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Keep Active to Manage Joint Pain

By Christie Aschwanden | October 30, 2020 | The Washington Post

Your knees ache, your neck cracks or maybe there's a twinge in your hip. If you're suffering from painful joints, you're not alone. Genetics, obesity and prior injury can predispose someone to joint pain, but arthritis is by far the most common cause, and more than 54 million Americans experience some form of it, according to the Centers for Disease Control and Prevention.

Osteoarthritis is the most common type, and it happens when the cartilage in the joint breaks down and the surrounding bone develops inflammation. Osteoarthritis becomes more common with age, but you don't have to just grit your teeth and suffer through it, says Jason McDougall, a professor at Dalhousie University in Canada who specializes in arthritis and pain research.

An array of strategies are available for treating joint pain, ranging from physical therapy to pain medications, injections and surgery, but one of the most effective ways to manage joint discomfort is one that can seem counterintuitive: Keep moving.

If you're feeling pain in your joints, you might be inclined to lay off them, but that's one of the worst things you can do, says A. Lynn Millar, a physical therapist and fellow emeritus at the American College of Sports Medicine.

It's a vicious cycle — it hurts, so you stop moving the area that's painful, but "immobilization actually causes deterioration in the joints," Millar says. Hence the saying among physical therapists, "Motion is lotion." Movement brings nutrients to the joints and keeps them healthy, Millar says. "Everyone wants a magic bullet," she says, and physical activity is the closest thing we have.

Even if you've had an X-ray or MRI that shows arthritic changes in your joint, that shouldn't dissuade you from exercising. "Your structure isn't your destiny," says Greg Lehman, a Toronto-based physiotherapist, chiropractor and clinical educator in physiotherapy.

Turns out, the findings on an imaging test aren't a good indicator of pain, he says. Imagine going to a ski area and finding all the people 50 and older who were skiing around enjoying themselves. Lehman says that if you gave these skiers a scan of their knees and hips, the "vast majority of them" would have structural changes in their knee and hips without even knowing about it.

For a 2012 study, researchers took MRIs of the knees of 710 people 50 and older and found that nearly 90 percent had at least one feature of osteoarthritis on the MRI, irrespective of whether they had knee pain.

An X-ray or MRI is not a good indicator of whether someone has pain, Lehman says. "It's not that those changes you can see in a joint or tendon or muscle are irrelevant," he says, but they are not very good at predicting how someone feels or what they can do.

Joint pain is complicated, and it's not just about what's going on with your bones and ligaments, but also how your nervous system is interpreting the signals it's receiving.

Chemical mediators, such as enzymes and neuropeptides, released into the joint when someone has arthritis can sensitize the nerve endings around it to make them more active than normal. "These signals are translated by the brain as pain," McDougall says.

Researchers are just starting to characterize the different kinds of chemical mediators that might be involved in these pain signals, he says.

Even when it hurts, "putting more stress on the joint in the form of physical activity does not lead to more degeneration," Lehman says. Moving the joints can help by promoting blood flow to deliver nutrients and the circulation of synovial fluid, which can act as a lubricant for the joint.

Most people with joint pain respond well to physical therapy and an activity program, Lehman says, and studies have shown that exercise programs can reduce pain and increase physical function for people with osteoarthritis in their hips.

Low impact activities such as swimming, biking, walking or using an elliptical trainer can be gentle ways to move your joints, but even something as high impact as running can be fine for people who can tolerate it, Millar says.

A study that followed nearly 500 runners over a period of 14 years found that "there was no progressive increase in musculoskeletal pain in older adults who participated in regular vigorous exercise, including running, compared with those who did not." Arthritis does not progress any faster in people who run than in people who don't, Millar says, and people with arthritis who are regular runners report less pain and maintain function longer than people who don't run.

Strength training can also help by building up the muscles around the joint so they're better able to deal with the force coming through the joints. You don't have to lift heavy weights to reap benefits, Millar says. Even doing some simple leg lifts or bending and straightening your legs can yield benefits for your knees and hips, for instance.

If you're carrying extra weight, losing even as little as a single pound can make a noticeable difference.

Research has show that one pound of weight on the body equates to four pounds of weight across your knee, says Antonia Chen, an orthopedic surgeon at Brigham and Women's Hospital in Boston. "I tell my patients to celebrate losing one pound. Even one pound is four pounds off your joint and it will make you feel better."

