How to Keep Bones Healthy and Prevent Fractures From Osteoporosis

By Drs. Ting Zhang and Jianying Zhang

Because there are typically no symptoms until the first fracture occurs, osteoporosis is considered a silent disease. Some call it a silent killer.

Osteoporosis is a bone disease characterized by decreased bone density and strength, leading to fragile, brittle bones that increase the risk of fractures, especially in the spine, hips and wrists.

The National Osteoporosis Foundation estimates that more than 10 million Americans have osteoporosis. Another 43 million have low bone mass, which is the precursor to osteoporosis. By 2030, the number of adults with osteoporosis or low bone mass is estimated to increase by more than 30%, to 71 million.

The reasons for the increase include lifestyle issues, particularly smoking, lack of physical activity and alcohol abuse. Our aging population, along with the insufficient attention paid to this disease, are also why osteoporosis is on the rise.

If you are older, it may be discouraging to read those statistics. But as orthopedic specialists who have studied this disease, we know that osteoporosis is not inevitable. The key to having healthy bones for a lifetime is to take some simple preventive measures – and the earlier, the better.

Although the symptoms are not obvious early on, certain signs will indicate your bones are becoming weaker. The most serious complications of osteoporosis are fractures, which can lead to chronic pain, hospitalization, disability, depression, reduced quality of life and increased mortality. Worldwide, osteoporosis causes nearly 9 million fractures annually. That’s one osteoporotic fracture every three seconds.

Height Loss a Common Symptom

Minor bumps or falls may lead to fractures, especially in the hip, wrist or spine. These types of fractures are often the first sign of the disease.

If you notice that you’re getting shorter, the cause could be compression fractures in the spine; this too is a common symptom of osteoporosis.

Although it’s typical for most people to lose height as they age – about 1 to 1½ inches (2.5 to 3.8 centimeters) over a lifetime – those with osteoporosis who have multiple spinal fractures could lose 2 to 3 inches or more in a relatively rapid time frame.

Curved posture, or noticeable changes in posture, may lead to a hunched back, which could be a sign that your spine is weakening and losing density.

Persistent back pain is another indicator – this too is the result of tiny fractures or compression of the spine.

Calcium and Vitamin D

Osteoporosis cannot be completely cured, but certain lifestyle and dietary factors can lower your risk.

Calcium and vitamin D are essential for bone health. Calcium helps maintain strong bones, while vitamin D assists in calcium absorption. Women over age 50 and men over 70 should consume at least 1,200 milligrams of calcium daily from food and, if necessary, supplements.

The easy way to get calcium is through dairy products. Milk, yogurt and cheese are among the richest sources. One cup of milk provides about 300 milligrams of calcium, one-fourth of the daily requirement. If you are vegan, calcium is in many plant-based foods, including soy, beans, peas, lentils, oranges, almonds and dark leafy greens.

Adults should aim for two to three servings of calcium-rich foods daily. Consuming them throughout the day with meals helps improve absorption.

Vitamin D is obtained mostly from supplements and sunlight, which is the easiest way to get the recommended dose. Your body will produce enough vitamin D if you expose your arms, legs and face to direct sunlight for 10 to 30 minutes between 10 a.m. and 3 p.m., two to three times a week.

Although it’s best to wear short-sleeve shirts and shorts during this brief period, it’s okay to wear sunglasses and apply sunscreen to your face. Sunlight through a window won’t have the same effect – glass reduces absorption of the UV rays needed for vitamin D production. People with darker skin, or those living in less sunny regions, may need more sunlight to get the same effect.

If a doctor has given you a diagnosis of osteoporosis, it’s possible the calcium and vitamin D that you’re getting through food and sun exposure alone is not enough; you should ask your doctor if you need medication.

Regular Exercise Important for Women

Regular exercise is an excellent activity that can help stave off osteoporosis. Weight-bearing exercises, such as brisk walking, jogging and dancing, are great for increasing bone density. Strength training, such as lifting weights, helps with stability and flexibility, which reduces the risk of falling.

Aim for 30 minutes of weight-bearing exercise at least four days a week, combined with muscle-strengthening exercises at least twice a week.

Particularly for women, who lose bone density during and after menopause, regular exercise is critical. Working out prior to menopause will reduce the risk of osteoporosis in your later years.

And avoid harmful habits – smoking and heavy alcohol consumption can weaken bone density and increase the risk of fractures.

Fall prevention strategies and balance training are crucial and can help reduce the risk of fractures.

Screening and Treatment

Women should start osteoporosis screening at age 65, according to the U.S. Preventive Services Task Force. Men should consider screening if they have risk factors for osteoporosis, which include smoking, alcohol use disorder, some chronic diseases such as diabetes, and age. Men over 70 are at higher risk.

Medical imaging such as a bone density scan and spinal X-rays can help confirm osteoporosis and detect compression fractures. These basic tests, combined with age and medical history, are enough to make a clear diagnosis.

Managing osteoporosis is a long-term process that requires ongoing commitment to lifestyle changes. Recognizing the early warning signs and making these proactive lifestyle changes is the first step to prevent the disease and keep your bones healthy.

Ting Zhang, MD, is a Research Scholar of Orthopedics at the University of Pittsburgh.

Jianying Zhang, PhD, is a Research Professor of Orthopaedic Surgery at the University of Pittsburgh.

This article originally appeared in The Conversation and is republished with permission.

The Best Remedy for Low Back Pain? Go for a Walk

By Pat Anson, PNN Editor

Almost everyone experiences low back pain at some point in their lives. Repeated episodes of acute low back pain are also very common, with 70% of people who recover from one episode having another one within a year.

