Medical Barriers: Chronic Pain Conditions

Today’s post is another excerpt from “Best Weight: A Practical Guide to Office-Based Weight Management“, recently published by the Canadian Obesity Network. This guide is meant for health professionals dealing with obese clients and is NOT a self-management tool or weight-loss program. However, I assume that even general readers may find some of this material of interest. CHRONIC PAIN CONDITIONS Any condition that leads to chronic pain can contribute to obesity by increasing physiological and psychological stress. Pain also makes exercise more difficult to undertake and enjoy. Osteoarthritis and Back Pain Obesity is commonly associated with musculoskeletal pain and osteoarthritis, resulting in functional and motor limitations. Obese patients usually move more slowly, are less flexible and feel pain when performing tasks at floor level. There is a strong association between knee osteoarthritis and obesity. Degenerative arthritis resulting from chronic trauma associated with excess body weight develops primarily in weight-bearing joints such as the knee and ankle. However osteoarthritis can also be seen in non-weight-bearing joints, suggesting a systemic inflammatory response. Excess body weight is also closely related to lower back pain. Both static and compressive loading may damage the integrity of intervertebral discs. Increased biomechanical force can also cause muscle sprain and ligament strain.Sleep disorders are very prevalent among obese people. Obstructive sleep apnea is the most common disorder, but disturbed sleep may also be due to primary insomnia, or insomnia secondary to medications, medical or psychiatric disorders. The presence of significant pain can promote immobility, leading to loss of muscle mass and reduced cardiopulmonary fitness. This can precipitate psychological and metabolic changes that promote further weight gain. Patients with painful joints may benefit from water-based (non-weight-bearing) exercise and may require pain management before embarking on a weight-loss program. Obese patients requiring joint-replacement surgery are generally advised to lose weight (often in unrealistic amounts) before surgery, but this is very difficult if they are already partially immobilized by pain. To complicate matters further, most commercial gyms are ill-equipped to handle the needs of obese clients, many of whom cannot go from lying down on the floor to standing up without assistance. Step classes and aerobics classes are in many cases ill-advised, and exercise machines and weight benches are not usually designed for obese users. Fibromyalgia Obesity is often associated with fibromyalgia, a common disorder characterized by fatigue, pain, stiffness in the trunk and extremities and a number of specific tender… Read More »

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Osteoarthritis Management in Obesity

Osteoarthritis is one of the most disabling and painful conditions attributable (in part) to excess weight. Once established, osteoarthritis significantly reduces quality of life and mobility, often precipitating further weight gain and posing an important barrier to weight management. A panel of experts (The Ottawa Panel) has now released a comprehensive set of evidence-based clinical practice guidelines for the management of osteoarthritis in overweight and obese patients, published in PHYSICAL THERAPY. The recommendations are based on an extensive review of published articles with strict application of quality criteria to rate the strength of evidence (A, B, C, C+, D, D+, or D-) as well as experimental design (I for randomized controlled trials and II for nonrandomized studies). Clinical significance was established by an improvement of ≥15% in the experimental group compared with the control group. The panel decided on a total of 79 recommendations: 36 positive (21 grade A and 15 grade C+) – all were of clinical benefit. Overall the data supports the recommendation that physical activity combined with (mildly restrictive) diet programs are beneficial for pain relief, functional status, strength and quality of life. Although 5% reduction in body weight reduced pain and functional status, this degree of weight loss was insufficient to slow disease progression. Both aquatic and land-based aerobic exercise were shown to be more effective in reducing pain than home-based strengthening exercises. On the other hand, land-based exercise performed in a gym that included strength, aerobic, stretching, and range-of-motion training was more effective in reducing pain compared with a home-based strengthening exercise program. These benefits of exercise are independent of any changes in body weight and the authors suggest: “The significant improvements in QoL among study participants with OA who were obese or overweight may be a reflection of mental health and social benefits associated with the participation in physical activities. Physical activity promotes psychological well-being by reducing feelings of fatigue, depression, and anxiety and improving self-esteem, confidence, concentration, and mental awareness. The social benefits of participation in physical activity include a reduction in the sense of isolation and loneliness, improved social networks and social capital, and increased community connectedness and cohesion.” Importantly, the authors also note that: “To the knowledge of the Ottawa Panel, there is no conclusive evidence on the most appropriate methodological scale to apply for OA and obesity research. The use of BMI, waist circumference, and body weight as valid indicators of successful weight loss… Read More »

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Would Reducing Obesity Save Thousands of Knees?

