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What is Multiple Sclerosis?

An unpredictable disease of the central nervous system, multiple sclerosis (MS) can range from relatively benign to somewhat disabling to devastating, as communication between the brain and other parts of the body is disrupted. Many investigators believe MS to be an autoimmune disease -- one in which the body, through its immune system, launches a defensive attack against its own tissues. In the case of MS, it is the nerve-insulating myelin that comes under assault. Such assaults may be linked to an unknown environmental trigger, perhaps a virus.

Most people experience their first symptoms of MS between the ages of 20 and 40; the initial symptom of MS is often blurred or double vision, red-green color distortion, or even blindness in one eye. Most MS patients experience muscle weakness in their extremities and difficulty with coordination and balance. These symptoms may be severe enough to impair walking or even standing. In the worst cases, MS can produce partial or complete paralysis. Most people with MS also exhibit paresthesias, transitory abnormal sensory feelings such as numbness, prickling, or "pins and needles" sensations. Some may also experience pain. Speech impediments, tremors, and dizziness are other frequent complaints. Occasionally, people with MS have hearing loss. Approximately half of all people with MS experience cognitive impairments such as difficulties with concentration, attention, memory, and poor judgment, but such symptoms are usually mild and are frequently overlooked. Depression is another common feature of MS.

Is there any treatment?

There is as yet no cure for MS. Many patients do well with no therapy at all, especially since many medications have serious side effects and some carry significant risks. However, three forms of beta interferon (Avonex, Betaseron, and Rebif) have now been approved by the Food and Drug Administration for treatment of relapsing-remitting MS. Beta interferon has been shown to reduce the number of exacerbations and may slow the progression of physical disability. When attacks do occur, they tend to be shorter and less severe. The FDA also has approved a synthetic form of myelin basic protein, called copolymer I (Copaxone), for the treatment of relapsing-remitting MS. Copolymer I has few side effects, and studies indicate that the agent can reduce the relapse rate by almost one third. An immunosuppressant treatment, Novantrone (mitoxantrone), is approved by the FDA for the treatment of advanced or chronic MS. The FDA has also approved dalfampridine (Ampyra) to improve walking in individuals with MS.

One monoclonal antibody, natalizumab (Tysabri), was shown in clinical trials to significantly reduce the frequency of attacks in people with relapsing forms of MS and was approved for marketing by the U.S. Food and Drug Administration (FDA) in 2004. However, in 2005 the drug's manufacturer voluntarily suspended marketing of the drug after several reports of significant adverse events. In 2006, the FDA again approved sale of the drug for MS but under strict treatment guidelines involving infusion centers where patients can be monitored by specially trained physicians.

While steroids do not affect the course of MS over time, they can reduce the duration and severity of attacks in some patients. Spasticity, which can occur either as a sustained stiffness caused by increased muscle tone or as spasms that come and go, is usually treated with muscle relaxants and tranquilizers such as baclofen, tizanidine, diazepam, clonazepam, and dantrolene. Physical therapy and exercise can help preserve remaining function, and patients may find that various aids -- such as foot braces, canes, and walkers -- can help them remain independent and mobile. Avoiding excessive activity and avoiding heat are probably the most important measures patients can take to counter physiological fatigue. If psychological symptoms of fatigue such as depression or apathy are evident, antidepressant medications may help. Other drugs that may reduce fatigue in some, but not all, patients include amantadine (Symmetrel), pemoline (Cylert), and the still-experimental drug aminopyridine. Although improvement of optic symptoms usually occurs even without treatment, a short course of treatment with intravenous methylprednisolone (Solu-Medrol) followed by treatment with oral steroids is sometimes used.

What is the prognosis?

A physician may diagnose MS in some patients soon after the onset of the illness. In others, however, doctors may not be able to readily identify the cause of the symptoms, leading to years of uncertainty and multiple diagnoses punctuated by baffling symptoms that mysteriously wax and wane. The vast majority of patients are mildly affected, but in the worst cases, MS can render a person unable to write, speak, or walk. MS is a disease with a natural tendency to remit spontaneously, for which there is no universally effective treatment.

What research is being done?

The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes of the National Institutes of Health (NIH) conduct research in laboratories at the NIH and also support additional research through grants to major medical institutions across the country. Scientists continue their extensive efforts to create new and better therapies for MS. One of the most promising MS research areas involves naturally occurring antiviral proteins known as interferons. Beta interferon has been shown to reduce the number of exacerbations and may slow the progression of physical disability. When attacks do occur, they tend to be shorter and less severe. In addition, there are a number of treatments under investigation that may curtail attacks or improve function. Over a dozen clinical trials testing potential therapies are underway, and additional new treatments are being devised and tested in animal models.

Source: National Institute of Neurological Disorders and Stroke

Reviewed by athealth on February 6, 2014.

Neurotherapy is a clinically proven, non-drug method of treating ADD/ADHD and other learning disabilities

Neurotherapy is an innovative, non-drug treatment using EEG Neurofeedback to create positive, lasting changes in adults and children.

At the Enhancement Institute, neurotherapy is used to help the individual train his or her brainwaves to produce more of the faster brainwaves associated with concentration and focus.

Someone with ADD/ADHD has an excess of slow brainwaves associated with daydreaming, which makes it difficult to concentrate long enough to accomplish a task quickly or efficiently.

Once a patient learns to produce faster brainwaves, they can access them as needed to better perform everyday tasks such as:

• Reading
• Following directions
• Working analytical problems
• Staying focused

Diminish the symptoms of ADD/ADHD

Most patients are able to diminish the symptoms of ADD/ADHD in a few short months and therefore significantly reduce or eliminate their use of medications.

In addition to ADD/ADHD, other disorders helped by this program include head trauma, addiction, depression, anxiety and other psychobiological disorders. Neurotherapy appears to produce changes in brain chemistry, which may underlie some personality disturbances.

Author: Nancy White, PhD, LMFT, is a recognized leader in the field of Neurotherapy. She is a Diplomate in Quantitative EEG Technology, a member of the Quantitative EEG Certification Board, and a Consulting Editor of the Journal of Neurotherapy. Dr.White has conducted Neurotherapy workshops across the country and abroad teaching health practitioners how to utilize this technology with their own patients.

For more information on this innovative treatment contact The Enhancement Institute.

Reviewed by athealth on February 6, 2014.

by Alan Siegel, PhD

Our children do not have to suffer their nightmares in silence, brooding about the lingering feeling of suffocation left by the formless ghost or shuddering at the memory of the razor-sharp teeth of a pack of wolves ripping into their flesh. There are remedies for even the most dreadful nightmares.

Unfortunately, the raw terror that lingers after a nightmare may accentuate a child's insecurity and bring on anxiety for hours or even days afterward. It may even disturb their ability to sleep by inducing insomnia, or fears and phobias about sleeping and dreaming. To help your child restore their capacity to sleep and to harness the healing and creative potential of scary dreams, we must help them break the spell of their nightmares.

The silver lining of painful nightmares is that through the often-transparent symbolism, they shine a spotlight on the issues that are most the upsetting, yet inexpressible for your child. Every nightmare, no matter how distressing, contains vital information about crucial emotional challenges in your child's life. To a parent whose ears and heart are open, listening to the most distressing nightmares is like hearing your child's unconscious, speaking directly to you delivering a special call for help.

Most nightmares are a normal part of coping with changes in our lives. They are not necessarily a sign of pathology and may even be a positive indication that we are actively coping with a new challenge. For children, this could occur in response to such events as entering school, moving to a new neighborhood or living through a divorce or remarriage.

Using role-playing and fantasy rehearsals, parents can coach their children to assert their magical powers and tame the frights of the night. New endings for dreams can be created so that falling dreams become floating dreams and chase dreams end with the capture of the villain. When we give our children reassurance and encouragement to explore creative solutions to dream dilemmas, we restore their ability to play with the images in their nightmares rather than feeling threatened or demoralized. These assertiveness skills carry over into future dream confrontations and lead to greater confidence to face waking challenges.

Sophia's Spider Dream

Even very young children can learn to encounter and overcome the threatening creatures of their nightmares. My daughter, Sophia, mentioned her first dream just before she turned two. She woke from a nap one day and spontaneously said "bird fly outside" while motioning towards the window with her hands. Because Sophia had always been fascinated with the flight and sounds of birds and airplanes, my wife and I weren't sure if it was really a dream or just a fantasy. However, a month later, Sophia woke up screaming and sobbing with a bona fide nightmare about spiders.

The Attack of the Dream Spider

'Pider on Sophia...off Sophia's leg...Dad, no more 'pider please!"

While holding Sophia and comforting her, she continued to sob, saying, "Sophia scared". I reassured her that "Daddy will protect you from spiders". I am going to teach you how to get those bad spiders away from Sophia" She listened with wide eyes. "When you see those spiders, tell them Go away bad spiders. Get out of Sophia's bed and don't come back!" I emphatically repeated this anti-spider anthem three times. Suddenly Sophia smiled a slightly mischievous smile. "Go away 'piders" She said tentatively. She repeated it twice and smiled waving her hands as if to motion the spiders away. She was significantly calmed and after a bit of rocking and a short story, she fell back to sleep easily.

When Sophia woke the next morning, I asked her "Did you have any more dreams?" She flashed a playful smile and said "piders!" and laughed. For two more days, she grinned and said 'piders' when she woke. These subsequent dream reports were probably fabricated judging by the mischievous look on her face. However, within a few days she began to report other dreams, mostly animals, some threatening and some friendly.

Sophia's dream spiders were more terrifying than anything in waking reality. I took the dream spiders seriously by talking directly to them and offering Sophia reassurance (both physical and emotional), a concrete strategy for facing the dream creatures and follow-up to reinforce her ability to break the spell of the attacking dream spiders.

Children's Nightmares

Children suffer more frequent nightmares than their parents and, prior to the age of six, nightmares are especially common. As soon as your child can speak, he or she may wake with a one or two word tale of a wolf or ghost. There is even speculation among specialists in child development that the sleep disturbances of infants in the first year of life may be wordless nightmares.

Nightmares diminish as children grow older, master their fears, and gain more control over their world. A long-term study of 252 children showed that five to ten percent of seven- and eight-year-old children had nightmares once a week. By the time children in the study were between eleven and fourteen, disturbing dreams were infrequent, especially for boys.¹

Most nightmares are a normal part of coping with changes in our lives. They are not necessarily a sign of pathology and may even be a positive indication that we are actively coping with a new challenge. For children, this could occur in response to such events as entering school, moving to a new neighborhood or living through a divorce or remarriage.

A good working assumption is that many nightmares in children are reactions to upsetting events, situations and relationships. It is important to keep in mind that often a stress such as moving to a new neighborhood will be complicated by a chain reaction of other changes. Nightmares will usually diminish in intensity and frequency as the child and the family recover and cope with stresses such as a death in the family or birth of a new family member.

Eight-year-old Brian and his younger brother Jake were not only moving from the house they had always lived in, they were changing schools and saying good-bye to school friends. After the last day at his old school, Brian's family moved into his friend Colin's house for the summer while Colin's family went on vacation. On the first night of sleeping in his friend's room, Brian had a dreadful nightmare.

In tears, Brian woke and came running into his parent's room, lamenting his bad dream. "I can't stop thinking about the awful smell". Brian's mother, Gina, gave him a sympathetic hug and invited him to sit down and tell the whole dream. Sobbing slightly, Brian blurted out what he could remember.

Poison Gas

I see my friends Colin and his brother Ross opening the door and going into a dark room like the room I am staying in. I keep waiting over 1/2 hour but they don't come out. Finally, I decide to go in and check on them. I smell gas and think it might be poison gas. Suddenly I see them lying dead on floor.

Seeing Brian's distress, Gina wanted to reassure him. "If someone is dead in a dream, does it mean they are really gonna die?" " No, Brian, things that we dream about are important but they don't usually come true when we are awake. Possibly this dream isn't about people dying but about missing your friends after we move." "Yeah but it was so gross seeing them dead and the gas made me feel like I was gonna get poisoned too". Gina responded "That must have been a horrible sight. I would have been scared too if I had that dream."

After a moment of pondering, Brian relaxed a bit and said "that room I am staying in does smell kinda stinky." He had complained before bed that his friend Colin's collection of old teddy bears smelled bad. Gina agreed and taking the dream at face value, she suggested that they spray some air freshener before he goes back to sleep. As she looked in the cabinets for the freshener, Gina realized that Brian's dream went beyond a simple reaction to the foul smell of the stuffed animals. She realized that she and her husband had been so busy packing and preparing for the move, they hadn't had time to really talk with Brian about his sense of loss and his fears of the unknown.

Brian's morbid nightmare helped his mother understand his emotional needs. As a result of the dream, Gina spent more time talking about the move with Brian and his brother. The family took steps to keep connections with old friends, and visited their new school during the summer to make it more familiar. While in their temporary house, they also moved the smelly bears and deodorized the room.

The poison gas was a response not only to the actual bad smell in the room in which Brian was staying but also symbolized the dangerous sense of insecurity Brian felt, moving from a familiar home and school and friends to an unfamiliar and unpleasant situation. If death or grief is not a current issue in the dreamer's life, death dreams frequently symbolize loss or painful changes. For Brian, the dark room that swallowed up his friends and killed them expressed his multiple losses as well as fear.

During a period of stress or family crisis, parents should expect more frequent nightmares. Likewise, when a child suddenly has an increase in nightmares, they are letting you know they are feeling overwhelmed and insecure. You don't have to interpret or explain their nightmares. Your reassurance and empathy plus some hugs are the first step towards helping them restore their emotional balance.

Recurring Nightmares

Anyone who keeps track of their dreams and nightmares will begin to notice recurring symbols and patterns. Studies of people who have kept dream journals for as long as 50 years have shown that certain animals or houses or people who appear in a person's childhood or teenage dreams will still turn up when their hair is gray.

Your own personal repertoire of nightmare symbols may emerge early in childhood, evolving and transforming throughout your life span. After being stung by a bee when she was three, Annie began to have repetitive dreams of being chased and bitten by bees and other bugs. While her parents initially assumed that the bee sting experience was still bothering her, they began to notice that Annie would get stung in her dreams when other things would upset her; when her Mom went on a business trip, when she temporarily lost her favorite doll, and just after her brother was born. Her bee sting dreams had become symbolic of events that threatened her security.

Through repeating dream patterns, such as Annie's bee sting dreams, by earlier traumatic events, they are later stimulated by current stressful situations. Repeating dream patterns may also be influenced by disturbing images from television and film (no one wants a Freddie Kreuger dream), family fears, cultural stereotypes, myths, and religious beliefs and stories.

What can we learn from recurrent dreams? They are often a warning of lingering psychological conflicts. For example, children of divorce frequently dream that their parents have reunited; abuse survivors are often victims or perpetrators of violence in their dreams; and adopted children intermittently dream of their birth parents.

Conversely, changes within recurring dreams may signal the onset of resolving a psychological impasse. For example, a survivor of child abuse who was making a therapeutic breakthrough in her emotional recovery dreamed of triumphing over a shadowy, hostile figure that had threatened and chased her in innumerable prior nightmares.

Stages of Resolution in Recurring Dreams

Three stages of resolution can be identified in children's nightmares.

• Threat: In the dream, a main character is threatened and unable to mount any defense. For example, he or she may be paralyzed while trying to flee the jaws of a hungry ghost imprisoned by aliens.
• Struggle: Attempts to confront the nightmare adversary are partially successful in fending off danger. An example would be temporarily escaping a robber with a knife and trying to dial the phone for help.
• Resolution: The nightmare enemy, opponent, or oppressor is vanquished and the threatening creatures are put in cages, slain, or held at bay with magic wands, or otherwise disarmed.

In some cases, children spontaneously resolve a recurring nightmare as the formerly distressing situations which caused the nightmares get worked out in the child's real life. Bob had one such persistent childhood nightmare that changed decisively with time. Although his father was not inherently cruel and abusive, his stormy personality often led to outbursts of anger that frightened Bob and his sister.

After his father's return from military service, Bob began having nightmares about horrific encounters with a ghost-like monster in the basement of his house. These ghost nightmares continued for almost two years from when he was seven until he was nine.

At first the ghost dreams would leave him shaking in abject terror. As time went by he would try to stand up to the ghost but as the following dream indicates, he did not immediately prevail.