Is there any reliable way to end the cycle before low back pain turns chronic?

A new Australian study suggests the best and most cost-effective way to keep low back pain from returning is simple: Go for a walk.

Researchers at Macquarie University’s Spinal Pain Research Group enrolled 701 adults who recently recovered from low back pain in a clinical trial. Half were randomly assigned to an individualized walking and education program led by a physiotherapist for six months; while the other half served as a control group, receiving no treatment at all.

Participants in the walking group were encouraged to walk five times a week for at least 30 minutes, but were free to do more or less. Most gradually increased their walking, with the average amount of walking time doubling in the first 3 months.

Both groups were then followed for at least one year, with researchers tracking any recurrences of low back pain lasting at least 24 hours that were severe enough to limit daily activities.

The study findings, recently published in The Lancet, show that participants in the control group had a recurrence of low back pain after 112 days on average, while those in the walking group were pain free nearly twice as long, a median of 208 days. The overall risk of having a new episode of low back pain fell by 28% for the walkers.

“We don’t know exactly why walking is so good for preventing back pain, but it is likely to include the combination of the gentle oscillatory movements, loading and strengthening the spinal structures and muscles, relaxation and stress relief, and release of ‘feel-good’ endorphins,” said senior author Mark Hancock, PhD, a Professor of Physiotherapy at Macquarie University.

"And of course, we also know that walking comes with many other health benefits, including cardiovascular health, bone density, healthy weight, and improved mental health.”

Another benefit is cost. A significantly higher percentages of participants in the control group sought treatment from massage therapists, chiropractors, physiotherapists and other healthcare providers.

While it’s hard to assign a dollar number to quality of life, researchers estimate the total cost-effectiveness of walking vs. no treatment at AU$7,802. In U.S. dollars, that’s $5,190.    

“It not only improved people’s quality of life, but it reduced their need both to seek healthcare support and the amount of time taken off work by approximately half,” said lead author Natasha Pocovi, PhD, a Postdoctoral Fellow at Macquarie University.

In 2023, the World Health Organization (WHO) released its first guideline for managing low back pain, recommending treatments such as exercise, physical therapy, and patient education. Pocovi and her colleagues say a regular program of walking would be a cheaper alternative to joining a gym or hiring a trainer.

“The exercise-based interventions to prevent back pain that have been explored previously are typically group-based and need close clinical supervision and expensive equipment, so they are much less accessible to the majority of patients,” Pocovi said. “Our study has shown that this effective and accessible means of exercise has the potential to be successfully implemented at a much larger scale than other forms of exercise.”

Low back pain is the leading cause of disability worldwide. According to a 2022 Harris Poll, nearly 3 out of 10 U.S. adults live with chronic low back pain. On average, the typical back pain sufferer seeks relief from at least three healthcare providers, with many treatments proving ineffective.   

Physical Activity Can Protect Against Chronic Pain

By Pat Anson, PNN Editor

Chronic pain sufferers are often told that physical activity and exercise can help reduce pain and improve quality of life. Now there is evidence that even light or moderate activity can have a protective effect against pain that lasts for years.

“We found that people who were more active in their free time had a lower chance of having various types of chronic pain 7-8 years later,” says Anders Årnes, a doctoral fellow at The Arctic University of Norway and University Hospital of North Norway.

“This suggests that physical activity increases our ability to tolerate pain and may be one of the ways in which activity helps to reduce the risk of developing severe chronic pain.”

Årnes is the lead author of a study, recently published in the journal PAIN, that found even light physical activity was associated with a 5% lower risk of developing chronic pain that lasts at least three months. More rigorous activity was associated with a 16% reduced risk of widespread moderate-to-severe chronic pain.

The findings are based on data from a large health survey -- the Tromsø Study --- in which over 6,800 Norwegians answered questions about their overall health, pain levels and physical activity, first in 2007-2008 and then again in 2015-2016. The average age of participants was nearly 55. Most reported some form of chronic pain, but only 5% had widespread moderate-to-severe chronic pain.

In a 2023 analysis of the survey data, Årnes and his colleagues found that people who reported vigorous physical activity had significantly more pain tolerance than those with a sedentary lifestyle.

Pain tolerance was assessed by how long they could keep a hand immersed in cold water that was a few degrees above freezing (3 degrees Celsius or 37.4 degrees Fahrenheit).

In their new follow-up study, researchers found that the ability to tolerate pain – or at least cold water -- plays a modest role in the protective effect of physical activity (PA).  

Stina Grønbech/Tromsøundersøkelsen

“We estimate that higher PA levels predict lower risk of chronic pain, with indications of a small mediated effect on this risk through cold pain tolerance for moderate-to-severe chronic pain states,” researchers reported.

Of course, many people with severe chronic pain are unable to exercise or fear that it will only make their pain worse. Previous studies have found that low-impact exercise programs, such as stretching while sitting in a chair, can ease pain from arthritis and other muscle and joint conditions.

“Physical activity is not dangerous in the first place, but people with chronic pain can benefit greatly from having an exercise program adapted to help them balance their effort so that it is not too much or too little,” said Årnes. “A rule of thumb is that there should be no worsening that persists over an extended period of time, but that certain reactions in the time after training can be expected.”

Even moderate physical activity can stimulate the production of endorphins and endocannabinoids – hormones and lipids naturally produced by the body -- which can relieve pain and inflammation. Regular exercise can also help us lose weight, reduce the risk of heart disease, and boost overall health.  

Can Exercise Help Relieve Shoulder Pain?