On most days, our obesity clinic could easily be confused with an orthopedic clinic given the sheer number of patients who present with severe pains in their backs, knees, hips, and ankles – often to the point of immobility. It turns out (perhaps not surprisingly) that today, obesity and knee osteoarthritis are among the most frequent chronic conditions affecting Americans aged 50 to 84 years – my guess is that these conditions are no less frequent among Canadians. Given the high prevalence of both obesity and knee osteoarthritis and their very significant impact on quality of life, Losina and a team of researchers from Harvard, Boston University, Chapel Hill, Yale and the University of Sydney undertook the rather momentous task of estimating the impact of these conditions on morbidity and mortality in older Americans. Their results were now published in the Annals of Internal Medicine. The researchers based their analyses on U.S. Census and national obesity data with estimated prevalence of symptomatic knee osteoarthritis, whereby they assigned the US population aged 50 to 84 years to four subpopulations: nonobese without knee osteoarthritis (reference group), nonobese with knee osteoarthritis, obese without knee osteoarthritis, and obese with knee osteoarthritis. They then used a computer simulation model (The Osteoarthritis Policy Model) to estimate quality-adjusted life-year losses due to knee osteoarthritis and obesity and to determine health benefits of reducing obesity prevalence to levels observed a decade ago. It turns out that the estimated total losses of per-person quality-adjusted life-years ranged from around 2 years in nonobese persons with knee osteoarthritis to about 3.5 years for persons affected by both conditions. Although these numbers may not sound shocking, they actually represent 10% to 25% of the remaining quality-adjusted survival of persons aged 50 to 84 years. When calculated for the entire US population in that age range, this amounts to a staggering 86 million quality-adjusted lost to these conditions. The researchers also calculate that reversing obesity prevalence to levels seen 10 years ago would avert just over 110,000 total knee replacements – so reducing obesity (even to where it was just 10 years ago) could indeed save a substantial number of knees. What the paper of course does not disclose is how exactly such a reversal in obesity rates could possibly be achieved. Clearly, the impact of weight loss on knee (and other) pain that we see in our clinic is often dramatic, but achieving weight… Read More »

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Is Osteoarthritis a Risk Factor for Metabolic Syndrome?

Both osteoarthritis (OA) and metabolic syndrome (MetS) are associated with obesity and it may therefore not be unexpected to see increased prevalence of OA in patients with MetS and vice versa. On the other hand, given the negative impact of OA on physical activity levels, it may also not be unreasonable to assume that individuals with OA may be more likely to present with weight gain and features of the MetS. Finally, both OA and obesity have been associated with low levels of systemic inflammation, another factor that may promote metabolic abnormalities in these patients. But how close is the relationship between OA and MetS in the general population? This question was recently addressed by Rajitkanok Punepatom and colleagues from Chadds Ford, PA, in a paper just published in Postgraduate Medicine. This study examined whether having OA predicts the presence of MetS in the National Health and Nutrition Examination Survey (NHANES) III, a representative sample of the general US population. The data set included 7714 subjects, of whom 975 subjects had OA. Metabolic syndrome was present in 59% of the OA population and 23% of the population without OA with each of the 5 cardiovascular risk factors that comprise MetS being more prevalent in the OA population: hypertension (75% vs 38%), abdominal obesity (63% vs 38%), hyperglycemia (30% vs 13%), elevated triglycerides (47% vs 32%), and low high-density lipoprotein cholesterol (44% vs 38%). The association between OA and MetS was strongest in younger subjects, where having OA at age 44 years was associated with an over 5-fold increased risk of MetS – a relationship that remained significant despite adjustment for body weight and other confounders. This, not entirely unexpected association between OA and MetS, particularly in younger individuals, has a number of important clinical implications: 1) Cardiovascular risk factors should be routinely assessed and addressed in younger individuals presenting with OA. 2) Vice versa, assessment of joint health should perhaps be a routine part of assessment in younger patients presenting with signs of MetS. 3) It is likely that the common presentation of OA in patients presenting with MetS can be a significant barrier to increasing physical activity and weight management and therefore likely needs to be specifically addressed with appropriate physical and medical treatments. AMS Ottawa, Ontario

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Diet, Exercise, or Both for Knee Pain?

The musculoskeletal consequences of overweight and obesity are perhaps by far the most disabling and costly sequelae of excess weight. Although they may be less likely to kill you than heart disease or stroke (also consequences of obesity), obesity related pains in your muscle, bones and joints can reduce your quality of life to a level where having a heart attack may seem like taking the easy way out. So what is the best conservative treatment for weight-related knee pain? This question was addressed now in a randomised controlled trial published last month in the British Medical Journal. Specifically, Claire Jenkinson and colleagues from the University of Nottingham, UK examined the effects of dietary intervention and quadriceps strengthening exercises on pain and function in overweight people with knee pain. The study was performed in five general practices in Nottingham and involved 389 men and women aged 45 and over with a body mass index equal or greater than 28.0 and self reported knee pain. Participants were randomised to dietary intervention plus quadriceps strengthening exercises; dietary intervention alone; quadriceps strengthening exercises alone; or and advice leaflet only (control group). Dietary intervention consisted of individualised healthy eating advice that would reduce normal intake by 600 kcal a day. Interventions were delivered at home visits over a two year period. In the 289 (74%) participants who completed the trial, patients in the knee exercise groups reported greater reduction in knee pain than in the non-exercise groups at 24 months, although the effect size was moderate (number needed to treat for a 30% improvement in knee pain was 9). As expected the dietary intervention group lost some weight (around 3 Kg), but this degree of weight loss did not have any meaningful effect on knee pain or function but was associated with a reduction in depression. The authors conclude that a home based, self managed programme of simple knee strengthening exercises over a two year period can significantly reduce knee pain and improve knee function in overweight and obese people with knee pain. Although a moderate sustained weight loss is achievable with dietary intervention and is associated with reduced depression, it is not enough to influence pain or function. As knee pain is a common problem in patients presenting with excess weight, which if not addressed, will ultimately result in immobility and increasing weight gain, exercise prescriptions should be routinely implemented in patients presenting with this… Read More »

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