Screaming at the Ghost in the Basement

I was down in the basement in bed sleeping and it was the terror of all terrors. I knew the ghost was around the corner to the right between me and these stairways where you could get back up to the house. I knew if I moved or made the slightest sound the ghost would get me. I couldn't stand the tension so I finally decided I would just yell and let the ghost come out and get me. I sat up in bed and screamed as loud as I could. The ghost came roaring out of its hiding place and jumped all over me and attacked me and I instantly woke up.

Bob woke up feeling simultaneously scared and defiant. Despite the consequences, he was determined to fight back. He later interpreted the threatening ghost as a symbol of his father's angry outbursts.

When his father had returned from overseas, he had not only interfered with Bob's special relationship with his mother, but had been punitive with Bob as he tried to reassert his role as "man of the house." Gradually, as Bob adjusted to his father's presence, he became less intimidated by his father's moods and began to identify with the positive characteristics of his father -- especially his father's creativity with tools and building.

Bob's gradually improving relationship with his father was reflected in a breakthrough dream.

Dad Helps Me Float to Safety

I was at the top of the basement stairs looking down. The stairs disappeared from under me and I was falling and falling into the basement, terrified the ghost would get me when I hit the floor. Just then I saw my dad down there. He turned on this blue light and as soon as he did I floated into the basement and knew that I was safe.

Bob's father who had been verbally harsh during the months after returning from overseas had begun to soften and allow Bob to work with him in his workshop which, happened to be in the basement. Providing the blue light symbolized how his father had transformed from a competitor for Bob's mother's love into a positive paternal role model and protector. That positive change in the father/son relationship allowed Bob to work out his recurrent nightmare.

A crucial factor in understanding repetitive dreams is looking at the degree of resolution or mastery in the dream. As children mature emotionally and intellectually, they gain increasing control over their childhood fears and feel more confident in their ability to solve problems and handle situations independently. This gradually increasing sense of control is reflected not only in their waking achievements but in their dream life.

The Four R's That Spell Nightmare Relief

There are many potentially beneficial nightmare remedies that parents, family members, and even siblings can use to help a child break the spell of a disturbing nightmare and transform terror into creative breakthroughs. In order to soothe the lingering terror and banish the demons of the night, you must learn the Four R's that spell nightmare relief for your children. They are Reassurance, Rescripting, Rehearsal, and Resolution.

Reassurance is the first and most important dimension of remedying children's nightmares. This includes "welcoming the dream" with special emphasis on physical and emotional reassurance, which will calm your child's anxiety and help them feel safe enough to give details about the nightmare and be open to further exploration.

Everyone has nightmares and no one has to bear the pain without help. Reassurance quells the post-nightmare jitters and allows you and your child an opportunity to discover both the creative possibilities and the source of what sparked the nightmare that may still be disturbing your child.

Rescripting means inviting and guiding your child to imagine changes in the outcome of their dream by reenacting or rewriting the plot. Even with young children, rescripting is most effective when it is a collaborative process of brainstorming together. The most well known form of rescripting is creating one or more new endings for a dream using art work, fantasy, drama, and writing.

Rescripting² is like assertiveness training for the imagination. Ominous dream monsters, demons, and werewolves can be tricked and trapped, tamed and leashed, given time-outs, bossed around, and generally made less intimidating. With parental assistance, the child with nightmares can be taught to revolt and throw off the yoke of dream oppression by using magical means such as fairy dust, a wizard's wand, Star Trek™ "Phasers," special incantations and spells, or other handy tools of the imagination. Very often developing and rehearsing solutions to dream dilemmas carries over to increased confidence in facing waking conflicts.

One of the most enjoyable aspects of resolving nightmares is helping your child create their own repertoire of "Magical Tools" for dream assertiveness. These tools are limited only by your imagination and can be inspired by your child's interests, current movies or television shows, your families cultural background, books or projects they are completing for school, and so on. Just as garlic or a crucifix repels a werewolf or a silver bullet kills a vampire, some magical tools can be chosen to disarm a specific character in a recurring nightmare such as a special spray for ghosts or an invisible shield for gunmen. Other tools can be of the all-purpose variety such as the old reliable magic wand, Luke Skywalker's "force" from Star Wars or even trusty police tools such as handcuffs or a secure jail cell with the key thrown away!

Zoe, at age six, had occasional, recurrent nightmares of fire ever since she witnessed the Oakland/Berkeley Firestorm³ when she was two years old. The following dream was one of the worst episodes of this theme.

The Killing Fire

I was at my school and about six people came and set fire to the whole school and it burned all the way to the Golden Gate Bridge and they were going to kill all the kids and they only chose to save my sister.

She woke from the dream in the middle of the night, tearfully pleading for hugs and reassurance. She did not feel comfortable or ready to talk about the nightmare at the time or even in the morning before school. Because of her artistic inclination, she was, however, intrigued with the idea of drawing her fire dream that evening and ended up making a series of sketches with markers.

By talking about the elements of her drawing, the bright colors, the architecture of her school, and placement of the Golden Gate Bridge, Zoe was able to begin exploring the dream through the medium of her sketches. This led her to recall some of her earlier fire dreams and to ask a series of questions about the Firestorm--how it had started and where she was during the event. She decided she wanted to actually see the site of the fire, which was located quite near some friends of the family. At the time of the visit, many houses had been rebuilt, but she was fascinated by the fact that there were still empty lots and burned out foundations where homes had been destroyed.

Like many children her age and older, Zoe did not want to discuss other fears connected to her recent fire dream except to say that she had the dream after watching a violent movie at a friend's house. Although she may have had other worries at the time of the nightmare, her desire not to explore further was respected by her parents. However her artistic rendition of the dream, curious questions, and resulting visit to the fire zone resolved her fire nightmares. Subsequent to her creative exploration of this nightmare, she gradually became more forthcoming in reporting upsetting dreams and even offering ideas about what caused them based on the previous day's events.

Even chronic nightmare sufferers, both adults and children, have found relief from relatively simple treatments and techniques. Vietnam veterans with persistent nightmares have been successfully treated with psychotherapy approaches that focus on resolving both the dreams and the unresolved traumas that caused the dreams to continue.

There are a few areas of caution that should be considered with respect to rescripting. The first is the use of violence in fantasy solutions to bad dreams. Killing the nightmare adversary may not be the optimal solution even in imaginary battles. Ann Sayre Wiseman, author of Nightmare Help warns that suggesting the murder or destruction of a dream foe may subtly encourage violent solutions to life problems and reinforce a tendency that children are already overexposed to through television, movies, news and violence in our society. On the other hand, encouraging creative, nonviolent, assertion in working out dream battles, may lead to improved and more constructive waking problem-solving skills.

The second caution is about the limits of creating new endings for nightmares. There is a misconception that using fantasy and magical tools to create a new dream ending assures that the underlying problem that stimulated the dream has been resolved. This may not be the case. While impressive results have been obtained using rescripting to reduce the frequency and intensity of nightmares, we must remember that nightmares, especially recurring ones, are messages--even warnings--from within that we are overwhelmed by a new situation, crisis, or chronic conflict such as a custody dispute or marital conflict. When there is a persistent problem in a child's life, we may need to go beyond reassurance and rescripting to discover fundamental solutions to the life problems that set off the dream. This leads us to the two final R's - rehearsal and resolution.

Rehearsal is practicing solutions to a nightmare's various threats. Going a step beyond the new endings or magical tools used in rescripting a nightmare, rehearsal involves repeating the dream and its solutions in various forms until a sense of mastery or accomplishment has been achieved. This stage parallels the stage of psychotherapy called "working through," where for adults, the insights they have gained need to be put to the test--at first in the relationship with their therapist and gradually by practicing new forms of relating with others and experiencing themselves in new ways.

Resolution is the final stage of alleviating the haunting spell of a nightmare. Discovering the source of the nightmare in your child's life and working towards acknowledging and even correcting the life problem that has caused the nightmares are preliminary steps. Resolution can only come after a child feels secure enough (reassurance) to explore new solutions through art, writing, drama, and discussion (rescripting) and has practiced those solutions (rehearsal) with a parent or adult guide.

If a child continues to be curious about what is emerging from his or her exploration of a dream, they can be encouraged to honor their dream by connecting it to a person, situation, or feeling in their current life. By keeping in mind the major emotional issues affecting your child such, as the birth of a sibling or starting at a new school, parents can be alerted to the probable sources of a nightmare.

Through the process of exploring, brainstorming, and rehearsing metaphoric solutions to their children's nightmares, parents begin to feel more secure in linking dream symbols to the current events and relationships in their child's waking world. Nightmares emphasize to parents exactly what is most difficult for their child and open up possibilities for resolving important emotional challenges.

When To Seek Help for Nightmares

Whereas moderate nightmare activity may be a potentially healthy sign that the unconscious mind is actively coping with stress and change, frequent nightmares indicate unresolved conflicts that are overwhelming your child. When children's nightmares persist, when their content is consistently violent or disturbing, and when the upsetting conflicts in the dreams never seem to change or even achieve partial resolution, it may be time to seek further help from a mental health specialist or pediatrician. Especially if there is no obvious stress in your child's life, repetitive nightmares could also be caused by a reaction to drugs or a physical condition, so it is advisable to consult a physician to rule out medical causes when nightmares do not appear to have a psychological origin.

Repetitive nightmares are often accompanied by other symptoms especially fears of going to sleep, anxieties or phobias. Increased nightmares can usually be linked to a recognizable stress in the child's life such as absence or loss of a parent, suffering abuse or violence, marital or custody disputes in the family, social or academic difficulties at school, such as being teased or having an undiagnosed learning or attention problem.

Nightmares are more often like a vaccine than a poison. A vaccination infects us with a minute dose of a disease that mobilizes our antibodies and makes us more resistant to the virulence of smallpox or polio. As distressing as nightmares can be, they offer powerful information about issues that are distressing your child. When children share their nightmares and receive reassurance from their parents, they feel the emotional sting of the dream, but also begin the process of strengthening their psychological defenses and facing their fears with more resilience. Gradually, a parent's empathic response to their child's nightmares can break the cycle of bad dreams and transform intensely negative experiences into triumphs of assertiveness and collaborative family problem solving.

The above excerpt was reprinted with permission from Dreamcatching: Every Parent's Guide to Exploring and Understanding Children's Dreams and Nightmares by Alan Siegel and Kelly Bulkeley. Published by Random House's Three Rivers Press. Copyright © 1998.

Notes

1. Ernest Hartmann, 1991.
2. The concept of "rescripting" was adapted from Gordon Halliday, "Treating Nightmares in Children" in Charles Schaeffer, (editor) Clinical Handbook of Sleep Disorders in Children (New York, Jason Aronson, 1995)
3. Alan Siegel, "The Dreams of Firestorm Survivors", in Barrett, Deirdre (editor), Trauma and Dreams, (Boston: Harvard University Press, 1996).

Reprinted with permission from Alan Siegel, PhD

For additional articles on sleep and dreams, click on http://www.asdreams.org/magazine/articles/index.htm

Reviewed by athealth on February 6, 2014.

What is OCD?

Obsessive-compulsive disorder, one of the anxiety disorders, is a potentially disabling condition characterized by obsessive thoughts or compulsive behaviors. While most people at one time or another experience such thoughts or behaviors, an individual with OCD experiences obsessions and compulsions for more than an hour each day, in a way that interferes with his or her life.

How Common Is OCD?

Approximately 2.2 million American adults age 18 and older, or about 1.0 percent of people in this age group in a given year, have OCD.^1,2 It occurs equally in men and women. The first symptoms of OCD often begin during childhood or adolescence; however, the median age of onset is 19.³

What Are Key Features and Symptoms of OCD

Obsessions are unwanted ideas or impulses that repeatedly well up in the mind of the person with OCD. Persistent fears that harm may come to self or a loved one, an unreasonable concern with becoming contaminated, an excessive need to do things correctly or perfectly, or an excessive concern with sin or blasphemy are common. Again and again, the individual experiences a disturbing thought, such as, "My hands may be contaminated; I must wash them"; "I may have left the stove on"; or "I am going to injure my child." These thoughts are intrusive, unpleasant, and produce a high degree of anxiety. Sometimes the obsessions are of a violent or a sexual nature, or concern illness.

In response to their obsessions, most people with OCD resort to repetitive behaviors called compulsions. The most common of these are washing and checking. Other compulsive behaviors include counting (often while performing another compulsive action such as hand washing), repeating, hoarding, and endlessly rearranging objects in an effort to keep them in precise alignment with each other. Mental problems, such as mentally repeating phrases, listmaking, or checking are also common. These behaviors generally are intended to ward off harm to the person with OCD or others. Some people with OCD have regimented rituals while others have rituals that are complex and changing. Performing rituals may give the person with OCD some relief from anxiety, but it is only temporary.

People with OCD show a range of insight into the senselessness of their obsessions. Often, especially when they are not actually having an obsession, they can recognize that their obsessions and compulsions are unrealistic. At other times they may be unsure about their fears or even believe strongly in their validity.

Most people with OCD struggle to banish their unwanted, obsessive thoughts and to prevent themselves from engaging in compulsive behaviors. Many are able to keep their obsessive-compulsive symptoms under control during the hours when they are at work or attending school. But over the months or years, resistance may weaken, and when this happens, OCD may become so severe that time-consuming rituals take over the sufferers' lives, making it impossible for them to continue activities outside the home.

OCD sufferers may attempt to hide their disorder rather than seek help. Often they are successful in concealing their obsessive-compulsive symptoms from friends and coworkers. An unfortunate consequence of this secrecy is that people with OCD may not receive professional help until years after the onset of their disease. By that time, they may have learned to work their lives - and their family members' lives - around the rituals.

What Is the Treatment for OCD?

OCD is generally treated with psychotherapy, medication, or both.

Psychotherapy. A type of psychotherapy called cognitive behavior therapy is especially useful for treating OCD. It teaches a person different ways of thinking, behaving, and reacting to situations that help him or her feel less anxious or fearful without having obsessive thoughts or acting compulsively.

One type of therapy called exposure and response prevention is especially helpful in reducing compulsive behaviors in OCD. In this approach, the patient deliberately and voluntarily confronts the feared object or idea, either directly or by imagination. At the same time the patient is strongly encouraged to refrain from ritualizing, with support and structure provided by the therapist, and possibly by others whom the patient recruits for assistance. For example, a compulsive hand washer may be encouraged to touch an object believed to be contaminated, and then urged to avoid washing for several hours until the anxiety provoked has greatly decreased. Treatment then proceeds on a step-by-step basis, guided by the patient's ability to tolerate the anxiety and control the rituals. As treatment progresses, most patients gradually experience less anxiety from the obsessive thoughts and are able to resist the compulsive urges.

Medication. Doctors also may prescribe medication to help treat OCD. The most commonly prescribed medications for OCD are anti-anxiety medications and antidepressants.

Anti-anxiety medications are powerful and there are different types. Many types begin working right away, but they generally should not be taken for long periods.

Antidepressants are used to treat depression, but they are also particularly helpful for OCD, probably more so than anti-anxiety medications. They may take several weeks - 10 to 12 weeks for some - to start working. Some of these medications may cause side effects such as headache, nausea, or difficulty sleeping. These side effects are usually not a problem for most people, especially if the dose starts off low and is increased slowly over time. Talk to your doctor about any side effects you may have.

It's important to know that although antidepressants can be safe and effective for many people, they may be risky for some, especially children, teens, and young adults. A "black box" - the most serious type of warning that a prescription drug can have - has been added to the labels of antidepressant medications. These labels warn people that antidepressants may cause some people to have suicidal thoughts or make suicide attempts. Anyone taking antidepressants should be monitored closely, especially when they first start treatment with medications.

Some people with OCD do better with cognitive behavior therapy, especially exposure and response prevention. Others do better with medication. Still others do best with a combination of the two. Talk with your health care provider about the best treatment for you.

What Can Family Members Do to Help?

OCD affects not only the sufferer but the whole family. The family often has a difficult time accepting the fact that the person with OCD cannot stop the distressing behavior. Family members may show their anger and resentment, resulting in an increase in the OCD behavior. Or, to keep the peace, they may assist in the rituals or give constant reassurance.