By Drs. Marc-Olivier Dubé, François Desmeules and Jean-Sébastien Roy

It is estimated that close to 70 per cent of the population will experience shoulder pain at some point in their lives.

This pain would not pose a problem if it disappeared as quickly as it appeared. Unfortunately, shoulder pain tends to persist over time. In half of patients, the pain lingers or reoccurs one year after its initial appearance. It can even persist for several years in some cases.

Approximately 70 per cent of shoulder pain episodes requiring consultation with a health-care provider can be identified as rotator cuff related shoulder pain. This refers to pain and loss of function in the shoulder, mainly during movements requiring the arm to be lifted. Although a number of effective options are available to patients, a third of them will not experience any significant improvement in their condition, regardless of the interventions used.

There are several possible reasons for this limited success. Exercise selection and some psychological and contextual characteristics specific to each individual have been identified as potential hypotheses.

As experts in the field of shoulder pain, we propose to shed light on the effectiveness of various interventions for the management of shoulder pain, and the role that some variables may play in the resolution of this pain.

Our research team therefore set out to find out:

1. Whether one type of exercise should be prioritized over another in the management of shoulder pain.

2. Whether the addition of exercises (the pet peeve of many people who consult a rehabilitation provider) lead to additional benefits compared with an intervention comprising only of education and advice to foster pain self-management.

3. Whether some psychological and contextual characteristics, such as participants’ expectations of the intervention effectiveness and pain self-efficacy, are associated with a better prognosis.

Pain self-efficacy is the level of confidence someone has in their ability to carry out their activities and achieve their goals despite pain.

What We Found

In our new study published in the British Journal of Sports Medicine, 123 people with shoulder pain lasting for more than three months were randomly assigned to one of three 12-week interventions:

1. Education

2. Education combined with motor control exercises

3. Education combined with strengthening exercises

Questionnaires were used to monitor changes in participants’ condition over time, particularly in terms of their pain and functional capacity.

Before the start of the intervention, we also used questionnaires to measure participants’ expectations of the effectiveness of the intervention they were about to receive, as well as their level of pain self-efficacy.

Education: Participants in this group received two sessions of education and advice with a physiotherapist. The information was about the shoulder and pain, and the advice included strategies for the self-management of their condition.

Participants were also told about the importance of being active and adopting a healthy lifestyle to optimize the management of persistent pain, including proper diet, hydration, stress management and sleep hygiene.

Finally, participants were asked to watch six short videos on these themes. Here’s one:

After viewing, they were asked to identify the aspects they felt were important and those that raised questions in order to discuss them with the physiotherapist.

Education combined with motor control exercises: Participants in this group completed a 12-week program that combined education with exercises.

The exercises included modifications in the way they performed their movements to enable them to move their arm with less pain. These modifications were integrated with exercises reproducing gestures involving the shoulder during daily activities.

Education combined with strengthening exercises: Participants in this group received the same education component, along with  a shoulder muscle strengthening program to be performed daily for 12 weeks.

At the end of the study, participants in all three groups showed improvements in pain and function. However, the addition of exercises (motor control or strengthening) to the education intervention did not lead to additional benefits.

People recruited into the study whose symptoms were considered resolved following the 12-week intervention had more positive expectations regarding the effectiveness of their intervention and had higher levels of pain self-efficacy.

Key Takeaways

Adding strengthening or motor control exercises to an educational intervention did not result in additional benefits compared to an approach based solely on education and advice. For some people with persistent shoulder pain, education and advice focusing on pain self-management may be sufficient to promote symptom resolution.

Exercise, in any form, remains a highly relevant intervention for shoulder pain management, as well as for maintaining independence and optimizing long-term health.

Participants’ pain self-efficacy and expectations of the effectiveness of the intervention they receive may play a role in the prognosis of their shoulder pain.

When you’re experiencing shoulder pain, it can be beneficial to temporarily reduce certain activities that can aggravate your pain. However, it’s important not to delay gradually reintegrating these activities into your daily routine.

The presence of pain, especially when it persists over time, is not necessarily a sign that your condition is deteriorating. It could simply indicate that the gestures or activities performed exceed the shoulder’s current ability to tolerate the load imposed on it.

In any case, don’t hesitate to consult a health professional, such as a physiotherapist, who will be able to help you “shoulder” the responsibility of managing your condition.

Marc-Olivier Dubé, PhD, is a Physiotherapist and Postdoctoral researcher in rehabilitation at Laval University.

Francois Desmeules, PhD, is a professor in physiotherapy and musculoskeletal health, School of Rehabilitation, University of Montréal.

Jean-Sébastien Roy, PhD, is a professor at the School of Rehabilitation Sciences, Laval University.

This article originally appeared in The Conversation and is republished with permission.

Most Americans and Canadians Use OTC Drugs and Self-Care for Pain Relief

By Pat Anson, PNN Editor

Most Americans and Canadians who experience pain prefer over-the-counter drugs, exercise and bed rest over prescription pain medication, according to a large new survey. A surprising number of respondents said they do nothing or simply accept their pain.  

The online survey, led by a research team at Ontario’s Western University, asked over 4,100 adults in 2020 what types of treatment, medication or self-care methods they use to deal with or prevent pain. Respondents were given ten different pain management techniques to choose from.

The survey findings, published in the journal Innovation in Aging, show that most people use a combination of methods for pain relief, along with a healthy dose of stoicism. Over half said they use OTC pain relievers, often in combination with self-care techniques such as exercise, bed rest or physical therapy.

Over 41% selected “just live with pain” and 10% chose “do nothing” – which essentially amounts to pain acceptance.