Obesity is a well-known risk factor for joint pain, and it's not just the added stress on joints that comes with the extra weight. Researchers are starting to see that obesity can be associated with changes in metabolism and the microbiome that may be related to chronic pain, McDougall says.

"Bugs in our stomachs talk to the nerves in our bodies," McDougall says. And research suggests being overweight may also increase inflammatory markers in the blood that could make joint inflammation worse, Millar says.

Nonsteroidal anti-inflammatory drugs such as ibuprofen and naproxen are the go-to medications for managing arthritic pain, but they're no panacea.

"Most of the time, they work for a little bit, and then they stop working," says Ali Guermazi, a professor of radiology and medicine at Boston University School of Medicine. They also have side effects such as internal bleeding, especially when taken long-term, Guermazi says. For people who cannot take NSAIDs because of side effects, acetaminophen (Tylenol) can also be an option. In severe cases, opioids may be used short term, but they aren't a great option and should be carefully managed because of addiction risk, Guermazi says.

When pain meds aren't helping, corticosteroid injections to the joint are sometimes used, but they're not without risks. Although they can offer relief for many patients, they can also damage the cartilage in the joint, Chen says. Guermazi's research has found that a small subset of patients who receive corticosteroid injections for joint pain experience rapid bone degeneration in the joint. "People are taking steroids thinking it's a good treatment," Guermazi says, "but there is no study that I can think of that is showing a long-term pain relief from steroids. It's all temporary."

A pain management specialist might be needed for severe cases where the pain isn't responding to any of these other treatments, Chen says. Options include numbing agents to block the nerve or nerve ablation, a treatment that uses heat or cold to destroy nerve tissue that's involved in the pain.

With cannabis being legalized in many parts of the country, cannabinoids (compounds derived from the cannabis plant) are becoming another option for treating pain. McDougall's group has studied the use of cannabinoids for controlling joint pain. "We have found that they can be highly effective and relatively safe and well-tolerated by patients," he says.

The nonintoxicating cannabis derivative called cannabidiol, or CBD, is one type to try for those with joint pain, McDougall says. "CBD won't make you high. It might make some people feel a little sleepy," he says, adding that drowsiness might be a good thing for people who aren't sleeping well because of pain.

Tetrahydrocannabinol, or THC, the cannabinoid responsible for marijuana's famous high, also has anti-inflammatory properties, studies have found. Whether that's an option depends on legality in your state, and some patients will tolerate THC and the "high" it can produce better than others, McDougall says. "It's a personal preference. The patient should be driving what feels good for them."

When all else fails, joint replacement surgery is a final option.

"The recommendation is that you should try to put it off as long as possible," McDougall says. Although a joint replacement can be life-changing in a good way for some patients, it's not a magical cure. A small 2005 study involved in-depth interviews with 25 people who had undergone total knee replacements and found that most of them reported a "good" outcome, but "further discussion revealed concern and discomfort with continuing pain and mobility difficulties," the authors wrote.

Treatment or torment? Some knee replacements fail to solve chronic pain.

Chen says that it's important to have realistic expectations for the surgery: "It's not like you get the joint replacement and you're up and jumping around. It can take up to one full year to recover."

Chen specifically doesn't recommend to her patients several popular treatments. One is a kind of injection, called "gel shots," or viscosupplementation, where a gel-like fluid is injected into the joint to increase cushioning. Chen says that this treatment has "demonstrated minimal benefits" and the injections are not supported by the American Academy of Orthopaedic Surgeons (AAOS)

Glucosamine and chondroitin sulfate supplements are another popular joint pain treatment she tells her patients to skip. The evidence that they help is so slim, she says, that in 2013 the AAOS put out a statement that said, "don't use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee." The supplements "do not provide relief for patients."

There's no way around it - exercise remains the bedrock for joint health. "If your knees are sore, it doesn't always mean you should stop what you're doing," Lehman says.

Doing the activities you love can be therapeutic, not just mechanically and biologically for the joint, he says, but because you're moving again and that can be emotionally and psychologically healing, too.


Aschwanden is author of "Good to Go: What the Athlete in All of Us Can Learn From the Strange Science of Recovery."

This content is licensed with permission. Read more in health and wellness at www.washingtonpost.com.


Christie Aschwanden
The Washington Post