Education about OCD is important for the family. Families can learn specific ways to encourage the person with OCD to adhere fully to behavior therapy and/or pharmacotherapy programs. Self-help books are often a good source of information. Some families seek the help of a family therapist who is trained in the field. Also, in the past few years, many families have joined one of the educational support groups that have been organized throughout the country.

Sources

1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.
2. U.S. Census Bureau Population Estimates by Demographic Characteristics. Table 2: Annual Estimates of the Population by Selected Age Groups and Sex for the United States: April 1, 2000 to July 1, 2004 (NC-EST2004-02) Source: Population Division, U.S. Census Bureau Release Date: June 9, 2005. http://www.census.gov/popest/national/asrh/
3. Kessler RC, Berglund PA, Demler O, Jin R, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry. 2005 Jun;62(6):593-602.
4. American Psychiatric Association. Diagnostic and Statistical Manual on Mental Disorders, fourth edition (DSM-IV). Washington, DC: American Psychiatric Press, 1994.
5. Foa EB and KoZak MJ. Obsessive-compulsive disorder: long-term outcome of psychological treatment. In Mavissakalian & Prien (Eds.), Long-term Treatments of Anxiety Disorders. Washington, DC: American Psychiatric Press, 1996, 285-309.

Adapted from NIH Publications 96-3755 and TR 10-4676

Reviewed by athealth on February 6, 2014.

What is obsessive-compulsive disorder or OCD?
People with obsessive-compulsive disorder have either obsessions, or compulsions, or both. The obsessions and/or compulsions are great enough to cause significant distress in their employment, schoolwork, or personal and social relationships.
What characteristics are associated with OCD?
Obsessions:
People with obsessions are bothered by thoughts or images that continue to repeat themselves and are almost impossible to ignore. These thoughts, which are annoying, distracting, and inappropriate, tend to cause the person to have moderate to severe anxiety and other emotional discomfort. Common obsessive thoughts include themes of violence, fear of germs and/or infection, and doubts about one’s character and/or behavior. People who suffer from OCD worry excessively and often attempt to avoid or to get rid of the bothersome thoughts by trying to replace them with more pleasant thoughts or actions.
Compulsions:
Compulsions are behaviors. These specific behaviors are in direct response to the person's troublesome, obsessive thinking. Therefore, people engage in the compulsive behaviors in order to reduce their obsessive thoughts.
Some of the most prevalent compulsions are:

• Repeated checking of doors, locks, electrical appliances, or light switches
  
• Frequent cleaning of hands or clothes
  
• Strict attempts to keep various, personal items in careful order
  
• Mental activities that are repetitious, such as counting or praying

Are there genetic factors associated with OCD?
Yes, there are some genetic factors associated with obsessive-compulsive disorder. Research shows that people who have OCD frequently have close relatives who have a similar problem.
Does OCD affect males, females, or both?
In the United States, obsessive-compulsive disorder affects males and females in equal numbers.
At what age does OCD appear?
Males tend to experience obsessions and compulsions at an earlier age than females. OCD seems to frequently affect males somewhere between the ages of six (6) and fifteen (15). It is more common for females to be first diagnosed with OCD in late adolescence or early adulthood.
How common is OCD in our society?
It is believed that OCD affects between two to three percent (2%-3%) of the U.S. population.
How is OCD diagnosed?
Commonly, obsessive-compulsive disorder is first diagnosed when parents recognize that their young child or teenager seems preoccupied with ritualistic behaviors associated with excessive cleanliness or unusually meticulous organization, and they seek help from a mental health professional. Adults, on the other hand, may seek professional help when they realize that it is becoming difficult for them to do their job or school work because they are spending too much time with their obsessive thoughts or compulsive behaviors.
Therapists make the diagnosis of OCD by taking a careful personal history from the patient/client and any available family members, such as in the case of a young child.
How is OCD treated?
Some of the most common methods of treatment for people with obsessive-compulsive disorder are behavior therapy, prescription medication, or a combination of both. Current medications used for the treatment of OCD include Anafranil (clomipramine), Luvox (fluvoxamine), Paxil (paroxetine), and Prozac (fluoxetine). These medications can help diminish obsessive thinking and the subsequent compulsive behaviors.
What happens to someone with OCD?
Although most people improve with adequate treatment, the condition can continue for many years.
What can people do if they need help?
If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.
Page last modified or reviewed on January 4, 2010

by James Lehman, MSW

When Hunter was a baby, Pat never imagined parenting him would mean becoming trapped in an argument that would last 15 years. From the time he was old enough to express himself, it seemed that he was looking for a fight with her.

"He's a very strong-willed person," says Pat, her polite demeanor belying an obvious understatement. "He's manipulative, and he learned at a very young age how to make that work for him to get what he wanted."

"The simplest things always seem to turn into huge problems because Hunter simply refuses to do what he is asked to do, whether it was brushing his teeth at age five, or raking the yard at age 15. The word 'no' lights his fuse, especially when in response to something he wants to do. He's always doing these irritating things," Pat explains, "as if he enjoys bothering you."

Getting out of bed in the morning is the issue around which Hunter and his parents argue the most. "We've had the worst time in the world getting him up in the morning and into the shower. I know this is unbelievable, but he gets in the shower, stretches out in the bottom of the tub with the water beating on him, and goes back to sleep. From that moment on, we have to micromanage his morning to get him to the bus stop."

Recently, Hunter was diagnosed with Oppositional Defiant Disorder, and Pat finally has a name for the behavior that's been exhausting her all these years. Now, she needs a solution. How does a parent stop the arguments with a child whose primary way of communicating is arguing?

A day with a child who has Oppositional Defiant Disorder is a series of battles in an undeclared war. It starts when they wake up, continues at breakfast, intensifies when they have to get dressed, and doesn't end until they fight with you over bedtime.

Kids with ODD lose their temper quickly and often. They're easily annoyed and frustrated by other people, resentful and hostile with adults, bossy and pushy with other kids. They blame everyone else for their difficulties and make excuses for their inability to cope. They gravitate toward negative peers and tend to be sulking, angry adolescents.

Unrestricted free time is a breeding ground for aggressive behavior for these children. In an unstructured environment, they become annoying, threatening or destructive to kids around them and to adult authority figures. They will use this time to deliberately antagonize anyone they see as "in charge."

As a parent, you can't satisfy a child with ODD, since their thinking is irrational. They clamor for your attention and then tell you to leave them alone. The sad truth is, kids with ODD aren't very likeable. Parents often feel guilty about the fact that they love their kids, but don't like being around them.

Parents get blamed for their child's oppositional behavior and tend to heap even more blame on themselves. The parent of a child with ODD often feels incompetent and isolated. They live with the self-imposed shame that other people think they're bad parents, and that humiliation grows larger as their world gets smaller. Left untreated, Oppositional Defiant Disorder can lead to Conduct Disorder, a more serious pathology that is a precursor for anti-social behavior and criminality.

Of course, for many parents, ODD is not the primary issue. Rather, they are dealing with continuous, low-level defiance that is not incendiary and aggressive, but is aggravating, annoying and disruptive to the family. Whether the defiance has turned into a diagnosis of ODD or has not, the parent's approach should be the same.

How to Stop the War and Restore Peace at Home

Most parents lack the tools to deal with oppositional defiance. So they generally respond to this behavior with a range of responses that includes negotiating, bargaining, giving in, threatening and screaming. The problem is when you scream, argue, or negotiate, you are giving your child's defiance even more power.

Everyone from the school psychologist to your mother-in-law will tell you what this child needs is "structure." But no one really shows you what kind of structure and how to put it in place. It's not as simple as giving the child a time out. A child with ODD won't use the time out to change his thinking. He'll use it to plot revenge. Parents need to change their parenting style and method of operation with the child.

• Children with ODD need structure with an aggressive training component that is built around learning how solve the problems that trigger their defiant behaviors. Your child becomes oppositional when he is confronted with a problem and he can't figure out how to fix it. The problem can be anything from not wanting to get up in the morning (as in Hunter's case) to not wanting to do homework. Screaming at the child to get out of bed won't work. You need to show the child that he has a problem that has to be solved and address it as such. Example: "Lying in bed after your alarm goes off won't solve your problem. It makes you late and you miss the bus. What can you do to solve your problem?"
• The focus of treatment should be on developing compliance and coping skills, not primarily on self-esteem or personality. ODD is not a self-esteem issue; it's a problem solving issue. There's no evidence that self-esteem leads to compliance, and emotions are not, in and of themselves, a way to kids to cope with their problems. Kids get self-esteem by doing things that are hard for them. Children with ODD need a lot of strong praise and support as well as realistic rewards. They don't benefit from a pat on the back for doing something that's easy for them to do. They should be praised for doing things that are challenging to them. Don't create false situations for which to praise them to make them "feel better." Parents need to learn several different parenting styles that meet the needs of this child. You need to be less of a "cheerleader" and more of a trainer and coach.
• Avoid senseless power struggles. Pick your battles with your child carefully and win the ones you pick. Many times you can win fights with this child by not arguing back. When you argue, his resistance gets stronger. Instead of arguing, set limits in a businesslike way and expect compliance.
• Have a plan for managing your child's behavior. When you're going to the mall, know what you'll do when he acts out in the car. It's important to lay out the rules ahead of time, when things are calm. For instance, before you go to the mall, tell the child, "When you lose it in the car, it becomes dangerous for me and for everyone because it's distracting. So if you lose it in the car, I'm going to pull over for five minutes, and I'm not going to talk to you. You'll have five minutes to get your act together. If, after five minutes, you have not regained control of yourself, then we're not going to the mall. We're going to turn around and go home. " Have a plan you'll use if he throws a tantrum in the store or if he acts out at a family gathering. And be willing to follow through on the plan until the child learns defiance doesn't get him what he wants.

Parents dealing with ODD need a powerful mix of determination and strength. You can have a child with ODD and a peaceful home. The key is to decide: Are you going to change the world for your child or teach him to cope with it? It's not practical or effective to try to change the world for your kid. But by setting limits consistently, concisely and clearly, you will teach your child to cope with the world and succeed in it.

Oppositional Defiant Disorder: The War at Home reprinted with permission from Empowering Parents. For more information, visit www.EmpoweringParents.com

Author: James Lehman is a behavioral therapist and the creator of The Total Transformation® Program for parents. He has worked with troubled children and teens for three decades. James holds a Masters Degree in Social Work from Boston University.

Reviewed by athealth on February 6, 2014.

Cup half empty? Or cup half full? How would you describe yourself? Do you see events through a prism of optimism or through a prism of pessimism? There is a growing body of research which examines the effect that your attitude has on your health, your sense of well-being, and even on your longevity. Some studies have revealed that individuals with an optimistic perspective on life generally have a more positive sense of their own well being, are less likely to experience anxiety, are less prone to depression, and live longer and healthier lives.¹

Since 1994, researchers have examined the results from the Women's Health Initiative.¹ Approximately 100,000 women age fifty and over were studied in terms of their outlooks on life, their physical health, and their emotional well-being. The eight years of follow-up findings indicated that those who had optimistic outlooks lived longer and healthier lives than the pessimistic participants. Also, optimists were thirty percent less likely to die of heart disease and fourteen percent less likely to die of any cause as compared with the pessimists. In a Mayo Clinic Study following more than 800 people, those whose outlooks were pessimistic had a nineteen percent increase in risk of death, as compared to their optimistic counterparts.¹

If good health, supportive relationships, and longevity are priorities of yours, these findings warrant serious consideration. Optimists tend to be calmer, more tranquil and generally happier people. They report fewer health problems, fewer interpersonal difficulties at work and at home, and they evidence more energy and comfort in social settings.

If you view events through a prism of pessimism, you may wonder "How did I become this way?" This general attitude of yours did not just occur. It developed through a combination of nature, the genes you inherited, and nurture - all that comprises your upbringing and life experiences. While the contributing factors are numerous and intimately interrelated, they do not create an orientation that is etched in stone.

Psychotherapy can help people who are struggling with anxiety, depression, and substance abuse, as they impact on daily functioning, relationships and parenting. Through psychotherapy you can learn to identify your strengths, to overcome your challenges and limitations, and to introduce permanent change in your life. A shift in your perspective, while initially experienced as cerebral, contrived and foreign, can be a powerful tool in reorienting how you feel, think and behave. It can provide you with an opportunity to live with greater ease, to interact with others more comfortably, and to achieve greater fulfillment, as a result of the permanent change brought into your life.

References:

1. Mayo Clinic Health Letter, Volume 27, Number 7, July 2009;

Author: Maryann Schaefer, PhD

Dr. Schaefer is a Fellow of the American Psychotherapy Association and devotes her practice to helping others identify their strengths, while resolving issues that interfere with permanent change, productive living, and bonded loving. Submitted by Dr. Schaefer on July 26, 2009

Reviewed by athealth on February 6, 2014.

What Is Osteoarthritis?

Osteoarthritis (AH-stee-oh-ar-THREYE-tis) is the most common type of arthritis and is seen especially among older people. Sometimes it is called degenerative joint disease or osteoarthrosis.

Osteoarthritis mostly affects cartilage (KAR-til-uj), the hard but slippery tissue that covers the ends of bones where they meet to form a joint. Healthy cartilage allows bones to glide over one another. It also absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks and wears away. This allows bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Also, small deposits of bone - called osteophytes or bone spurs - may grow on the edges of the joint. Bits of bone or cartilage can break off and float inside the joint space. This causes more pain and damage.

People with osteoarthritis usually have joint pain and stiffness. Unlike some other forms of arthritis, such as rheumatoid arthritis, osteoarthritis affects only joint function. It does not affect skin tissue, the lungs, the eyes, or the blood vessels.
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In rheumatoid arthritis, the second most common form of arthritis, the immune system attacks the tissues of the joints, leading to pain, inflammation, and eventually joint damage and malformation. It typically begins at a younger age than osteoarthritis, causes swelling and redness in joints, and may make people feel sick, tired, and feverish. Also, the joint involvement of rheumatoid arthritis is symmetrical; that is, if one joint is affected, the same joint on the opposite side of the body is usually similarly affected. Osteoarthritis, on the other hand, can occur in a single joint or can affect a joint on one side of the body much more severely.

Who Has Osteoarthritis?

Osteoarthritis is by far the most common type of arthritis, and the percentage of people who have it grows higher with age. An estimated 27 million Americans age 25 and older have osteoarthritis.¹

Although osteoarthritis becomes more common with age, younger people can develop it, usually as the result of a joint injury, a joint malformation, or a genetic defect in joint cartilage. Both men and women have the disease. Before age 45, more men than women have osteoarthritis; after age 45, it is more common in women. It is also more likely to occur in people who are overweight and in those with jobs that stress particular joints.

As the population ages, the number of people with osteoarthritis will only grow. By 2030, a projected 67 million people will have doctor-diagnosed arthritis.²

1. Lawrence RC, Felson DT, Helmick CG, Arnold LM, Choi H, Deyo RA, Gabriel S, Hirsch R, Hochberg MC, Hunder GG, Jordan JM, Katz JN, Kremers HM, Wolfe F. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: Part II. Arthritis Rheum. 2008 Jan;58(1):26-35.
2. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum. 2006 Jan;54(1):226-29.

How Does Osteoarthritis Affect People?

People with osteoarthritis usually experience joint pain and stiffness. The most commonly affected joints are those at the ends of the fingers (closest to the nail), thumbs, neck, lower back, knees, and hips. Osteoarthritis affects different people differently. It may progress quickly, but for most people, joint damage develops gradually over years. In some people, osteoarthritis is relatively mild and interferes little with day-to-day life; in others, it causes significant pain and disability.

Although osteoarthritis is a disease of the joints, its effects are not just physical. In many people with osteoarthritis, lifestyle and finances also decline.

Lifestyle effects include

• depression
• anxiety
• feelings of helplessness
• limitations on daily activities
• job limitations
• difficulty participating in everyday personal and family joys and responsibilities.

Financial effects include

• the cost of treatment
• wages lost because of disability.

Fortunately, most people with osteoarthritis live active, productive lives despite these limitations. They do so by using treatment strategies such as rest and exercise, pain relief medications, education and support programs, learning self-care, and having a "good attitude."

What Areas Does Osteoarthritis Affect?

Osteoarthritis most often occurs at the ends of the fingers, thumbs, neck, lower back, knees, and hips.