Only one in four (24%) said they use prescription pain medication. Not surprisingly, respondents who said they had high pain levels were over four times as likely to use a prescription drug  

SOURCE: INNOVATION IN AGING

The responses from Americans and Canadians were similar, with one notable exception. Americans were twice as likely than Canadians to turn to alcohol to dull their pain, with just under 4% of Canadians using alcohol as a pain management strategy, compared to almost 8% in the U.S. Alcohol use jumped to 21% for those with the highest levels of pain in both countries.

"Our research shows that using alcohol to treat pain is somewhat common, unfortunately. Previous research has shown that is not only ineffective at treating pain, but it can actually be counterproductive," said lead author Anna Zajacova, PhD, a demographer and sociology professor at Western University. "Our study also indicates that there is likely a lot of unmet need for better treatment options for people to manage their pain."

Zajacova and her colleagues noted that high alcohol use in the U.S. may be a reflection of more limited access to healthcare than in Canada, which has a national health system.

"What we learned from this survey is that people aren't necessarily just visiting their doctor to manage their pain, and it's important to understand the non-medical and non-pharmacological strategies that people are using, for better or for worse," said Zajacova.

A major weakness of the study, which the authors acknowledge, is that they did not differentiate between acute, short-term pain and chronic pain. They also didn’t ask if the prescription pain medication used was an opioid or non-opioid.

Regular Exercise Boosts Pain Tolerance

By Pat Anson, PNN Editor

People who remain physically active over a long period have much greater pain tolerance than those who are sedentary and don’t get much exercise, according to a large new study in Norway.

While exercise has long been touted as a way to ease or even prevent chronic pain, this particular study falls short in actually proving it, which we’ll get to later.

Researchers at University Hospital of North Norway analyzed data from 10,732 adults who participated in a large health survey -- the Tromsø Study --- that is conducted periodically in Norway. The researchers used data from two rounds of the study that were conducted seven years apart, one in 2007-2008 and the other in 2015-2016.

Most of the participants (79%) said they were either sedentary or engaged in only light exercise, while the remainder reported moderate or vigorous activity. About a third of the participants (32%) said they had chronic pain,

Pain tolerance was assessed by how long they could keep a hand immersed in cold water that was a few degrees above freezing (3 degrees Celsius or 37.4 degrees Fahrenheit).

The study findings, published in the journal PLOS ONE, showed that participants who reported vigorous physical activity in either round had significantly more pain tolerance than the couch potatoes who maintained a sedentary lifestyle in both rounds.

The good news for couch potatoes is that pain tolerance can be improved. As the chart below demonstrates, people who boosted their physical activity (PA) over time were able to keep their hands in cold water for longer periods, suggesting they have more pain tolerance.

source: plos one

“In summary, these findings suggest that becoming or remaining active at a level above being sedentary, or making a positive change in activity level, over time is associated with higher pain tolerance as opposed to being sedentary or making a negative change,” researchers reported. “Whatever you do, the most important thing is that you do something!”

Interestingly, having chronic pain did not influence the findings one way or another. Researchers found that chronic pain “does not significantly interfere” with the relationship between physical activity and pain tolerance. However, they were hesitant to draw a conclusion from that, saying the findings “might look different” if pain conditions were broken down into different diagnostic groups, instead of under one broad term under the label “chronic pain.”      

Even moderate physical activity is known to stimulate the production of endocannabinoids – cannabis-like substances naturally produced by the body -- which can relieve pain and inflammation. Regular exercise can also help us lose weight, reduce the risk of heart disease, and boost overall health.  

How to Live Longer and Healthier with Chronic Illness

By Barby Ingle, PNN Columnist

Have you ever wondered what living with chronic illness or a rare disease does to your lifespan? I have.

My primary care doctor recently conducted a seminar about living longer and healthier. He gave the attendees a great resource: a “health span” guide that outlines five ways to enhance your day-to-day life and live longer. The guide got me thinking. As a person with rare diseases and chronic pain, can they help me achieve my goal of living to 100 years old? 

Step 1 of the guide is to eat a Mediterranean-style diet. Studies show that people who eat a diet rich in fruits, vegetables, fish, whole grains, nuts and legumes live longer and have fewer instances of type 2 diabetes, obesity, heart disease and cancer.

I believe in individualized care for my health. As I have talked about in the past, I did microbiome testing to assess my gut health, using an at-home test made by a company called Viome. The results I received revealed that many of the fruits, veggies and nuts that I loved were not suitable for me because of my genetics. My DNA would rather have me eat a rack of lamb than a tomato!

I think getting that kind of detailed, personalized health information is better than following a one-size-fits-all diet.

Step 2 of the health span guide is to exercise often. It states that people who exercise between 2.6 and 4.5 hours per week have a 40% lower risk of dying. 

I have found that exercise means different things to different people. When I was younger, I was an athlete. Today, I cannot imagine doing a simple jumping jack. Nevertheless, moving as best we can each day, without going into a pain flare, sounds reasonable. That is what I strive to achieve.

I try to do what I can physically and not get too down on myself for the fatigue, pain and times when my body is dystonic. I hope that will be enough “exercise” to reduce the risk of other chronic illnesses, such as diabetes or dementia. I know people who have diabetes who were able to exercise, change their eating habits, and live longer. But my father, ten years after being diagnosed, still passed away early. 

Step 3 of the guide is to manage your stress and mental health. Those of us with rare and chronic conditions often have increased anxiety. Who wouldn’t be depressed learning how to live with a new normal? Chronic stress reduces life span and ages us faster from the chemicals and bodily changes that occur.

Step 4 of the guide is to make good sleep a habit, which is not easy when you have chronic pain. But a night with 7 or 8 hours of restful sleep can help reduce pain levels and lead to a better, more productive tomorrow.

