching muscles associated with the joint. Techniques such as traction of the joint allows the joint to flush with synovial fluid, lubricating itself and reducing the friction and inflammation. Osteopaths will also aim to facilitate the function of other joints that work closely with the symptomatic joint.
Exercise and maintaining joint mobility is essential for the management of RA and maintaining treatment effects. Osteopaths will develop a specific exercise program to help maintain joint function and aid joint health allowing for a healthy active lifestyle. Joint range of motion will be encouraged through the use of resistance bands, light free weights to traction joints on your own and stretches to release the strain of the muscles on the joint.
Foods that encourage a reduction in inflammation such as oily fish, dark green vegetables and olive oil are also advised. Following a diet rich in these foods (The Mediterranean diet) will benefit all areas of your life and help take the edge off rheumatic flair ups. I will upload a document to facebook and instagram which I made whilst on a nutrition course at University with Dr Catherine Sanderson, which outlines foods that are naturally anti-inflammatory and recipes they can be incorporated into.
What is it?
Fibromyalgia (FM) (Myalgia meaning pain in muscles) is a chronic condition that affects up to 8% of the population. It is a disorder which is most common in females and its prevalence increases with age. Symptoms of the condition can be described as widespread musculoskeletal pain (usually effecting; the neck, buttocks, shoulders, arms and upper back) & aching which intensifies under human touch and can cause muscle spasm. Additionally, there is the presence of multiple “tender points”, disturbed sleep and fatigue as well joint stiffness in the morning which can last for over an hour.
Today, the cause of fibromyalgia is still somewhat an unsolved mystery. However, it is considered to have multifactorial roots, stemming from anxiety, physical or mental trauma and sleep disturbance. Although it is considered a rheumatic condition, it does not originate from an inflammatory response and may be related to chemical changes in the way the body transmits its pain signals.
Fibromyalgia interests me as it is difficult to diagnose, varies in severity and sometimes follows peculiar symptom patterns. It can also debilitate and considerably lower a person’s quality of life. It is a diagnosis which is becoming increasingly frequent in patients presenting to Osteopathic practices, yet still extremely misunderstood and underestimated.
Depression & stress
One of its peculiar characteristics, is that 70% of patients diagnosed with fibromyalgia, also suffer from depression. Referring to the Osteopathic principle “structure governs function” or as I previously discussed in a post “function governs structure”, it is unclear whether depression triggers a response which leads to symptoms of fibromyalgia or whether fibromyalgia leads to symptoms associated with depression. An example would be; someone suffering with pain due to fibromyalgia may become predisposed to the negative emotions of depression due to the constant battle against pain. Alternatively, depression may heighten the bodies sensitivity to pain.
It’s also possible that there is a stress related link. This concept is becoming ever more plausible, as patients diagnosed with FM also commonly suffer from abdominal pathologies such as irritable bowel syndrome, chronic fatigue syndrome and multiple chemical sensitivity. Some of which are common even in non-sufferers during high periods of stress. Changes in the hypothalamic pituitary axis, a key component of the stress adaptation response have also been detected in patients with fibromyalgia. This disturbance leads to increased stress induced symptoms e.g. IBS, anxiety etc.
In my experience of treating patients with Fibromyalgia, patients are often able to touch the painful area themselves with sufficient pressure, whereas they feel the pain more when someone else touches the area, even if the pressure is less. Sometimes to a point where they will scream out or attempt to avoid being touched. I believe, this points further to a psychological link between anxiety and pain.
A study conducted by Kaplan et al, investigated “The impact of a meditation-based stress reduction program on fibromyalgia” and used patient feedback in the form of pain ratings, sleep, fatigue and feeling refreshed in the mornings. Results found that all participants showed improvements, with 51% indicating a moderate to high improvement after a meditation based program.
Osteopaths take a detailed case history and are encouraged to discuss the topic of stress with their patients. Specifically, those they feel may benefit from finding a coping strategy, or lifestyle modification. Although stress is a complicated subject itself, certain measures can be taken to help relieve the burdens of life. Simple things such as exercise, meditation, taking part in activities you enjoy (going out with friends, or fishing), talking to someone about your stress and making sure you express yourself to your employer If you feel workload is becoming too much, can really make a difference.