Osteoarthritis Basics: The Joint and Its Parts

A joint is the point where two or more bones are connected. With a few exceptions (in the skull and pelvis, for example), joints are designed to allow movement between the bones and to absorb shock from movements like walking or repetitive motions. These movable joints are made up of the following parts:

• Cartilage. A hard but slippery coating on the end of each bone. Cartilage, which breaks down and wears away in osteoarthritis. Cartilage is the key to healthy joints. Cartilage is 65 to 80 percent water. The remaining three components - collagen, proteoglycans, and chondrocytes - are described below.
  

  Collagen (KAHL-uh-jen). A family of fibrous proteins, collagens are the building blocks of skin, tendon, bone, and other connective tissues.

Proteoglycans (PRO-tee-uh-GLY-kanz). Made up of proteins and sugars, strands of proteoglycans interweave with collagens and form a mesh-like tissue. This allows cartilage to flex and absorb physical shock.

Chondrocytes (KAHN-druh-sytz). Found throughout the cartilage, chondrocytes are cells that produce cartilage and help it stay healthy as it grows. Sometimes, however, they release substances called enzymes that destroy collagen and other proteins. Researchers are trying to learn more about chondrocytes.

• Joint capsule. A tough membrane sac that encloses all the bones and other joint parts.
• Synovium (sin-O-vee-um). A thin membrane inside the joint capsule that secretes synovial fluid.
• Synovial fluid. A fluid that lubricates the joint and keeps the cartilage smooth and healthy.
• Ligaments, tendons, and muscles. Tissues that surround the bones and joints, and allow the joints to bend and move. Ligaments are tough, cord-like tissues that connect one bone to another.
• Tendons. Tough, fibrous cords that connect muscles to bones. Muscles are bundles of specialized cells that, when stimulated by nerves, either relax or contract to produce movement.

How Do You Know if You Have Osteoarthritis?

Usually, osteoarthritis comes on slowly. Early in the disease, your joints may ache after physical work or exercise. Later on, joint pain may become more persistent. You may also experience joint stiffness, particularly when you first wake up in the morning or have been in one position for a long time.

Although osteoarthritis can occur in any joint, most often it affects the hands, knees, hips, and spine (either at the neck or lower back). Different characteristics of the disease can depend on the specific joint(s) affected. For general warning signs of osteoarthritis, see the box "The Warning Signs of Osteoarthritis." For information on the joints most often affected by osteoarthritis, see the following descriptions:

Hands. Osteoarthritis of the hands seems to have some hereditary characteristics; that is, it runs in families. If your mother or grandmother has or had osteoarthritis in their hands, you're at greater-than-average risk of having it too. Women are more likely than men to have hand involvement and, for most, it develops after menopause.

When osteoarthritis involves the hands, small, bony knobs may appear on the end joints (those closest to the nails) of the fingers. They are called Heberden's (HEBerr-denz) nodes. Similar knobs, called Bouchard's (boo-SHARDZ) nodes, can appear on the middle joints of the fingers. Fingers can become enlarged and gnarled, and they may ache or be stiff and numb. The base of the thumb joint also is commonly affected by osteoarthritis.

Knees. The knees are among the joints most commonly affected by osteoarthritis. Symptoms of knee osteoarthritis include stiffness, swelling, and pain, which make it hard to walk, climb, and get in and out of chairs and bathtubs. Osteoarthritis in the knees can lead to disability.

Hips. The hips are also common sites of osteoarthritis. As with knee osteoarthritis, symptoms of hip osteoarthritis include pain and stiffness of the joint itself. But sometimes pain is felt in the groin, inner thigh, buttocks, or even the knees. Osteoarthritis of the hip may limit moving and bending, making daily activities such as dressing and putting on shoes a challenge.

Spine. Osteoarthritis of the spine may show up as stiffness and pain in the neck or lower back. In some cases, arthritis-related changes in the spine can cause pressure on the nerves where they exit the spinal column, resulting in weakness, tingling, or numbness of the arms and legs. In severe cases, this can even affect bladder and bowel function.

The Warning Signs of Osteoarthritis Stiffness in a joint after getting out of bed or sitting for a long time Swelling or tenderness in one or more joints. Crunching feeling or the sound of bone rubbing on bone. About a third of people whose x rays show evidence of osteoarthritis report pain or other symptoms. For those who experience steady or intermittent pain, it is typically aggravated by activity and relieved by rest. If you feel hot or your skin turns red, or if your joint pain is accompanied by other symptoms such as a rash or fevers, you probably do not have osteoarthritis. Check with your doctor about other causes, such as rheumatoid arthritis.

How Do Doctors Diagnose Osteoarthritis?

No single test can diagnose osteoarthritis; however, sometimes doctors use tests to help confirm a diagnosis or rule out other conditions that could be causing a patient's symptoms. Most doctors use a combination of the following methods:

Clinical history: The doctor begins by asking the patient to describe the symptoms, and when and how the condition started, as well as how the symptoms have changed over time. The doctor will also ask about any other medical problems the patient and close family members have and about any medications the patient is taking. Accurate answers to these questions can help the doctor make a diagnosis and understand the impact the disease has on your life.

Physical examination: The doctor will check the patient's reflexes and general health, including muscle strength. The doctor will also examine bothersome joints and observe the patient's ability to walk, bend, and carry out activities of daily living.

X rays: X rays can help doctors determine the form of arthritis a person has and how much joint damage has been done. X rays of the affected joint can show such things as cartilage loss, bone damage, and bone spurs. But there often is a big difference between the severity of osteoarthritis as shown by the x ray and the degree of pain and disability felt by the patient. Also, x rays may not show early osteoarthritis damage until much cartilage loss has taken place.

Magnetic resonance imaging: Also known as MRI, magnetic resonance imaging provides high-resolution computerized images of internal body tissues. This procedure uses a strong magnet that passes a force through the body to create these images. Doctors often use MRI tests if there is pain; if x-ray findings are minimal; and if the findings suggest damage to other joint tissues such as a ligament or the pad of connective tissue in the knee known as the meniscus.

Other tests: The doctor may order blood tests to rule out other causes of symptoms. He or she may also order a joint aspiration, which involves drawing fluid from the joint through a needle and examining the fluid under a microscope. Joint fluid samples could reveal bacteria, indicating joint pain is caused by an infection or uric acid crystals, indicating gout.

Osteoarthritis is so common, especially in older people, that symptoms seemingly caused by the disease actually may be caused by other medical conditions. The doctor will try to find out what is causing the symptoms by ruling out other disorders and identifying conditions that may make the symptoms worse. The severity of symptoms in osteoarthritis can be influenced greatly by the patient's attitude, anxiety, depression, and daily activity level.

How Is Osteoarthritis Treated?

Most successful treatment programs involve a combination of treatments tailored to the patient's needs, lifestyle, and health. Osteoarthritis treatment has four general goals:

• Improve joint function
• Maintain an acceptable body weight
• Control pain with medicine and other measures
• Achieve a healthy lifestyle

Treatment Approaches to Osteoarthritis Exercise Weight control Rest and relief from stress on joints Nondrug pain relief techniques and alternative therapies Medications to control pain Surgery

Most successful treatment programs involve a combination of treatments tailored to the patient's needs, lifestyle, and health. Most programs include ways to manage pain and improve function. These can involve exercise, weight control, rest and relief from stress on joints, pain relief techniques, medications, surgery, and complementary and alternative therapies. These approaches are described below.

Exercise

Research shows that exercise is one of the best treatments for osteoarthritis. Exercise can improve mood and outlook, decrease pain, increase flexibility, strengthen the heart and improve blood flow, maintain weight, and promote general physical fitness. Exercise is also inexpensive and, if done correctly, has few negative side effects. The amount and form of exercise prescribed will depend on which joints are involved, how stable the joints are, and whether a joint replacement has already been done. Walking, swimming, and water aerobics are a few popular types of exercise for people with osteoarthritis. Your doctor and/or physical therapist can recommend specific types of exercise depending on your particular situation. (See section "What You Can Do: The Importance of Self-Care and a Good Health Attitude").

On the Move: Fighting Osteoarthritis With ExerciseYou can use exercises to keep strong and limber, improve cardiovascular fitness, extend your joints' range of motion, and reduce your weight. The following types of exercise are part of a well-rounded arthritis treatment plan. Strength exercises: These exercises strengthen muscles that support joints affected by arthritis. They can be performed with weights or with exercise bands, inexpensive devices that add resistance. Aerobic activities: These are exercises, such as brisk walking or low-impact aerobics, that get your heart pumping and can keep your lungs and circulatory system in shape. Range of motion activities: These keep your joints limber. Balance and agility exercises: These can help you maintain daily living skills. Ask your doctor or physical therapist what exercises are best for you. Ask for guidelines on exercising when a joint is sore or if swelling is present. Also, check if you should (1) use pain-relieving drugs, such as analgesics or anti-inflammatories (also called NSAIDs or nonsteroidal anti-inflammatory drugs) to make exercising easier, or (2) use ice afterward.

Weight control: Osteoarthritis patients who are overweight or obese should try to lose weight. Weight loss can reduce stress on weight-bearing joints, limit further injury, and increase mobility. A dietitian can help you develop healthy eating habits. A healthy diet and regular exercise help reduce weight.

Rest and relief from stress on joints: Treatment plans include regularly scheduled rest. Patients must learn to recognize the body's signals, and know when to stop or slow down. This will prevent the pain caused by overexertion. Although pain can make it difficult to sleep, getting proper sleep is important for managing arthritis pain. If you have trouble sleeping, you may find that relaxation techniques, stress reduction, and biofeedback can help, as can timing medications to provide maximum pain relief through the night. If joint pain interferes with your ability to sleep or rest, consult your doctor.

Some people find relief from special footwear and insoles that can reduce pain and improve walking or from using canes to take pressure off painful joints. They may use splints or braces to provide extra support for joints and/or keep them in proper position during sleep or activity. Splints should be used only for limited periods of time because joints and muscles need to be exercised to prevent stiffness and weakness. If you need a splint, an occupational therapist or a doctor can help you get a properly fitted one.

Nondrug pain relief and alternative therapies: People with osteoarthritis may find many nondrug ways to relieve pain. Below are some examples:

Heat and cold. Heat or cold (or a combination of the two) can be useful for joint pain. Heat can be applied in a number of different ways - with warm towels, hot packs, or a warm bath or shower - to increase blood flow and ease pain and stiffness. In some cases, cold packs (bags of ice or frozen vegetables wrapped in a towel), which reduce inflammation, can relieve pain or numb the sore area. (Check with a doctor or physical therapist to find out if heat or cold is the best treatment.)

Transcutaneous electrical nerve stimulation (TENS). TENS is a technique that uses a small electronic device to direct mild electric pulses to nerve endings that lie beneath the skin in the painful area. TENS may relieve some arthritis pain. It seems to work by blocking pain messages to the brain and by modifying pain perception.

Massage. In this pain-relief approach, a massage therapist will lightly stroke and/or knead the painful muscles. This may increase blood flow and bring warmth to a stressed area. However, arthritis-stressed joints are sensitive, so the therapist must be familiar with the problems of the disease.

Complementary and alternative therapies. When conventional medical treatment doesn't provide sufficient pain relief, people are more likely to try complementary and alternative therapies to treat osteoarthritis. Some people have found pain relief using acupuncture, a practice in which fine needles are inserted by a licensed acupuncture therapist at specific points on the skin. Scientists think the needles stimulate the release of natural, pain-relieving chemicals produced by the nervous system. A large study supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and the National Center for Complementary and Alternative Medicine (NCCAM) revealed that acupuncture relieves pain and improves function in knee osteoarthritis, and it serves as an effective complement to standard care.[3]

Folk remedies include the wearing of copper bracelets, following special diets, and rubbing WD-40 on joints to "lubricate" them. Although these practices may or may not be harmful, no scientific research to date shows that they are helpful in treating osteoarthritis. They can also be expensive, and using them may cause people to delay or even abandon useful medical treatment.

Nutritional supplements such as glucosamine and chondroitin sulfate have been reported to improve the symptoms of people with osteoarthritis, as have certain vitamins. Additional studies have been carried out to further evaluate these claims (see "Research Highlights"). It is unknown whether they might change the course of disease.

3 Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AM, Hochberg MC. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med. 2004 Dec 21;141(12):901-10.

Medications to control pain: Doctors prescribe medicines to eliminate or reduce pain and to improve functioning. Doctors consider a number of factors when choosing medicines for their patients with osteoarthritis. These include the intensity of pain, potential side effects of the medication, your medical history (other health problems you have or are at risk for), and other medications you are taking.

Because some medications can interact with one another and certain health conditions put you at increased risk of drug side effects, it's important to discuss your medication and health history with your doctor before you start taking any new medication, and to see your doctor regularly while you are taking medication. By working together, you and your doctor can find the medication that best relieves your pain with the least risk of side effects.

The following types of medicines are commonly used in treating osteoarthritis:

Acetaminophen: A medication commonly used to relieve pain, acetaminophen, is available without a prescription. It is often the first medication doctors recommend for osteoarthritis patients because of its safety relative to some other drugs and its effectiveness against pain.

NSAIDs (nonsteroidal anti-inflammatory drugs): A large class of medications useful against both pain and inflammation, (NSAIDs)4 are staples in arthritis treatment. Aspirin, ibuprofen, naproxen, and naproxen sodium are examples of NSAIDs. They are often the first type of medication used. All NSAIDs work similarly: by blocking substances called prostaglandins that contribute to inflammation and pain. However, each NSAID is a different chemical, and each has a slightly different effect on the body.

Some NSAIDs are available over the counter, while more than a dozen others, including a subclass called COX-2 inhibitors, are available only with a prescription.

All NSAIDs can have significant side effects, and for unknown reasons, some people seem to respond better to one NSAID than another. Any person taking NSAIDs regularly should be monitored by a doctor.

Reducing the Risks of NSAID Use

Certain health problems and lifestyle habits can increase the risk of side effects from NSAIDs. These include a history of peptic ulcers or digestive tract bleeding, use of oral corticosteroids or anticoagulants (blood thinners), smoking, and alcohol use.

There are measures you can take to help reduce the risk of side effects associated with NSAIDs. These include taking medications with food and avoiding stomach irritants such as alcohol, tobacco, and caffeine. In some cases, it may help to take another medication along with an NSAID to coat the stomach or block stomach acids. Although these measures may help, they are not always completely effective.

Warning: NSAIDs can cause stomach irritation or, less often, they can affect kidney function. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs, because NSAIDs alter the way the body uses or eliminates these other drugs. Check with your health care provider or pharmacist before you take NSAIDs. Also, NSAIDs sometimes are associated with serious gastrointestinal problems, including ulcers, bleeding, and perforation of the stomach or intestine. People over age 65 and those with any history of ulcers or gastrointestinal bleeding should use NSAIDs with caution.

Narcotic or central acting agents. Tramadol is a prescription pain reliever and synthetic opioid that is sometimes prescribed when over-the-counter medications don't provide sufficient relief. It works through the central nervous system to achieve its effects. Tramadol carries risks that don't exist with acetaminophen and NSAIDs, including the potential for addiction.

Mild narcotic painkillers containing analgesics such as codeine or hydrocodone are often effective against osteoarthritis pain. But because of concerns about the potential for physical and psychological dependence on these drugs, doctors generally reserve them for short-term use.

Injections. Corticosteroids are powerful anti-inflammatory hormones made naturally in the body or man made for use as medicine. They may be injected into the affected joints to temporarily relieve pain. This is a short-term measure, generally not recommended for more than two to four treatments per year. Oral corticosteroids are not routinely used to treat osteoarthritis. They are occasionally used for inflammatory flares.

Hyaluronic acid substitutes. Sometimes called viscosupplements, hyaluronic acid substitutes are designed to replace a normal component of the joint involved in joint lubrication and nutrition. Depending on the particular product your doctor prescribes, it will be given in a series of three to five injections. These products are approved only for osteoarthritis of the knee.

Other medications. Doctors may prescribe several other medicines for osteoarthritis. They include topical pain-relieving creams, rubs, and sprays, which are applied directly to the skin over painful joints. They contain ingredients that work in one of three different ways: (1) by stimulating the nerve endings to distract the brain's attention from the joint pain, (2) by depleting the amount of a neurotransmitter called substance P that sends pain messages to the brain, or (3) by blocking chemicals called prostaglandins that cause pain and inflammation.