When our sleep is disturbed long-term, it can affect our mood, organ function and contribute to an early death. I remember back in 2009, before I began infusion therapy, I tried many recommendations for better sleep, such as a warm drink before bedtime, having a set time to go to bed and wake up, and cutting out caffeine. After the infusions, when my pain was better managed, I realized just how bad my sleeping was and how much I needed 8 hours of sleep. Here are some tips for better sleep from the CDC.  

Step 5 of the guide is to build strong social circles. Having at least six different social connections each month has been associated with better health. I have found that people who are not chronically ill have difficulty understanding why we don't get better. They make comments like, "Are you still sick?" and "You’re still not feeling better yet?”

It is sad that it is harder for us to make and keep friends who are healthy and happy. A network of friends is essential for many reasons. This New York Times article on “How to Be a Better Friend” has some tips on how to improve our connections with others. 

I want to live longer and healthier, and to work towards it with good connections, preventative care and palliative care. We live in a great time when medical care and genetic testing are advancing, helping us live healthier. Being in the best shape possible to live past our potential expiration dates will help us enjoy our limited time here on earth. It all goes back to being the best you, so that you can fulfill your earthly purpose while participating in society. 

Living longer comes from individualized care and making the most of each aspect of your life. Changing how you live, respond, and act today can make your life longer and more meaningful.

Barby Ingle is a reality TV personality living with multiple rare and chronic diseases. She is a chronic pain educator, patient advocate, motivational speaker, and best-selling author on pain topics. Barby has received over 25 awards for her advocacy efforts. You can follow her at www.barbyingle.com 

‘No Pain, No Gain’ Approach Helps People With Peripheral Artery Disease

By Pat Anson, PNN Editor

“No pain, no gain” is a phrase that caught on in the 1980’s when fitness videos promoting aerobic exercise became popular. Most doctors today will say that’s bad advice, because physical pain during exercise could be a sign of a serious injury or health problem. Pain is your body’s way of warning you that something is wrong.  

But it turns out that pain and discomfort while walking for exercise may actually be a good thing for people with peripheral artery disease – PAD for short – a condition that occurs when arteries become narrow or clogged, reducing the flow of blood and oxygen throughout the body.

In a new study published in the Journal of the American Heart Association, researchers reported that people with PAD who experienced cramping, soreness, fatigue and other ischemic leg symptoms while walking may actually benefit from the pain.

“We were surprised by the results because walking for exercise at a pace that induces pain in the legs among people with PAD has been thought to be associated with damage to leg muscles,” said senior author Mary McDermott, MD, an Internal Medicine and Geriatric Professor at Northwestern University’s Feinberg School of Medicine. “Based on these results, clinicians should advise patients to walk for exercise at a pace that induces leg discomfort, instead of at a comfortable pace without pain.”

McDermott and her colleagues followed 264 mostly elderly people with PAD for 12 months, randomly assigning them to one of three groups. The first group walked at home at a comfortable pace; the second group walked at a faster pace that induced ischemic leg symptoms; and the third group did not walk for exercise.

Participants who walked were asked to exercise 5 days per week for up to 50 minutes, while wearing an ActiGraph, a device that monitored the intensity and duration of their walking.

After six months, researchers found that people who walked at a pace that induced ischemic leg symptoms walked significantly faster in daily life than those who did not exercise or walked at a comfortable pace without leg symptoms. They also performed better on a physical performance test that assessed their speed, strength and balance. The findings were similar after 12 months.

“This finding is consistent with ‘no pain, no gain’ with regard to walking exercise in PAD,” McDermott said in a press release. “Exercise that induces leg pain is beneficial, though difficult.

“We now are working to identify interventions that can make the higher intensity exercise easier -- and still beneficial -- for people with PAD.”

Between 8 and 10 million people in the United States have PAD. The condition disproportionately affects African-Americans, Native Americans and those with low socioeconomic status.

Previous research found that walking for exercise improves walking ability and walking distance for people with PAD. What remained unclear, until now, were the potential effects of walking at a pace that induced symptoms such as leg pain.

The American Heart Association and 24 other organizations recently launched the PAD National Action Plan, a guide to assist in the prevention of PAD complications, reduce cardiovascular risk, and improve quality of life for those living with the disease.

“PAD is a lifelong medical condition, but people with PAD can lead active and long lives,” said Joshua Beckman, MD, professor of medicine at Vanderbilt University. “If you notice walking is becoming more difficult, keeping up with others is hard, or you have pain when you walk, talk with a doctor and describe when it happens and how it feels.” 

A recent study found that walking for exercise is also beneficial for people with osteoarthritis, who experienced 40% less knee pain than non-walkers.

Walking Reduces Pain From Knee Osteoarthritis

By Pat Anson, PNN Editor

It may seem counterintuitive, but a new study suggests that walking may be the best medicine to reduce knee pain from osteoarthritis.

Nearly 40 percent of Americans over the age of 45 have some degree of knee osteoarthritis, a progressive joint disorder caused by inflammation of soft tissue, which leads to thinning of cartilage and joint damage. Osteoarthritis (OA) of the knee is not to be taken lightly, as studies have found that it is strongly associated with early death, high blood pressure, diabetes, elevated cholesterol and cardiovascular disease, particularly for women.

Moderate exercise like walking may help prevent all of those health problems.

In a multi-year study of 1,212 people over the age of 50, researchers at Baylor College of Medicine found that participants who walked for exercise at least 10 times had 40% less risk of developing frequent knee pain than non-walkers.