The mechanism behind the pain experienced with fibromyalgia is not typical of the pain mechanism of other conditions as no structural change or injury need occur for pain to be felt e.g. no fracture, disc dysfunction of muscular strain. Changes in the pain processing mechanisms may result in pain becoming a chronic phenomenon. Central sensitisation, diminishing of the inhibitory pain pathways and the alteration in neurotransmitters, can all cause a lowering effect on the threshold of pain and amplification of normal sensory signals. This means that every day stimuli, such as being patted on the back or putting on clothes, results in the brain feeling pain around the location of contact.
A study published in the Journal of the American Osteopathic Association (JAOA) investigating Osteopathic treatment in conjunction with medication for FM patients, used a pain threshold test, participant pain rating scale and self-evaluation questionnaire as outcome measures to distinguish whether medication combined with Osteopathy held more efficacy over medication alone for lowering pain in fibromyalgia patients. Results found that those who used both medication and Osteopathic techniques combined, gained more relief from pain than those on medication alone.
Management of Fibromyalgia
A journal article “Fibromyalgia—Management of a misunderstood disorder” states that the patients understanding of the condition is crucial in overcoming it and controlling the pain. Osteopaths are trained in the skill of differential diagnosis and are experts at spotting and testing for the signs and symptoms of conditions such as fibromyalgia syndrome. You can use an Osteopath to gain information and clarification if you suspect or have previously been diagnosed as having FM. Osteopathic treatment and advise will offer relief and management skills as well as someone to talk to and question.
Things to do if you’re suffering from fibromyalgia or know someone who is:
Gamber, R., Shores, J., Russo, D., Jiminez, C. and Rubin, B. (2002). Osteopathic manipulative treatment in conjunction with medication relieves pain associated with fibromyalgia syndrome: results of a randomized clinical pilot project. The Journal of the American Osteopathic Association, 102, pp.321-325.
Hare, B. and Okifuji, A. (2013). Management of Fibromyalgia Syndrome: Review of Evidence. Pain and Therapy, 2(2), pp.87-104.
Jahan, F., Nanji, K., Qidwai, W. and Qasim, R. (2012). Fibromyalgia Syndrome: An Overview of Pathophysiology, Diagnosis and Management. OMAN Medical Journal, 27(3), p.192.
Patterson, E. (2007). Fibromyalgia—Management of a misunderstood disorder. Journal of the American Association of Nure Practitioners, 19(7), pp.341-348.
People suffering from impingement often describe a pinching, aggravating, sometimes sharp pain in the shoulders during movements. This is caused by the tendon of the supraspinatus muscles being compressed between the acromion process, head of the humerus and the coracoclavicular ligament, which make up the "sub acromial space"
I see a lot of impingement both in private practice as an Osteopath & at the gym! It is often attributed to increased activity, particularly overhead activities like throwing, weightlifting and swimming. Other structures in the same area can also called pain. A subacromial bursa is a little fluid filled sack which acts as a buffer, lubricator and as a way of decreasing friction in the joint. Bursa can become inflammed and cause pain. Impingement in this area often goes hand in hand with bursitis. Lowering one, will probably aid in lowering the other, due to them both being aggravated by activity and inflammation.
Despite the prevelance of impingement being huge, most people don't realise that there can be a genetic predisposition to impingement, caused by the shape of your acromion process (extension of the scapula that you can feel yourself, distally next to your collar bone). There are 4 classification types of process as shown in the picture below! Types 2 and 3 are curved or hooked downwards, narrowing the subacromial space and rubbing against the tendon as it moves through the space. The orientation of the process is illustrated with the red dotted lines
If you're one of those people who feel like you do all the mobility, warming up, stretching and ice packs possible, yet still get twice as much impingement as your friend who does the same activities, then perhaps your morphology holds the answer! .
Lowering the rate of inflammation is crucial to speeding up the rate of recovery as it directly increases the space available for the tendon and bursa. Mobilisation, articulations, soft tissue work and rotator cuff strengthening exercises are all part of an Osteopaths treatment regime. Non-steroidal anti inflammatory drugs such as ibuprofen may aslo help reduce the inflammation temporarily, giving you relief and time to do the corrective exercises prescribed by Niall. Always check with your GP or pharmacist before starting NSAIDs.