Because most medicines used to treat osteoarthritis have side effects, it's important to learn as much as possible about the medications you take, even the ones available without a prescription. Certain health problems and lifestyle habits can increase the risk of side effects from NSAIDs. These include a history of peptic ulcers or digestive tract bleeding, use of oral corticosteroids or anticoagulants (blood thinners), smoking, and alcohol use.

There are measures you can take to help reduce the risk of side effects associated with NSAIDs. These include taking medications with food and avoiding stomach irritants such as alcohol, tobacco, and caffeine. In some cases, it may help to take another medication along with an NSAID to coat the stomach or block stomach acids. Although these measures may help, they are not always completely effective.

Questions To Ask Your Doctor or Pharmacist About Medicines

• How often should I take this medicine?
• Should I take this medicine with food or between meals?
• What side effects might occur?
• Should I take this medicine with the other prescription or over-the-counter medicines I take?
• Is this medication safe considering other medical conditions I have?

Surgery: For many people, surgery helps relieve the pain and disability of osteoarthritis. Surgery may be performed to achieve one or more of the following:

• removal of loose pieces of bone and cartilage from the joint if they are causing symptoms of buckling or locking (arthroscopy)
• repositioning of bones (osteotomy)
• resurfacing (smoothing out) bones (joint resurfacing).

Surgeons may replace affected joints with artificial joints called prostheses. These joints can be made from metal alloys, high-density plastic, and ceramic material. Some prostheses are joined to bone surfaces with special cements. Others have porous surfaces and rely on the growth of bone into that surface (a process called biologic fixation) to hold them in place. Artificial joints can last 10 to 15 years or longer. Surgeons choose the design and components of prostheses according to their patient's weight, sex, age, activity level, and other medical conditions.

Joint replacement advances in recent years have included the ability, in some cases, to replace only the damaged part of the knee joint, leaving undamaged parts of the joint intact, and the ability to perform hip replacement through much smaller incisions than previously possible.

The decision to use surgery depends on several factors, including the patient's age, occupation, level of disability, pain intensity, and the degree to which arthritis interferes with his or her lifestyle. After surgery and rehabilitation, the patient usually feels less pain and swelling and can move more easily.

Who Provides Care for People With Osteoarthritis?

Treating arthritis often requires a multidisciplinary or team approach. Many types of health professionals care for people with arthritis. You may choose a few or more of the following professionals to be part of your health care team:

Primary care physicians. Doctors who treat patients before they are referred to other specialists in the health care system. Often a primary care physician will be the main doctor to treat your arthritis. Primary care physicians also handle other medical problems and coordinate the care you receive from other physicians and health care providers.

Rheumatologists. Doctors who specialize in treating arthritis and related conditions that affect joints, muscles, and bones.

Orthopaedists. Surgeons who specialize in the treatment of, and surgery for, bone and joint diseases.

Physical therapists. Health professionals who work with patients to improve joint function.

Occupational therapists. Health professionals who teach ways to protect joints, minimize pain, perform activities of daily living, and conserve energy.

Dietitians. Health professionals who teach ways to use a good diet to improve health and maintain a healthy weight.

Nurse educators. Nurses who specialize in helping patients understand their overall condition and implement their treatment plans.

Physiatrists (rehabilitation specialists). Medical doctors who help patients make the most of their physical potential.

Licensed acupuncture therapists. Health professionals who reduce pain and improve physical functioning by inserting fine needles into the skin at specific points on the body.

Psychologists. Health professionals who seek to help patients cope with difficulties in the home and workplace resulting from their medical conditions.

Social workers. Professionals who assist patients with social challenges caused by disability, unemployment, financial hardships, home health care, and other needs resulting from their medical conditions.

Chiropractors. Health professionals who focus treatment on the relationship between the body's structure—mainly the spine—and its functioning.

Massage therapists. Health professionals who press, rub, and otherwise manipulate the muscles and other soft tissues of the body. They most often use their hands and fingers, but may use their forearms, elbows, or feet.

What You Can Do: The Importance of Self-Care and a Good Health Attitude

Although health care professionals can prescribe or recommend treatments to help you manage your arthritis, the real key to living well with the disease is you. Research shows that people with osteoarthritis who take part in their own care report less pain and make fewer doctor visits. They also enjoy a better quality of life.

Living well and enjoying good health despite arthritis requires an everyday lifelong commitment. The following six habits are worth committing to:

1. Get educated. To live well with osteoarthritis, it pays to learn as much as you can about the disease. Three kinds of programs help people understand osteoarthritis, learn self-care, and improve their good-health attitude. They are:

• patient education programs
• arthritis self-management programs
• arthritis support groups.

These programs teach people about osteoarthritis, its treatments, exercise and relaxation, patient and health care provider communication, and problem solving. Research has shown that people who participate in these programs are more likely to have positive outcomes.

Self-Management Programs Do HelpPeople with osteoarthritis find that self-management programs help them: Understand the disease Reduce pain while remaining active Cope physically, emotionally, and mentally Have greater control over the disease Build confidence in their ability to live an active, independent life

2. Stay active. Regular physical activity plays a key role in self-care and wellness. Four types of exercise are important in osteoarthritis management. The first type, strengthening exercises help keep or increase muscle strength. Strong muscles help support and protect joints affected by arthritis. The second type, aerobic conditioning exercises improve cardiovascular fitness, help control weight, and improve overall function. The third type, range-of-motion exercises, help reduce stiffness and maintain or increase proper joint movement and flexibility. The fourth type, balance and agility exercises, can help you maintain daily living skills.

You should start each exercise session with an adequate warm-up and begin exercising slowly. Resting frequently ensures a good workout and reduces the risk of injury.

Before beginning any type of exercise program, consult your doctor or physical therapist to learn which exercises are appropriate for you and how to do them correctly, because doing the wrong exercise or exercising improperly can cause problems. A health care professional can also advise you on how to warm up safely and when to avoid exercising a joint affected by arthritis.

3. Eat well. Though no specific diet will necessarily make your arthritis better, eating right and controlling your weight can help by minimizing stress on the weight-bearing joints such as the knees and the joints of the feet. It can also minimize your risk of developing other health problems.

4. Get plenty of sleep. Getting a good night's sleep on a regular basis can minimize pain and help you cope better with the effects of your disease. If arthritis pain makes it difficult to sleep at night, speak with your doctor and/or physical therapist about the best mattress or comfortable sleeping positions or the possibility of timing medications to provide more pain relief at night. You may also improve your sleep by getting enough exercise early in the day; avoiding caffeine or alcoholic beverages at night; keeping your bedroom dark, quiet, and cool; and taking a warm bath to relax and soothe sore muscles at bedtime.

5. Have fun. Although having osteoarthritis certainly isn't fun, it doesn't mean you have to stop having fun. If arthritis makes it difficult to participate in favorite activities, ask an occupational therapist about new ways to do them. Activities such as sports, hobbies, and volunteer work can distract your mind from your own pain and make you a happier, more well-rounded person.

6. Keep a positive attitude. Perhaps the best thing you can do for your health is to keep a positive attitude. People must decide to make the most of things when faced with the challenges of osteoarthritis. This attitude—a good-health mindset—doesn't just happen. It takes work, every day. And with the right attitude, you will achieve it.

Enjoy a "Good-Health Attitude" Focus on your abilities instead of disabilities. Focus on your strengths instead of weaknesses. Break down activities into small tasks that you can manage. Incorporate fitness and nutrition into daily routines. Develop methods to minimize and manage stress. Balance rest with activity. Develop a support system of family, friends, and health professionals.

Research Highlights

The leading role in osteoarthritis research is played by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the Department of Health and Human Services' National Institutes of Health (NIH). NIAMS funds many researchers across the United States to study osteoarthritis. Scientists at NIAMS Multidisciplinary Clinical Research Centers conduct basic and clinical research aimed at understanding the causes, treatment options, and prevention of arthritis and musculoskeletal diseases.

Some key areas of research supported by NIAMS and other institutes within NIH include the following:

Biomarkers

In 2004, NIAMS and other institutes and offices of the NIH began recruiting participants for the Osteoarthritis Initiative (OAI). The OAI is a public-private partnership that brings together new resources and commitment to help identify biomarkers of disease for osteoarthritis. The partnership is designed to stimulate the development of tools and identify targets to combat the disease. Biomarkers are biological clues to increased susceptibility, early stages of disease, the course of the disease, and the response of people with osteoarthritis to the various therapies. Researchers are collecting images (x rays and MRIs), biological specimens (blood, urine, and DNA) and clinical data from over 4,800 people at high risk for having osteoarthritis, as well as those at high risk for progression to severe osteoarthritis during the course of the study. Four sets of OAI data have been released. Data are available to researchers. As of March 2010, there were over 1,500 registered users of the OAI data from 63 countries.

Two separate NIAMS-supported studies revealed that mechanical stress can affect the release of osteoarthritis biomarkers. The first study, on the role of mechanical stress on biomarker release from normal cartilage, showed that mechanical stress in the ranges experienced from normal to intense physical activity increased the turnover of cartilage and the release of biomarkers from the tissue and varied with the amount of applied stress. This suggests that mechanical stress regulates turnover of molecules in the cartilage extracellular matrix. The second, which examined release of cartilage- and bone-derived biomarkers in college athletes undergoing high-intensity training (rowers, cross-country runners, and swimmers) and in nonathlete controls, suggests that rowers undergo the highest bone turnover and runners the highest cartilage turnover. These results suggest that biomarkers can vary between individuals involved in different types of physical activities, and that the interpretation of biomarker analyses from osteoarthritis patients will need to take into account the type and extent of physical activity of the patients.

Diagnostic tools

A newly discovered method to detect and monitor cartilage changes could eventually enable doctors to diagnose osteoarthritis long before traditional x rays would show damage. It could also allow clinicians the opportunity to monitor the impact of therapeutic interventions very early in the disease process. The new noninvasive method uses an adaptation of established MRI techniques to separately visualize proteoglycans (molecular building blocks of cartilage) from water molecules in cartilage. Although further research and refinements are needed, the researchers are hopeful this approach could one day play an important role in the management of people with osteoarthritis.

Other NIAMS-supported researchers are combining a technique called microcomputed tomography (microCT), which yields high-resolution, three-dimensional x-ray images, with an x-ray-absorbing contrast agent to image the distribution of proteoglycans in the laboratory. By detecting proteoglycan content and distribution, the technique reveals information about both the thickness and composition of cartilage, both of which are important factors for monitoring the progression and treatment of osteoarthritis. So far, the technique's use has been limited to cartilage samples from animals. The researchers don't know yet if the technique would be successful in people. The hope is that their research will lead to ways to monitor cartilage changes with good resolution and little or no invasion of the tissue, and that eventually the technique will allow pharmaceutical researchers to obtain more detailed information about the effects of new drugs and other treatment strategies for osteoarthritis.

Pharmacologic treatments

Researchers are looking for drugs that would prevent, slow down, or reverse joint damage. One drug under study is doxycycline, an antibiotic drug that may stop certain enzymes known to damage cartilage. A recent clinical trial found that doxycycline had a modest effect on slowing the rate at which the joint space narrows in the knee. The trial also found that people who were taking doxycycline experienced joint pain less often than those who were not.

Scientists are also examining the bisphosphonate drug risedronate. In a recent British study of several hundred people with mild-to-moderate osteoarthritis of the knee, those treated with risedronate showed a clear trend toward reduced symptoms and improved joint structure.

More studies are needed for both drugs.

Complementary and alternative therapies

In recent years, the nutritional supplement pair glucosamine and chondroitin has shown some potential for reducing the pain of osteoarthritis, though no conclusive proof has emerged to date. Both of these nutrients are found in shark cartilage, the shells of shellfish, and pig ears and noses, and are components of normal cartilage.

The Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), which was cosponsored by the National Center for Complementary and Alternative Medicine (NCCAM) and NIAMS, assessed the effectiveness and safety of these supplements when taken together or separately. The trial found that the combination of glucosamine and chondroitin sulfate did not provide significant relief from osteoarthritis pain among all participants. However, a subgroup of study participants with moderate-to-severe pain showed significant relief with the combined supplements.

The 4-year trial was conducted at 16 sites across the United States.[5] The results were published in the Feb. 23, 2006 edition of the New England Journal of Medicine.

There are other complementary and alternative therapies under investigation. The longest and largest randomized, controlled phase 3 clinical trial of acupuncture ever conducted revealed that the therapy relieves pain and improves function in knee osteoarthritis, and it serves as an effective complement to standard care. The trial, supported by NIAMS and NCCAM, was the first with sufficient rigor, size, and duration to show that acupuncture reduces the pain and functional impairment of osteoarthritis of the knee. These results also indicate that acupuncture can serve as an effective addition to a standard regimen of care and improve quality of life for people who suffer from knee osteoarthritis.

The progression of osteoarthritis may be slower in people who take higher levels of vitamins D, C, or E, or beta carotene. NIAMS is sponsoring a clinical trial to see if vitamin D slows the progression of knee osteoarthritis. More studies are needed to confirm a possible role of this vitamin in osteoarthritis treatment.

Many studies have shown that green tea possesses anti-inflammatory properties. One study showed that mice predisposed to a condition similar to human osteoarthritis had mild arthritis and little evidence of cartilage damage and bone erosion when green tea polyphenols were added to their drinking water. Another study showed that when added to human cartilage cell cultures, the active ingredients in green tea inhibited chemicals and enzymes that lead to cartilage damage and breakdown. Further studies are needed to determine the effects of green tea compounds on human cartilage.

5 Clegg DO, Reda DJ, Harris CL, Klein MA, O'Dell JR, Hooper MM, Bradley JD, Bingham CO 3rd, Weisman MH, Jackson CG, Lane NE, Cush JJ, Moreland LW, Schumacher HR Jr., Oddis CV, Wolfe F, Molitor JA, Yocum DE, Schnitzer TJ, Furst DE, Sawitzke AD, Shi H, Brandt KD, Moskowitz RW, Williams HJ. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. NEJM 2006 Feb 23;354(8):795-808.

Healing joint injuries and cartilage damage

When the anterior cruciate ligament (ACL)—one of the main ligaments of the knee, which connects the shin bone to the thigh—is torn, it doesn't heal the way other tissues do. Unless the tear is repaired, the knee can become unstable, resulting in damage to the joint surfaces and the eventual development of knee osteoarthritis. Traditionally, repair has involved replacing the ligament with ligament or tendon graft, but NIAMS-funded research shows that filling the tear with a collagen- and platelet-rich gel material may enable it to heal, making a graft unnecessary. Physicians believe that preserving the patient's own ACL (if it becomes possible) would likely better protect the mechanics of the knee.

Other NIAMS-supported scientists are researching a way to patch damaged cartilage that will allow new cartilage to grow in and repair the damage. Using a unique weaving machine of their own design, the researchers have created a three-dimensional fabric scaffold patch. In laboratory tests, the scaffold had the same mechanical properties as native cartilage. In the future, surgeons will likely be able to impregnate custom-designed scaffold with cartilage-forming stem cells (taken from a person's own fat tissue, for example) and biochemicals that stimulate their growth, and then implant them into a patient in a single procedure.

Genetics studies

Osteoarthritis in all its various forms appears to have a strong but complex genetic connection. Gene mutations may be a factor in predisposing individuals to develop osteoarthritis. For example, scientists have identified a mutation (a gene defect) affecting collagen, an important part of cartilage, in patients with an inherited kind of osteoarthritis that starts at an early age. The mutation weakens collagen protein, which may break or tear more easily under stress. Scientists are looking for other gene mutations in osteoarthritis. Researchers have also found that the daughters of women who have knee osteoarthritis have a significant increase in cartilage breakdown, thus making them more susceptible to disease. In the future, a test to determine who carries the genetic defect (or defects) could help people reduce their risk for osteoarthritis by making lifestyle adjustments.

Patient education and self-management

When patients understand and feel that they have some control over their chronic disease, the course of their disease is often improved. One recent NIAMS-supported study found that improvement can be made in the self-management of osteoarthritis when spouses provide help. The intervention that was tested used spouse-assisted coping skills training and exercise training to improve physical fitness, pain coping, and self-efficacy in patients with osteoarthritis of the knee. The results from the study suggest that a combination of both spouse-assisted pain coping skills training and exercise training leads to more improvements than could be achieved with either intervention alone.