“Until this finding, there has been a lack of credible treatments that provide benefit for both limiting damage and pain in osteoarthritis,” said Grace Hsiao-Wei Lo, MD, assistant professor of Immunology, Allergy and Rheumatology at Baylor and lead author of the study published in Arthritis & Rheumatology.

“These findings are particularly useful for people who have radiographic evidence of osteoarthritis but don’t have pain every day in their knees,” Lo explained in a press release. “This study supports the possibility that walking for exercise can help to prevent the onset of daily knee pain.  It might also slow down the worsening of damage inside the joint from osteoarthritis.”  

Lo says walking for exercise has other health benefits, such as improved cardiovascular health and decreased risk of obesity, diabetes and even some cancers. Walking is also a free activity with minimal side effects.

“People diagnosed with knee osteoarthritis should walk for exercise, particularly if they do not have daily knee pain,” says Lo, who is chief of rheumatology at the Michael E. DeBakey VA Medical Center in Houston. "If you already have daily knee pain, there still might be a benefit, especially if you have the kind of arthritis where your knees are bow-legged.”

Exercise Reduces Pain by Increasing Beneficial Bacteria

By Pat Anson, PNN Editor

Regular exercise can benefit people in many different ways, helping us lose weight, reduce the risk of heart disease, and boosting overall health.  

But researchers at the University of Nottingham have found that exercise has an unexpected benefit for people with arthritis. Regular exercise increases levels of beneficial bacteria in their digestive tracts, which reduces pain and inflammation by increasing levels of endocannabinoids – cannabis-like substances naturally produced by the body.

The study, published in the journal Gut Microbes, is believed to be the first to find a potential link between endocannabinoids, exercise and gut microbes.

"Our study clearly shows that exercise increases the body's own cannabis-type substances. Which can have a positive impact on many conditions,” says lead author Amrita Vijay, a Research Fellow at Nottingham’s School of Medicine. "As interest in cannabidiol oil and other supplements increases, it is important to know that simple lifestyle interventions like exercise can modulate endocannabinoids."

Vijay and her colleagues enrolled 78 people in their study. Half of the participants did 15 minutes of muscle strengthening exercises every day for six weeks, and the rest did nothing. Blood and fecal samples were collected from both groups.

At the end of the study, participants who exercised not only had lower pain levels, they also had significantly more Bifidobacteria and Coprococcus 3 -- bacteria that produce anti-inflammatory substances and lower levels of cytokines, which regulate inflammation.

These gut bacteria were particularly adept at raising levels of short chain fatty acids (SCFAs), which increase levels of endocannabinoids. About a third of the anti-inflammatory effects of the gut microbes was due to their ability to raise endocannabinoid levels.

Importantly, the exercise group also had lower levels of Collinsella – a bacteria known to increase inflammation that is strongly associated with processed food and diets low in vegetables.    

“In this study we show that circulating levels of ECs (endocannabinoids) are consistently associated with higher levels of SCFAs, with higher microbiome diversity and with lower levels of the pro-inflammatory genus Collinsella. We also show statistically that the anti-inflammatory effects of SCFAs are up to one third mediated by the EC system,” researchers concluded.

Previous studies have also found an association between gut bacteria and painful conditions. A 2019 study at McGill University found that women with fibromyalgia had 19 different species of bacteria that were present in either greater or lesser quantities than a healthy control group.

Bacteria associated with irritable bowel syndrome, chronic fatigue syndrome and interstitial cystitis were also found to be abundant in the fibromyalgia patients, but not in the control group.    

Having a healthy diet can also affect pain levels for migraine, neuropathy and other types of chronic pain. A recent study funded by the National Institutes of Health found that migraine sufferers who ate more fatty fish and reduced their consumption of polyunsaturated vegetable oils — frequently found in processed foods — had fewer headaches.

Follow Treatment Guidelines for Low Back Pain and Get Back to Work Sooner

By Pat Anson, PNN Editor

Employees with acute low back pain miss fewer days of work if they exercise, take over-the-counter pain relievers and are not prescribed opioid medication, according to a large new study of worker compensation claims in California.

"The closer people's care follows evidence-based guidelines, the faster their back pain resolves, by quite a bit," said Kurt Hegmann, MD, director of the University of Utah Rocky Mountain Center for Occupational and Environmental Health.

Hegmann and his colleagues analyzed insurance data for nearly 60,000 people with low back pain from 2009 to 2018, comparing their treatment to guidelines created by the American College of Occupational and Environmental Medicine. Those guidelines recommend non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants and physical therapy for low back pain, while frowning on the use of opioids or invasive procedures such as spinal injections.

The research findings, recently published in PLOS ONE, showed that people who didn’t follow treatment guidelines missed an average of 11 more days of work each year compared to those who only had recommended treatments.

Opioids were once commonly prescribed for low back pain, a practice that has fallen out of favor due to fears of addiction and overdose. In the nine years of the study, researchers found that opioid prescribing for low back pain declined by 86 percent, fueled in part by insurers who were unwilling to pay for the drugs.

"The reduction in opioids prescription is particularly impressive," Hegmann said. "In this case, the insurer is likely to not pay for opioids even if they are prescribed. It suggests what's possible when the 'carrot' of good health care is missed and instead the 'stick' of compliance with a guideline is in place."

Nearly two-thirds of the people included in the study received at least one non-recommended treatment, although adherence to treatment guidelines improved over time. In 2009, 10% were treated according to guidelines, but that rose to 18% by 2018.

Low back pain is the world’s leading cause of disability. It mostly affects adults of working age in lower socioeconomic groups, who often have physically demanding jobs.

Treatment guidelines for low back pain have changed considerably in the last 20 years. At one time, bed rest was commonly recommended, a treatment now seen as counterproductive. Moderate exercise and physical activity help people return to work sooner.

"Being out of work impacts many facets of your life," said first author Fraser Gaspar, PhD. "In addition to the physical disability that's causing the person to miss work, the worker is making less money, while they often incur additional costs and experience mental strain. Getting people back to their normal lives is really important, and our research shows that following guidelines makes that happen faster."

Study Finds Regular Exercise Reduces Migraine Triggers

By Pat Anson, PNN Editor

Two-and-a-half hours of moderate to vigorous exercise a week can significantly reduce migraine triggers like stress, depression and poor sleep, according to a new survey that found more than two-thirds of migraine sufferers do not get enough exercise.

“Migraine is a disabling condition that affects millions of people in the United States, and yet regular exercise may be an effective way to reduce the frequency and intensity of some migraines,” says lead author Mason Dyess, DO, a Senior Fellow at the University of Washington School of Medicine.

“Exercise releases natural pain killers called endorphins, helps people sleep better and reduces stress. But if people with migraine are not exercising, they may not be reaping these benefits.”

The survey involved 4,647 people diagnosed with migraine. About three-fourths of participants had chronic migraine, meaning 15 or more migraines a month. The others had episodic migraine, or up to 14 a month.

Participants completed a questionnaire about their migraines, sleep, depression, stress, anxiety and the amount of exercise they get each week.

Researchers then divided them into five groups based on their level of exercise: those who did not exercise; people who exercised up to 30 minutes per week; those who exercised 31 to 90 minutes; people who exercised 91 to 150 minutes; and participants who exercised more than 150 minutes per week.

Types of exercise that qualified as moderate to vigorous included jogging, very brisk walking, playing a sport, heavy cleaning and bicycling.

Researchers found that only 1,270 participants – about 27 percent -- reported the highest level of exercise. Those who got less than 150 minutes of exercise had increased rates of depression, anxiety and sleep problems:

• Depression was reported by nearly half of people who got no exercise, compared to 25% of those that exercised the most.

• Anxiety was reported by 39% of people in the no exercise group, compared to 28% of people in the high exercise group.

• Sleep problems were reported by 77% of people in the no exercise group, compared to 61% in the high exercise group.

Researchers also found an association between exercise and increased frequency of migraines. Among people in the no exercise group, nearly half had 25 or more headache days per month. That compares to only 28% of people in the high exercise group.

“There are new therapeutics available for migraine, but they are very expensive. People with migraine should consider incorporating more exercise into their daily life because it may be a safe and low-cost way to manage and minimize some of the other problems that often accompany migraine,” said Dyess.

Two-and-a-half hours a week of moderate to vigorous exercise, or 150 minutes, is the minimum amount recommended by the World Health Organization.

The study findings, which will be presented at the annual meeting of the American Academy of Neurology in April, have not yet been peer-reviewed or published. One weakness of the study was that participants self-reported their exercise minutes, rather than having their activity monitored with a device. It also only shows an association between exercise and migraines, and does not prove cause and effect. 

Exercise Is Best Treatment for Low Back Pain, But Why?

By Pat Anson, PNN Editor

There has long been a consensus that the best way to treat chronic lower back pain (CLBP) – the world’s leading cause of disability – is by staying active and exercising. But a new study by Australian researchers failed to identify precisely why exercise is beneficial.

“A lot of treatments have stemmed from studies for people with CLBP, but the one with the most consistent evidence of benefit is exercise,” says senior author Matt Jones, PhD, an exercise physiologist, clinician and researcher at the UNSW Sydney School of Medical Sciences. “Despite decades of research in the area and more than 100 studies we analysed in our review, we still do not have a good idea of why exercise might be effective for CLBP.”

Jones and his colleagues recently reported their findings in the journal Musculoskeletal Science and Practice. They reviewed 110 research papers on CLBP conducted in Australia, United States, China, Brazil and Europe, and found little agreement on why researchers thought exercise relieved lower back pain.

“Researchers proposed common reasons as to why exercise was beneficial, including improvements in fitness – for example, core stability, aerobic fitness – and improvements in mood and confidence,” Jones said. “But the effects of these proposed reasons on outcomes for people with CLBP were seldom examined in the papers.

“There have been trends in research over time, where everyone focuses on a ‘flavour of the month’ – like motor control or McKenzie therapy, for example – but because the effects of exercise are broad and it impacts on many different systems in the human body, it’s difficult for researchers to pinpoint exactly why they think it might be benefiting people with pain.”

At any given time, over 500 million people worldwide are suffering from CLBP, which is “non-specific” back pain lasting three months or longer – not the severe back pain caused by degenerative disc disease, spinal injuries, arthritis and other chronic conditions. CLBP mostly affects adults of working age in lower socioeconomic groups, who often have physically demanding jobs.

A 2018 review published in The Lancet by an international team of researchers found that CLBP is often treated with bad advice, inappropriate tests, risky surgeries and painkillers. The authors said there was limited evidence to support the use of opioids for low back pain, and epidural steroid injections and acetaminophen (paracetamol) were not recommended at all.

“The majority of cases of low back pain respond to simple physical and psychological therapies that keep people active and enable them to stay at work,” said lead author Professor Rachelle Buchbinder of Monash University in Australia. “Often, however, it is more aggressive treatments of dubious benefit that are promoted and reimbursed.”

Jones said the aggressive treatments may not work because they don’t address underlying psychological reasons for back pain.