Other research shows that patient education and social support is a low-cost, effective way to decrease pain and reduce the amount of medicine patients use. One NIAMS-funded project involves developing and testing an interactive Web site by which health professionals and patients could communicate concerning appointments and treatment instructions, thus giving patients a greater role in and control of their care.

Exercise and weight reduction

Exercise plays a key part in a comprehensive treatment plan. Researchers are studying exercise in greater detail and finding out just how to use it in treating or preventing osteoarthritis. For example, several scientists have studied knee osteoarthritis and exercise. Their results included the following:

• Walking can result in better functioning, and the more you walk, the farther you will be able to walk.
• People with knee osteoarthritis who are active in an exercise program feel less pain. They also function better.

Research has shown that losing extra weight can help people who already have osteoarthritis. Moreover, overweight or obese people who do not have osteoarthritis may reduce their risk of developing the disease by losing weight.

Hope for the Future

Research is opening up new avenues of treatment for people with osteoarthritis. A balanced, comprehensive approach is still the key to staying active and healthy with the disease. People with osteoarthritis should combine exercise, relaxation, education, social support, and medications in their treatment strategies. Meanwhile, as scientists unravel the complexities of the disease, new treatments and prevention methods should become apparent. Such developments are expected to improve the quality of life for people with osteoarthritis and their families.

Where Can People Find More Information About Osteoarthritis?

National Institute of Arthritis and Musculoskeletal and Skin Diseases
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484
Toll Free: 877-22-NIAMS (877-226-4267)
TTY: 301-565-2966
Fax: 301-718-6366
Email: [email protected]
http://www.niams.nih.gov

National Institute of Arthritis and Musculoskeletal and Skin Diseases
Adapted from NIH Publication No. 10-4617

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Reviewed by athealth on February 6, 2014.

What is the prevalence of overweight and obesity among U.S. adults?

Results of the National Health and Nutrition Examination Survey for 1999-2002 indicate that the following percentages of U.S. adults are overweight or obese:

• An estimated 30 percent of U.S. adults aged 20 years and older - over 60 million people - are obese, defined as having a body mass index (BMI) of 30 or higher.
• An estimated 65 percent of U.S. adults aged 20 years and older are either overweight or obese, defined as having a BMI of 25 or higher.

What is the prevalence of overweight among U.S. children?

Results of the National Health and Nutrition Examination Survey for 1999-2002 indicate that an estimated 16 percent of children and adolescents ages 6-19 years are overweight. For children, overweight is defined as a body mass index (BMI) at or above the 95th percentile of the CDC growth charts for age and gender.

What is the difference between being overweight and being obese?

Overweight and obesity are both labels for ranges of weight that are greater than what is generally considered healthy for a given height. The terms also identify ranges of weight that have been shown to increase the likelihood of certain diseases and other health problems.

For adults, overweight and obesity ranges are determined by using weight and height to calculate a number called the "body mass index" (BMI).

• An adult who has a BMI between 25 and 29.9 is considered overweight. A
• n adult who has a BMI of 30 or higher is considered obese.

See the following table for an example.

Height	Weight Range	BMI	Considered
5' 9"	124 lbs or less	Below 18.5	Underweight
	125 lbs to 168 lbs	18.5 to 24.9	Healthy weight
	169 lbs to 202 lbs	25.0 to 29.9	Overweight
	203 lbs or more	30 or higher	Obese

It is important to remember that although BMI correlates with the amount of body fat, BMI does not directly measure body fat. As a result, some people, such as athletes, may have a BMI that identifies them as overweight even though they do not have excess body fat. For more information about BMI, visit Body Mass Index.

For children and teens, BMI ranges above a normal weight have different labels (at risk of overweight and overweight). Additionally, BMI ranges for children and teens are defined so that they take into account normal differences in body fat between boys and girls and differences in body fat at various ages. For more information about BMI for children and teens (also called BMI-for-age), visit BMI for Children and Teens.

What are some of the factors that contribute to overweight and obesity?

Researchers have found that several factors can contribute to the likelihood of someone's becoming overweight or obese.

• Behaviors. What people eat and their level of physical activity help determine whether they will gain weight. A number of factors can influence diet and physical activity, including personal characteristics of the individual, the individual's environment, cultural attitudes, and financial situation.
• Genetics. Heredity plays a large role in determining how susceptible people are to becoming overweight or obese. Genes can influence how the body burns calories for energy and how the body stores fat.

How does being overweight or obese affect a person's health?

When people are or overweight or obese, they are more likely to develop health problems such as the following:

• Hypertension
• Dyslipidemia (for example, high total cholesterol or high levels of triglycerides)
• Type 2 diabetes
• Coronary heart disease
• Stroke
• Gallbladder disease
• Osteoarthritis
• Sleep apnea and respiratory problems
• Some cancers (endometrial, breast, and colon)

The more overweight a person is, the more likely that person is to have health problems. Among people who are overweight and obese, weight loss can help reduce the chances of developing these health problems. Studies show that if a person is overweight or obese, reducing body weight by 5 percent to 10 percent can improve one's health.

What can be done about this major public health problem?

The Surgeon General has called for a broad approach to help prevent and reduce obesity. The Surgeon General has identified 15 activities as national priorities.

What are the costs associated with overweight and obesity?

According to The Surgeon General's Call to Action to Prevent and Decrease Overweight and Obesity, the cost of obesity in the United States in 2000 was more than $117 billion ($61 billion direct and $56 billion indirect).

What is being done by CDC to address the problem of overweight and obesity?

CDC and its partners work in a variety of ways to prevent and control obesity. A few examples of these efforts include:

• CDC funds a number of programs in state health departments, communities, and schools. For example, CDC's Division of Nutrition and Physical Activity funds state health department programs to help develop and carry out targeted nutrition and physical activity interventions to prevent obesity and other chronic diseases. CDC also provides consultation, technical assistance, and training to use programs.
• CDC funds other programs which have physical activity, nutrition, and obesity components, such as STEPS to a HealthierUS and Coordinated School Health Programs.
• CDC monitors weight status or related behaviors, such as diet and physical activity. These efforts include the Behavioral Risk Factor Surveillance System (BRFSS), National Health and Nutrition Examination Survey (NHANES), Pediatric Nutrition Surveillance System (PedNSS), and Youth Risk Behavior Surveillance System (YRBSS).
• CDC funds and conducts research on the individual and environmental factors that determine weight status and related health effects, on strategies and interventions to change weight or weight-related behaviors, and on the economic impact of overweight and obesity.
• CDC provides growth charts that are used to identify weight problems among young people and provides training on the use of those charts.

What are some suggestions for losing weight?

Most experts recommend that someone attempting to lose a large amount of weight consult with a personal physician or health care professional before beginning a weight-loss program. The Surgeon General's Healthy Weight Advice for Consumers makes the following general recommendations:

• Aim for a healthy weight. People who need to lose weight should do so gradually, at a rate of one-half to two pounds per week.
• Be active. The safest and most effective way to lose weight is to reduce calories and increase physical activity.
• Eat well. Select sensible portion sizes and follow the Dietary Guidelines for Americans.

How can physical activity help prevent overweight and obesity?

Physical activity, along with a healthy diet, plays an important role in the prevention of overweight and obesity (USDHHS, 2001). In order to maintain a stable weight, a person needs to expend the same amount of calories as he or she consumes.

Although the body burns calories for everyday functions such as breathing, digestion, and routine daily activities, many people consume more calories than they need for these functions each day. A good way to burn off extra calories and prevent weight gain is to engage in regular physical activity beyond routine activities.

The Dietary Guidelines for Americans 2005 offers the following example of the balance between consuming and using calories:

If you eat 100 more food calories a day than you burn, you'll gain about 1 pound in a month. That's about 10 pounds in a year. The bottom line is that to lose weight, it's important to reduce calories and increase physical activity.

Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
Division of Nutrition and Physical Activity
Last Reviewed: 09/29/2006

Reviewed by athealth on February 6, 2014.

"Pain Control: A Guide for People With Cancer and Their Families" will help you learn about pain control for people with cancer. You will find out how to work with your doctors, nurses, and pharmacists to find the best method to control your pain; about different types of pain medications and nondrug methods of controlling pain; how to take your medicines safely; and how to talk with your doctors and nurses about your pain and how well the treatment is working for you.

Having cancer does not always mean having pain. For those with pain, there are many different kinds of medicines, ways to receive the medicine, and nonmedicine methods that can relieve the pain you may have. You should not accept pain as a normal part of having cancer. When you are free of pain, you can sleep and eat better, enjoy the company of family and friends, and continue with your work and hobbies.

Only you know how much pain you have. Telling your doctor and nurse when you have pain is important. Not only is pain easier to treat when you first have it, but pain can be an early warning sign of the side effects of the cancer or the cancer treatment. Together - you, your nurse, and doctor - can talk about how to treat your pain. You have a right to pain relief, and you should insist on it.

Here are some facts about cancer pain that may help answer some of your questions.

Cancer pain can almost always be relieved.

There are many different medicines and methods available to control cancer pain. You should expect your doctor to seek all the information and resources necessary to make you as comfortable as possible. However, no one doctor can know everything about all medical problems. If you are in pain and your doctor suggests no other options, ask to see a pain specialist or have your doctor consult with a pain specialist. Pain specialists may be oncologists, anesthesiologists, neurologists, or neurosurgeons, other doctors, nurses, or pharmacists. A pain control team may also include psychologists and social workers.

If you have trouble locating a pain program or specialist, contact a cancer center, a hospice, or the oncology department at your local hospital or medical center. The National Cancer Institute's (NCI) Cancer Information Service (CIS) and other organizations can give you a list of pain management facilities. The American Cancer Society (ACS) and other organizations may also be able to provide names of pain specialists, pain clinics, or programs in your area. See "Resources" for information on these organizations.

Controlling your cancer pain is part of the overall treatment for cancer.

Your doctor wants and needs to hear about what works and what doesn't work for your pain. Knowing about the pain will help your doctor better understand how the cancer and the treatment are affecting your body. Discussions about pain will not distract your doctor from treating the cancer.

Preventing pain from starting or getting worse is the best way to control it.

Pain is best relieved when treated early. You may hear some people refer to this as "staying on top" of the pain. Do not try to hold off as long as possible between doses. Pain may get worse if you wait, and it may take longer, or require larger doses, for your medicine to give you relief.

You have a right to ask for pain relief.

Not everyone feels pain in the same way. There is no need to be "stoic" or "brave" if you have more pain than others with the same kind of cancer. In fact, as soon as you have any pain you should speak up. Telling the doctor or nurse about pain is not a sign of weakness. Remember, it is easier to control pain when it just starts rather than waiting until after it becomes severe.

People who take cancer pain medicines rarely become addicted to them.

Addiction is a common fear of people taking pain medicine. Such fear may prevent people from taking the medicine. Or it may cause family members to encourage you to "hold off" as long as possible between doses. Addiction is defined by many medical societies as uncontrollable drug craving, seeking, and use. When opioids (also known as narcotics) - the strongest pain relievers available - are taken for pain, they rarely cause addiction as defined here. When you are ready to stop taking opioids, the doctor gradually lowers the amount of medicine you are taking. By the time you stop using them completely, the body has had time to adjust. Talk to your doctor, nurse, or pharmacist about how to use pain medicines safely and about any concerns you have about addiction.

Most people do not get "high" or lose control when they take cancer pain medicines as prescribed by the doctor.

Some pain medicines can cause you to feel sleepy when you first take them. This feeling usually goes away within a few days. Sometimes you become drowsy because, with the relief of the pain, you are now able to catch up on the much needed sleep you missed when you were in pain. On occasion, people get dizzy or feel confused when they take pain medicines. Tell your doctor or nurse if this happens to you. Changing your dose or type of medicine can usually solve the problem.

Side effects from medicines can be managed or often prevented.

Some medicines can cause constipation, nausea and vomiting, or drowsiness. Your doctor or nurse can help you manage these side effects. These problems usually go away after a few days of taking the medicine. Many side effects can be managed by changing the medicine or the dose or times when the medicine is taken.

Your body does not become immune to pain medicine.

Pain should be treated early. It is important to take whatever medicine is needed at the time. You do not need to save the stronger medicines for later. If your body gets used to the medicine you are taking, your medicine may not relieve the pain as well as it once did. This is called tolerance. Tolerance is not usually a problem with cancer pain treatment because the amount of medicine can be changed or other medicines can be added.

When pain is not treated properly, you may be:

• Tired
• Depressed
• Angry
• Worried
• Lonely
• Stressed

When cancer pain is managed properly, you can:

• Enjoy being active
• Sleep better
• Enjoy family and friends
• Improve your appetite
• Enjoy sexual intimacy
• Prevent depression

About Cancer Pain

What Are the Different Types of Pain?

Pain may be acute or chronic. Acute pain is severe and lasts a relatively short time. It is usually a signal that body tissue is being injured in some way, and the pain generally disappears when the injury heals. Chronic or persistent pain may range from mild to severe, and it is present to some degree for long periods of time. Some people with chronic pain that is controlled by medicine can have breakthrough pain - this occurs when moderate to severe pain "breaks through" or is felt for a short time. It may occur several times a day, even when the proper dose of medicine is given for chronic and persistent pain.

What Causes Pain in People With Cancer?

The pain you feel may be from the cancer itself. Whether you have pain and the amount of pain you have may depend on the type of cancer, the stage (extent) of the disease, and your pain threshold (tolerance for pain). Most of the pain comes when a tumor presses on bones, nerves, or body organs. It can also be caused by the treatment or procedures for diagnosing cancer. Or you may have pain that has nothing to do with your illness or treatment. Like anyone, you can get headaches, muscle strains, and other aches and pains.

Pain From Procedures

Some methods used to diagnose cancer and to see how well the treatment is working are painful. If you and your doctors agree that a diagnostic procedure is necessary, concern about pain should not prevent you from having the procedure. Usually any pain you have during and after the procedure can be relieved. The needs of the person and the type of procedure to be done determine the kinds of medicine that can be given for the pain. You may be told that the pain from the procedure can't be avoided or that it won't last long. Even so, you should ask for pain medicine if you feel the need.

Phantom Pain

If you have had an arm or leg removed by surgery, you may still feel pain or other unusual or unpleasant sensations as if they were coming from the absent (phantom) limb. Doctors are not sure why this occurs, but phantom limb pain is real; it is not "in your mind." This pain can also occur if you have had a breast removed - you may have a sensation of pain at the site of the missing breast.

No single pain relief method controls phantom pain in all patients all the time. Many methods have been used to treat this type of pain, including pain medicine, physical therapy, antidepressant medicines, and transcutaneous electric nerve stimulation (TENS). If you are having phantom pain, ask your doctor, nurse, or pharmacist about what can be done.

Spinal Cord Compression

When a tumor spreads to the spine, it can press on the spinal cord and cause spinal cord compression. The first sign of the compression is usually back and/or neck pain. It is often made worse by coughing, sneezing, or other movements. If you have this pain, it is important to notify your doctor right away. Your doctor can treat the cause of the pain and also give you medicine to relieve the pain. If you receive treatments for the compression soon after the pain occurs, complications such as bladder or bowel problems can usually be avoided. Treatments usually involve radiation therapy to shrink the tumor or surgery to remove the tumor followed by radiation.

How Is Cancer Pain Treated?

Cancer pain is usually treated with medicine (also called analgesics) and with nondrug treatments such as relaxation techniques, biofeedback, imagery, and others. Ask your doctor, nurse, or pharmacist for advice before you take any medicine for pain. Medicines are safe when they are used properly. You can buy some effective pain relievers without a prescription or doctor's order. These medicines are also called nonprescription or over-the-counter pain relievers. For others, a prescription from your doctor is necessary.

For the small number of people for whom medicine and nondrug treatments do not work, other treatments are available: radiation therapy to shrink the tumor; surgery to remove part or all of the tumor; nerve blocks whereby pain medicine is injected into or around a nerve or into the spine to block the pain; and neurosurgery, where pain nerves are cut to relieve the pain.

Developing a Plan for Pain Control

The first step in developing a plan is talking with your doctor, nurse, and pharmacist about your pain. You need to be able to describe your pain to your health professionals as well as to your family or friends. You may want to have your family or friends help you talk to your health professionals about your pain control, especially if you are too tired or in too much pain to talk to them yourself.

Using a pain scale is helpful in describing how much pain you are feeling. An example of a pain scale can be found in the Appendix. Try to assign a number from 0 to 10 to your pain level. If you have no pain, use a 0. As the numbers get higher, they stand for pain that is getting worse. A 10 means the pain is as bad as it can be.

You may wish to use your own pain scale using numbers from 0 to 5 or even 0 to 100. Be sure to let others know what pain scale you are using and use the same scale each time, for example, "My pain is a 7 on a scale of 0 to 10."

You can use a rating scale to describe:

• How bad your pain is at its worst.
• How bad your pain is most of the time.
• How bad your pain is at its least.
• How your pain changes with treatment.

Tell your doctor, nurse, pharmacist and family or friends:

• Where you feel pain.
• What it feels like - sharp, dull, throbbing, steady.
• How strong the pain feels.
• How long it lasts.
• What eases the pain, what makes the pain worse.
• What medicines you are taking for the pain and how much relief you get from them.

Your doctor, nurse, and pharmacist may also need to know:

• What medicines you are taking now and what pain medicines you have taken in the past, including what has worked and not worked. You may want to record this information on the charts, "Medicines Taking Now" and "Pain Medicines Taken in the Past," found in the Appendix.
• Any known allergies to medicines.

Questions to ask your doctor or nurse about pain medicine:

• How much medicine should I take? How often?
• If my pain is not relieved, can I take more? If the dose should be increased, by how much?
• Should I call you before increasing the dose?
• What if I forget to take it or take it too late?
• Should I take my medicine with food?
• How much liquid should I drink with the medicine?
• How long does it take the medicine to start working (called "onset of action")?
• Is it safe to drink alcoholic beverages, drive, or operate machinery after I have taken pain medicine?
• What other medicines can I take with the pain medicine?
• What side effects from the medicine are possible and how can I prevent them?

Keeping Track of Details About the Pain

You may find it helpful to keep a record or a diary to track the pain and what works best to ease it. You can share this record with those caring for you. This will help them figure out what method of pain control works best for you. You may wish to use copies of the "Pain Control Record" found in the Appendix to record this information. Your records can include:

• Words to describe the pain.
• Any activity that seems to be affected by the pain or that increases or decreases the pain.
• Any activity that you cannot do because of the pain.
• The name and the dose of the pain medicine you are taking.
• The times you take pain medicine or use another pain-relief method.
• The number from your rating scale that describes your pain at the time you use a pain-relief measure.
• Pain rating 1 to 2 hours after the pain-relief method.
• How long the pain medicine works.
• Pain rating throughout the day to record your general comfort.
• How pain interferes with your normal activities, such as sleeping, eating, sexual activity, or working.
• Any pain-relief methods other than medicine you use such as rest, relaxation techniques, distraction, skin stimulation, or imagery.
• Any side effects that occur.

What If I Need to Change My Pain Medicine?

If one medicine or treatment does not work, there is almost always another one that can be tried. Also, if a schedule or way that you are taking medicine does not work for you, changes can be made. Talk to your doctor or nurse about finding the pain medicine or method that works best for you. You may need a different pain medicine, a combination of pain medicines or a change in the dose of your pain medicines if:

• Your pain is not relieved.
• Your pain medicine does not start working within the time your doctor said it would.
• Your pain medicine does not work for the length of time your doctor said it would.
• You have breakthrough pain.
• You have side effects.
• You have serious side effects such as trouble breathing, dizziness, and rashes. Call your doctor right away if these occur. Side effects such as sleepiness, nausea, and itching usually go away after your body adjusts to the medication. Let your doctor know if these bother you.
• The schedule or the way you are taking the medicine does not work for you.
• Pain interferes with your normal activities, such as eating, sleeping, working, and sexual activity.

To help make the most of your pain control plan:

• Take your pain medicine on a regular schedule (by the clock) to help prevent persistent or chronic pain.
• Do not skip doses of your scheduled medicine. Once you feel the pain, it is harder to control.
• If you experience breakthrough pain, use your short-acting medicine as your doctor suggests. Don't wait for the pain to get worse - if you do, it may be harder to control.
• Be sure only one doctor prescribes your pain medicine. If another doctor changes your medicine, the two doctors should discuss your treatment with each other.
• Never take someone else's medicine. Medicines that worked for you in the past or that helped a friend or relative may not be right for you.
• Pain medicines affect different people in different ways. A very small dose may work for you, while someone else may need to take a much larger dose to obtain pain relief.
• Remember, your pain control plan can be changed at any time.

Medicines Used to Relieve Pain

The type of medicine and the method by which the medicine is given depend on the type and cause of pain. For example, constant, persistent pain is best relieved by methods that deliver a steady dose of pain medicine over a long period of time, such as a patch that is filled with medicine and placed on the skin (skin patch) or slow-release oral tablets. Below is an overview of the types of medicines used to relieve pain.

For Mild to Moderate Pain

Nonopioids: Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen. You can buy many of these over-the-counter (without a prescription). For others, you need a prescription. Check with your doctor before using these medicines. NSAIDs can slow blood clotting, especially if you are on chemotherapy.

For Moderate to Severe Pain

Opioids (also known as narcotics): Morphine, fentanyl, hydromorphone, oxycodone, and codeine. You need a prescription for these medicines. Nonopioids may be used along with opioids for moderate to severe pain.

For Breakthrough Pain

Rapid-Onset Opioids: Immediate-release oral morphine. You need a prescription for these medicines. A short-acting opioid, which relieves breakthrough pain quickly, needs to be used with a long-acting opioid for persistent pain.

For Tingling and Burning Pain

Antidepressants: Amitriptyline, nortriptyline, desipramine. You need a prescription for these medicines. Antidepressants are also prescribed to relieve some types of pain. Taking an antidepressant does not mean that you are depressed or have a mental illness.

Anticonvulsants (antiseizure medicines): Carbamazepine and phenytoin. You need a prescription for these medicines. Despite the name, anticonvulsants are used not only for convulsions, but also to control burning and tingling pain.

For Pain Caused by Swelling

Steroids: Prednisone, dexamethasone. A prescription is needed for these medicines. They are used to lessen swelling, which often causes pain.

How Is Pain Medicine Given?

Some people think that if their pain becomes severe, they will need to receive injections or "shots." Actually, shots are rarely given to relieve cancer pain. There are many ways to get the medicine.

• Orally - medicine is given in a pill or capsule form.
• Skin patch - a bandage-like patch placed on the skin, which slowly but continuously releases the medicine through the skin for 2-3 days. One opioid medicine, fentanyl, is available as a skin patch. This form of medicine is less likely to cause nausea and vomiting.
• Rectal suppositories - medicine that dissolves in the rectum and is absorbed by the body.
• Injections
  • Subcutaneous (SC) injection - medicine is placed just under the skin using a small needle.
  • Intravenous (IV) injection - medicine goes directly into the vein through a needle.
  • Intrathecal and epidural injections - medicine is placed directly into the fluid around the spinal cord (intrathecal) or into the space around the spinal cord (epidural).
• Pump
  • Patient-controlled analgesia (PCA) - with this method, you can help control the amount of pain medicine you take. When you need pain relief, you can receive a preset dose of pain medicine by pressing a button on a computerized pump that is connected to a small tube in your body. The medicine is injected into the vein (intravenously), just under the skin (subcutaneously), or into the spinal area.

If your pain is not well controlled with one of the long-acting oral medicines, if you are having trouble taking pills, or if you are having irritating side effects, ask your doctor about trying one of the methods listed above.

What Are the Side Effects of Pain Medicine?

Many side effects from pain medicine can be prevented. Some mild side effects that do occur, such as nausea, itching, or drowsiness, will usually go away after a few days as your body adjusts to the medicine. Let your doctor or nurse know if you are having these side effects and ask for help in controlling them.

More serious side effects of pain medicine are rare. As with the more common ones, they usually happen in the first few hours of treatment. They include trouble breathing, dizziness, and rashes. If you have any of these side effects, you should call your doctor right away.

You usually cannot take aspirin, ibuprofen, and other NSAIDs when you are on chemotherapy.

Which Medicines Will I Be Given?

In many cases, nonopioids are all you will need to relieve your pain, especially if you "stay on top of the pain" by taking them regularly. These medicines are stronger pain relievers than most people realize. For example, certain doses of opioids given by mouth are no more effective than two or three regular tablets of aspirin, acetaminophen, or ibuprofen.

If you do not get pain relief from nonopioids, opioids will usually give you the relief you need. Most side effects from opioids can be prevented or controlled. You should discuss taking opioids along with nonopioids with your doctor, nurse, or pharmacist. The two types of medicine relieve pain in different ways. Aspirin, acetaminophen, or ibuprofen taken four times a day might help avoid or reduce the need for a stronger pain relievers.

Many people who take opioids can benefit from continuing to take regular doses of aspirin, acetaminophen, or ibuprofen.

Some pain medicines combine an opioid and a nonopioid, like aspirin or acetaminophen, in the same pill. Ask your doctor, nurse, or pharmacist how much aspirin or acetaminophen, if any, is in your prescription. They can help you figure out how much of these medicines you can take safely. Other classes of medicines, such as antidepressants and anticonvulsants, are also used to relieve certain types of cancer pain. This chart lists these other classes of medicines, how they work, and their side effects.

Nonopioids

Nonopioids control mild to moderate pain. Some can be bought without a prescription. For detailed information on nonopioids, review the chart below.

Table 1. NONOPIOIDS — ACETAMINOPHEN AND NSAIDs
TYPE			ACTION	SIDE EFFECTS
Acetaminophen			Reduces pain and fever.	Large doses can injure the liver or kidneys.Use by persons who have 3 or more alcoholic drinks per day may cause liver damage. Acetaminophen reduces fever, so ask your doctor about what to do if your body temperature is greater than normal (98.6°F or 37°C) while you are taking this medicine.

Over the counterReduce pain, inflammation, and fever

NSAID medicines can have the following side effects:

Can irritate the stomach.

Can cause bleeding of the stomach lining, especially if combined with alcohol.

Can cause kidney problems.

Avoid these medications if you are on anti-cancer drugs that may cause bleeding.

Aspirin and NSAIDs reduce fever, so ask your doctor about what to do if your body temperature is greater than normal (98.6°F or 37°C) while you are taking one of these medicines.

Over the counter Aspirin Ibuprofen Ketoprofen Naproxen sodium Prescription: Celecoxib Choline magnesium trisalicylate Diclofenac Etodolac Fenoprofen calcium Indomethacin Ketorolac Meclofenamic acid Meclofenamate sodium Nabumetone Naproxen Oxaprozin Piroxicam Rofecoxib Sulindac Tolmetin sodium

Reduce pain, inflammation, and fever

NSAID medicines can have the following side effects:

Brand-Name Drugs Versus Generic Drugs

Drugs may have as many as three different names: brand, generic, and chemical. Drug companies give their products brand names. The U.S. Food and Drug Administration (FDA) approves the generic, shortened names by which drugs are usually known. Chemical names are long and tend to be hard to pronounce. Here's an example:

Brand name: Tylenol

Generic name: Acetaminophen

Chemical name: N-(4-hydroxyphenyl) acetamide

Many pain relievers are available under both generic and brand names. Your doctor, nurse, or pharmacist can tell you the generic name.

Generic products are generally less costly than brand-name drugs. Sometimes medicines can have the same generic name, but are produced by different companies. Because the companies may produce the medicines differently, they may differ in the way they are absorbed by the body. For this reason, your doctor may prefer that you take a brand-name drug. You might want to ask your doctor, nurse, or pharmacist if you can use a less expensive medication. Pharmacists are careful to obtain high-quality generic products, so it is sometimes possible to make substitutions.

In addition to the main substance (aspirin, acetaminophen, or ibuprofen), some brands contain substances called additives. Common additives include:

• Buffers (e.g., magnesium carbonate, aluminum hydroxide) to decrease stomach upset.
• Caffeine to act as a stimulant and lessen pain.
• Antihistamines (e.g., diphenhydramine, pyrilamine) to help you relax or sleep.

Medicines with additives can cause some unwanted effects. For example, antihistamines sometimes cause drowsiness. This may be fine at bedtime, but it could be a problem during the day or while you are driving. Also, additives tend to increase the cost of nonprescription pain relievers. They can also change the action of other medicines you may be taking.

Plain aspirin, acetaminophen, or ibuprofen probably work as well as the same medicines with additives. But if you find that a brand with certain additives is a better pain reliever, ask your doctor, nurse, or pharmacist if the additives are safe for you. Talk with them about any concerns you may have about the drugs contained in your nonprescription pain medicines.

NSAIDs

Before you take aspirin, acetaminophen, or other nonopioids in any form, ask your doctor or nurse if there is any reason for you not to take it and how long you can take it.

NSAIDs are similar to aspirin. Either alone or in combination with other medicines, NSAIDs are useful in controlling pain and inflammation.

Precautions When Taking NSAIDs

Some people have conditions that may be made worse by NSAIDs or by any product that contains NSAIDs. In general, NSAIDs should be avoided by people who:

• Are allergic to aspirin.
• Are on chemotherapy (anticancer drugs).
• Are on steroid medicines.
• Have stomach ulcers or a history of ulcers, gout, or bleeding disorders.
• Are taking prescription medicines for arthritis.
• Are taking oral medicine for diabetes or gout.
• Have kidney problems.
• Will have surgery within a week.
• Are taking blood-thinning medicine.

Be careful about mixing NSAIDs with alcohol -- taking NSAIDs and drinking alcohol can cause stomach upset and sometimes bleeding in the lining of the stomach.

"Hidden Aspirin"

Some opioid medications also contain aspirin. If your doctor does not want you to take aspirin, be sure to read the labels carefully. If you are not sure if a medicine contains aspirin, ask your pharmacist.

Side Effects of NSAIDs

The most common side effect from NSAIDs is stomach upset or indigestion, especially in older patients. Taking NSAIDs with food or milk or immediately following a meal lessens the chance of this occurring. Ask your pharmacist to tell you which NSAIDs products are less likely to upset your stomach.

NSAIDs also prevent platelets - blood cells that help blood clot after an injury - from working correctly. When platelets don't function as they should, bleeding is more difficult to stop.

NSAIDs can also irritate the stomach and cause bleeding. If your stools become darker than normal or if you notice unusual bruising - both signs of bleeding - tell your doctor or nurse. Other side effects include kidney problems and stomach ulcers.

Acetaminophen

This medicine relieves pain in a way similar to NSAIDs, but it does not reduce inflammation as well as NSAIDs. People rarely have any side effects from the usual dose of acetaminophen. However, liver and kidney damage may result from using large doses of this medicine every day for a long time or drinking alcohol with the usual dose. Moderate amounts of alcohol can produce liver damage in people taking acetaminophen.

Your doctor may not want you to take acetaminophen regularly if you are receiving chemotherapy. It can cover up a fever. The doctor needs to know about any fever because it may be a sign of infection, which needs to be treated.

Opioids

These medicines are used alone or with nonopioids to treat moderate to severe pain. Opioids are similar to natural substances (endorphins) produced by the body to control pain. Some work better than others in relieving severe pain. These medicines were once made from the opium poppy, but today many are synthetic, that is, they are chemicals made by drug companies. See the table below for examples of opioids.

Table 2. OPIOIDS

GENERIC NAME

CodeineHydromorphone Levorphanol Methadone Morphine Oxycodone Meperidine Oxymorphone Fentanyl

Combination Opioid/NSAID preparations

Codeine (with aspirin or acetaminophen)Oxycodone Hydrocodone

What Is Drug Tolerance?

People who take opioids for pain sometimes find that over time they need to take larger doses. This may be due to an increase in the pain or the development of drug tolerance. Drug tolerance occurs when your body gets used to the medicine you are taking, and your medicine does not relieve the pain as well as it once did. Many people do not develop a tolerance to opioids. If tolerance does develop, usually small increases in the dose or a change in the kind of medicine will help relieve the pain.

Increasing the doses of opioids to relieve increasing pain or to overcome drug tolerance does NOT lead to addiction.