“Chronic pain is tricky and there are a lot of factors that can contribute to it – so, it's not simply biological aspects of tissue damage, but there are psychosocial elements at play, as well things like a person’s mood or confidence in their own abilities to do something,” he said. “Today’s evidence suggests CLBP likely comes from the brain and nervous system being a bit over-protective and generating a pain response – despite no obvious physical damage to the body.”

Although his review did not address what specific exercises were most effective for CLBP, Jones and his team recommended 33 “mechanisms” that people can use to relieve back pain, such as building muscle strength and flexibility or through social support and coping strategies.

“Many scientists have investigated this question before and the short answer is, there are no specific exercises recommended to alleviate CLBP,” he said. “But there are literally hundreds of studies on exercise for people with chronic pain, not only CLBP, and researchers consistently find exercise is one of the most effective treatments – it might not cause huge reductions in pain and disability, but it does help.”

Good Attitude Improves Effectiveness of Yoga and Physical Therapy

By Pat Anson, PNN Editor

Yoga is a four-letter word for a lot of chronic pain patients, who are often urged to try yoga or physical therapy to ease their pain. Many pain sufferers believe exercise will only make their pain worse.

But a new study by researchers at Boston Medical University found that people with chronic lower back pain are more likely to benefit from yoga and physical therapy if they have a positive attitude about exercise.

The study involved 299 mostly low-income patients with chronic lower back pain who took weekly yoga classes or had physical therapy for 12 weeks. They were compared to a control group who had “self-care” – which consisted of reading a handbook on self-management strategies for back pain, such as stretching and strengthening exercises.

Nearly half (42%) of those who had yoga or physical therapy responded to the treatment, while only 23% of those in the self-care group had improvement in their pain and physical function.

Interestingly, participants who continued taking pain medication during the study were more likely to benefit from yoga (42%) than those who had physical therapy (34%) or self-care (11%).

"Adults living with chronic low back pain could benefit from a multi-disciplinary approach to treatment including yoga or physical therapy, especially when they are already using pain medication,' said lead author Eric Roseen, DC, a chiropractic physician at Boston Medical Center.

Another important finding from the study, which was published in the journal Pain Medicine, is the effect that “fear avoidance” can have on patient outcomes.

Among the participants who had less fear of exercise, 53 percent responded to yoga, 42 percent responded to physical therapy and 13 percent responded to self-care. In contrast, participants who had a high fear of exercise usually had a poor response, regardless of what therapy group they were in.  

Other factors that appeared to improve patient response were a high school education, higher income, employment and being a non-smoker.

"Focusing on a diverse population with an average income well below the U.S. median, this research adds important data for an understudied and often underserved population," said Roseen. "Our findings of predictors are consistent with existing research, also showing that lower socioeconomic status, multiple comorbidities, depression, and smoking are all associated with poor response to treatment."

It doesn’t take a lot of time to benefit from exercise. A 2017 study found that just 45 minutes of moderate physical activity a week improved pain and function in patients with osteoarthritis.

A few weeks of yoga significantly improved the health and mental well-being of people suffering from arthritis, according to a 2015 study at Johns Hopkins University.

‘Space Pants’ Help Patients Walk Again

By Steve Weakley

Specially designed “space pants” worn by astronauts to regulate their body temperature are helping patients with Peripheral Artery Disease (PAD) walk and exercise again with less pain.

More than eight million Americans suffer from PAD -- a narrowing of peripheral arteries in the legs that can cause severe pain and cramping after a short walk or even just climbing a flight of stairs.

“I have patients that have trouble going to their mailbox,” said Bruno Roseguini, PhD, an assistant professor in the Department of Health and Kinesiology at Purdue University. “These patients, in order to avoid that pain, become very inactive. So, this is a vicious cycle that leads to more impairment and more functional decline over time.”

PURDUE UNIVERSITY

To get PAD patients moving again, Roseguini and his research team turned to NASA and the elastic space pants worn by astronauts.  Woven into the pants is an elaborate tubing system that circulates warm water and helps keep the astronauts’ body temperatures normal in a weightless environment. 

Researchers modified the pants for a clinical study of PAD patients and found they were able to lower blood pressure and increase circulation in their legs. Patients who wore the pants for 90 minutes every day for eight weeks reported less pain and more mobility.

"It's like putting your legs in a hot tub without getting wet," says PAD patient Stephen Scott, who is now able to stand longer and walk longer distances. "It feels good."

“Based on our initial findings, it is conceivable that repeated exposures to heat therapy might enhance the ability of the arteries in the legs to vasodilate” Roseguini said. “What that means is there would be more blood flow and greater oxygen delivery to calf muscles during exercise, and we anticipate this will prolong the time they can walk before they feel pain.”

Roseguini explains how the pants work in the video below:

Roseguini calls physical exercise the “gold standard” for treating PAD, even if many patients choose other routes of relief.  Some have stents surgically inserted into their leg arteries, but they can narrow without exercise and may have to be replaced every few years. Medication and dietary changes can also help manage PAD, for which there is no cure.

“Exercise is painful for these patients and leg pain is one of the main reasons for why most of these patients do not adhere to structured exercise programs,” said Roseguini. “Heat therapy, on the other hand, is not painful. If anything, heat therapy might actually reduce leg pain, so the patients see that as a treatment they would potentially adhere to.”

Studies show heat therapy can also improve the health of blood vessels and help muscles recover after an injury.

“Heat therapy is a powerful tool for rehabilitation,” says Roseguini, who hopes to develop a portable battery-powered pump that PAD patients can wear without being tethered to an electric outlet. “I want the patients to be able to receive the therapy while walking and performing their daily living activities, such as going to the grocery store.”