How to Get Proper Pain Relief With Opioids

When a medicine does not give you enough pain relief, your doctor may increase the dose or how often you take it. With careful medical observation, the doses of strong opioids can be raised safely to ease severe pain. Do not increase the dose of your pain medicine on your own. If these measures do not work, the doctor may prescribe a different or additional drug. Some opioids are stronger than others, and you may need a stronger one to control your pain.

If your pain relief is not lasting long enough, ask your doctor about extended-release medicines, which can control your pain for a longer period of time. Morphine and oxycodone are made in extended-release forms. Also, a skin patch that releases the opioid fentanyl can be used.

If your pain is controlled most of the time, but occasionally breaks through, your physician may prescribe a rapid-acting medicine, such as immediate-release morphine, to give you more pain relief when it is needed.

Precautions When Taking Opioids

Doctors carefully adjust the doses of pain medicines so there is little possibility of taking too much medicine. Therefore, it is important that two different doctors do not prescribe opioids for you unless they talk to one another about it.

If you drink alcohol or take tranquilizers, sleeping aids, antidepressants, antihistamines, or any other medicines that make you sleepy, tell your doctor how much and how often you take these medicines. Combinations of opioids, alcohol, and tranquilizers can be dangerous. Even small doses may cause problems.

Using such combinations can lead to overdose symptoms such as weakness, difficulty in breathing, confusion, anxiety, or more severe drowsiness or dizziness.

Side Effects of Opioids

Not everyone has side effects from opioids. Those that do occur are usually drowsiness, constipation, nausea, and vomiting. Some people might also experience dizziness, mental effects (nightmares, confusion, hallucinations), a moderate decrease in rate and depth of breathing, difficulty in urinating, or itching.

Drowsiness

At first, opioids cause drowsiness in some people, but this usually goes away after a few days. If your pain has kept you from sleeping, you may sleep more for a few days after beginning to take opioids while you "catch up" on your sleep. Drowsiness will also lessen as your body gets used to the medicine. Call your doctor or nurse if you feel too drowsy for your normal activities after you have been taking the medicine for a week.

Sometimes it may be unsafe for you to drive a car, or even to walk up and down stairs alone. Avoid operating heavy equipment or performing activities that require alertness.

Here are some ways to handle drowsiness:

• Wait a few days and see if it disappears.
• Check to see if other medicines you are taking can also cause drowsiness.
• Ask the doctor if you can take a smaller dose more frequently or an extended-release opioid.
• If the opioid is not relieving the pain, the pain itself may be wearing you out. In this case, better pain relief may result in less drowsiness. Ask your doctor what you can do to get better pain relief.
• Sometimes a small decrease in the dose of an opioid will still give you pain relief but no drowsiness. If drowsiness is severe, you may be taking more opioid than you need. Ask your doctor about lowering the amount you are now taking.
• Ask your doctor about changing to a different medicine.
• Ask your doctor if you can take a mild stimulant such as caffeine.
• If drowsiness is severe or if it occurs suddenly after you have been taking opioids for a while, call your doctor or nurse right away.

Constipation

Opioids cause constipation to some degree in most people. Opioids cause the stool to move more slowly along the intestinal tract, thus allowing more time for water to be absorbed by the body. The stool then becomes hard. Constipation can often be prevented and/or controlled.

After checking with your doctor or nurse, you can try the following to prevent constipation:

• Ask your doctor to recommend a stool softener, and how often and how much you should take.
• Drink plenty of liquids. Eight to ten 8-ounce glasses of fluid each day will help keep your stools soft. This is the most important step!
• Eat foods high in fiber or roughage such as uncooked fruits (with the skin on), vegetables, and whole grain breads and cereals.
• Add 1 or 2 tablespoons of unprocessed bran to your food. This adds bulk and stimulates bowel movements.
• Keep a shaker of bran handy at mealtimes to make it easy to sprinkle on foods.
• Exercise as much as you are able.
• Eat foods that have helped relieve constipation in the past.
• If you are confined to bed, try to use the toilet or bedside commode when you have a bowel movement, even if that is the only time you get out of bed.

If you are still constipated after trying all the above measures, ask your doctor to prescribe a stool softener or laxative. Be sure to check with your doctor or nurse before taking any laxative or stool softener on your own. If you have not had a bowel movement for 2 days or more, call your doctor.

Nausea and Vomiting

Nausea and vomiting caused by opioids will usually disappear after a few days of taking the medicine. The following ideas may be helpful:

• If nausea occurs mainly when you are walking around (as opposed to being in bed), remain in bed for an hour or so after you take your medicine. This type of nausea is like motion sickness. Sometimes over-the-counter medicines such as meclizine or dimenhydrinate help this type of nausea. Check with your doctor or nurse before taking these medicines.
• If pain itself is the cause of the nausea, using opioids to relieve the pain usually makes the nausea go away.
• Medicines that relieve nausea can sometimes be prescribed.
• Ask your doctor or nurse if the cancer, some other medical condition, or other medicine you are taking such as steroids, anticancer drugs, or aspirin might be causing your nausea. Constipation may also contribute to nausea.

Some people think they are allergic to opioids if they cause nausea. Nausea and vomiting alone usually are not allergic responses. But a rash or itching along with nausea and vomiting may be an allergic reaction. If this occurs, stop taking the medicine and tell your doctor at once.

When You No Longer Need Opioids

You should not stop taking opioids suddenly. People who stop taking opioids are usually taken off the medicine gradually so that any withdrawal symptoms will be mild or scarcely noticeable. If you stop taking opioids suddenly and develop a flu-like illness, excessive perspiration, diarrhea, or any other unusual reaction, tell your doctor or nurse. These symptoms can be treated and tend to disappear in a few days to a few weeks.

Other Types of Pain Medicine

Several different classes of medicines can be used along with (or instead of) opioids to relieve cancer pain. They may relieve pain or may increase the effect of opioids. Others lessen the side effects of opioids. The following chart shows the classes of nonopioid medicines that might be prescribed by your doctor to help you get the best pain relief with as few side effects as possible.

Table 3. OTHER MEDICINES USED TO RELIEVE CANCER PAIN
DRUG CLASS	GENERIC NAME	ACTION	SIDE EFFECTS
Antidepressants	Amitriptyline Nortriptyline Desipramine	Used to treat tingling or burning pain from damaged nerves. Nerve injury can result from surgery, radiation therapy, or chemotherapy.	Dry mouth, sleepiness, constipation, drop in blood pressure with dizziness or fainting when standing. Blurred vision. Urinary retention. Patients with heart disease may have an irregular heartbeat.
Antihistamines	Hydroxyzine Diphenhydramine	Help control nausea and help people sleep. Help control itching.	Drowsiness.
Anti-anxiety drugs	Diazepam Lorazepam	Used to treat muscle spasms that often go along with severe pain. Also lessen anxiety.	Drowsiness. May cause urinary incontinence.
Amphetamines	Caffeine Dextroamphetamine Methylphenidate	Increase the pain relieving action of opioids and reduce the drowsiness they cause.	Irritability. Rapid heartbeat. Decreased appetite.
Anticonvulsants	Carbamazepine Clonazepam Gabapentin Phenytoin	Help to control tingling or burning from nerve injury caused by the cancer or cancer therapy.	Liver problems and lowered number of red and white cells in the blood. Gabapentin may cause sedation and dizziness.
Steroids	Dexamethasone Prednisone	Help relieve bone pain, pain caused by spinal cord and brain tumors, and pain caused by inflammation. Increase appetite.	Fluid buildup in the body. Increased blood sugar. Stomach irritation. Rarely, confusion, altered behavior, and sleeplessness.

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Nondrug Treatments for Pain

Nondrug treatments are now widely used to help manage cancer pain. There are many techniques that are used alone or along with medicine. Some people find they can take a lower dose of medicine with such techniques. These methods include: relaxation, biofeedback, imagery, distraction, hypnosis, skin stimulation, transcutaneous electric nerve stimulation (TENS), acupuncture, exercise or physical therapy, and emotional support and counseling.

You may need the help of health professionals — social workers, physical therapists, psychologists, nurses, or others — to learn these techniques. Family and friends can also help. To find names and numbers of practitioners who specialize in and organizations knowledgeable about these techniques:

• Talk with your doctor or nurse.
• Contact a local hospice, cancer treatment center, or pain clinic.
• Visit your local bookstores or library.
• Contact the National Center for Complementary and Alternative Medicine Clearinghouse toll-free at 1-888-644-6226 or via e-mail at [email protected].

Because pain may be a sign that the cancer has spread, an infection is present, or there are problems caused by the cancer treatment, report any new pain problems to the doctor or nurse before trying to have the pain relieved by any of the following methods.

Some general guidelines for relieving pain with nondrug methods include:

• Learn which methods work for you. Try using a non- medicine method along with your medicine. For instance, you might use a relaxation technique (to lessen tension, reduce anxiety, and manage pain) at the same time you take medicine.
• Know yourself and what you can do. Often when people are rested and alert, they can use a method that demands more attention and energy. When tired, people may need to use a method that requires less effort. For example, try distraction when you are rested and alert; use hot or cold packs when you are tired.
• Be open-minded and keep trying. Keep a record of what makes you feel better and what doesn't help.
• Try each method more than once. If it doesn't work the first time, try it a few more times before you decide it is not helping you.

Relaxation

Relaxation relieves pain or keeps it from getting worse by reducing tension in the muscles. It can help you fall asleep, give you more energy, make you less tired, reduce your anxiety, and help other pain relief methods work better. Some people, for instance, find that taking pain medicine or using a cold or hot pack works faster and better when they relax at the same time.

How to Use Relaxation

Relaxation may be done sitting up or lying down. Choose a quiet place whenever possible.

Close your eyes. Do not cross your arms and legs because that may cut off circulation and cause numbness or tingling. If you are lying down, be sure you are comfortable. Put a small pillow under your neck and under your knees or use a low stool to support your lower legs.

There are many methods. Here are some for you to try:

Visual concentration and rhythmic massage:

• Open your eyes and stare at an object, or close your eyes and think of a peaceful, calm scene.
• With the palm of your hand, massage near the area of pain in a circular, firm manner. Avoid red, raw, or swollen areas. You may wish to ask a family member or friend to do this for you.

Inhale/tense, exhale/relax:

• Breathe in deeply. At the same time, tense your muscles or a group of muscles. For example, you can squeeze your eyes shut, frown, clench your teeth, make a fist, stiffen your arms and legs, or draw up your arms and legs as tightly as you can.
• Hold your breath and keep your muscles tense for a second or two.
• Let go! Breathe out and let your body go limp.

Slow rhythmic breathing:

• Stare at an object or close your eyes and concentrate on your breathing or on a peaceful scene.
• Take a slow, deep breath and, as you breathe in, tense your muscles (such as your arms).
• As you breathe out, relax your muscles and feel the tension draining.
• Now remain relaxed and begin breathing slowly and comfortably, concentrating on your breathing, taking about 9 to 12 breaths a minute. Do not breathe too deeply.
• To maintain a slow, even rhythm as you breathe out, you can say silently to yourself, "In, one, two; out, one, two." It may be helpful at first if someone counts out loud for you. If you ever feel out of breath, take a deep breath and then continue the slow breathing. Each time you breathe out, feel yourself relaxing and going limp. If some muscles, such as your shoulder muscles, are not relaxed, tense them as you breathe in and relax them as you breathe out. Do this only once or twice for each specific muscle group.
• Continue slow, rhythmic breathing for a few seconds up to 10 minutes, depending on your need.
• To end your slow rhythmic breathing, count silently and slowly from one to three. Open your eyes. Say silently to yourself, "I feel alert and relaxed." Begin moving about slowly.

Other methods you can add to slow rhythmic breathing:

Imagery. 

• Listening to slow, familiar music through an earphone or headset.
• Progressive relaxation of body parts. Once you are breathing slowly and comfortably, you may relax different body parts, starting with your feet and working up to your head. Think of words such as limp, heavy, light, warm, or floating. Each time you breathe out, you can focus on a particular area of the body and feel it relaxing. Try to imagine that the tension is draining from that area. For example, as you breathe out, feel your feet and ankles relaxing; the next time you breathe out, feel your calves and knees relaxing, and so on up your body.
• Ask your doctor or nurse to recommend commercially available relaxation tapes. These tape recordings provide step-by-step instructions in relaxation techniques.

Precautions:

Some people who have used relaxation for pain relief have reported the following problems and have suggested the following solutions:

• Relaxation may be difficult to use with severe pain. If you have this problem, use quick and easy relaxation methods such as visual concentration with rhythmic massage or breathe in/tense, breathe out/relax.
• Sometimes breathing too deeply for a while can cause shortness of breath. If this happens to you, take shallow breaths and/or breathe more slowly.
• You may fall asleep. This can be especially helpful if you are ready to go to bed. If you do not wish to fall asleep, sit in a hard chair while doing the relaxation exercise or set a timer or alarm.

If you have trouble using these methods, ask your doctor, nurse, social worker, or pain specialist to refer you to someone who is experienced in relaxation techniques. Do not continue any technique that increases your pain, makes you feel uneasy, or causes unpleasant effects.

Biofeedback

Learning this technique requires the help of a licensed biofeedback technician. With the help of special machines, people can learn to control certain body functions such as heart rate, blood pressure, and muscle tension. Biofeedback is sometimes used to help people learn to relax. You can use biofeedback techniques to help you relax and to help you cope with pain. This technique is usually used with other pain relief methods.

Imagery

Imagery is using your imagination to create mental pictures or situations. The way imagery relieves pain is not completely understood. Imagery can be thought of as a deliberate daydream that uses all of your senses — sight, touch, hearing, smell, and taste. Some people believe that imagery is a form of self-hypnosis.

Certain images may reduce your pain both during imagery and for hours afterward. If you must stay in bed or can't leave the house, you may find that imagery helps reduce the closed-in feeling; you can imagine and revisit your favorite spots in your mind. Imagery can help you relax, relieve boredom, decrease anxiety, and help you sleep.

How to Use Imagery

Imagery usually works best with your eyes closed. You may want to use a relaxation technique before using imagery. The image can be something like a ball of healing energy or a picture drawn in your mind of yourself as a person without pain (for example, imagine that you are cutting the wires that send pain signals from each part of your body to your brain). Or think of a pleasant, safe, relaxing place or activity that has made you happy. Exploring this place or activity in your mind in great detail can help you feel calm.

Here is an exercise with the ball of energy.

• Close your eyes. Breathe slowly and feel yourself relax.
• Concentrate on your breathing. Breathe slowly and comfortably from your abdomen. As you breathe in, say silently and slowly to yourself, "In, one, two." As you breathe out, say, "Out, one, two." Breathe in this slow rhythm for a few minutes.
• Imagine a ball of healing energy forming in your lungs or on your chest. It may be like a white light. It can be vague. It does not have to be vivid. Imagine this ball forming, taking shape.
• When you are ready, imagine that the air you breathe in blows this healing ball of energy to the area of your pain. Once there, the ball heals and relaxes you.
• When you breathe out, imagine the air blows the ball away from your body. As it goes, the ball takes your pain with it.
• Repeat the last two steps each time you breathe in and out.
• You may imagine that the ball gets bigger and bigger as it takes more and more discomfort away from your body.
• To end the imagery, count slowly to three, breathe in deeply, open your eyes, and say silently to yourself, "I feel alert and relaxed." Begin by moving about slowly.

Problems that may occur with imagery are similar to the ones that occur with the relaxation techniques.

Distraction

Distraction means turning your attention to something other than the pain. People use this method without realizing it when they watch television or listen to the radio to "take their minds off" a worry or their pain.

Distraction may be used alone to manage mild pain or used with medicine to manage brief episodes of severe pain, such as pain related to procedures. Distraction is useful when you are waiting for pain medicine to start working. If the pain is mild, you may be able to distract yourself for hours. Distraction can be a powerful way of relieving even the most intense pain for awhile.

How to Use Distraction

Any activity that occupies your attention can be used for distraction. Distractions can be internal, for example, such as counting, singing mentally to yourself, praying, or repeating to yourself statements such as "I can cope." Or distractions can be external, for example, doing crafts such as needlework, model building, or painting. Losing yourself in a good book might divert your mind from the pain. Going to a movie, watching television, or listening to music are also good distraction methods. Slow, rhythmic breathing can be used as distraction as well as relaxation. Visiting with friends or family is another useful distraction technique.

You may find it helpful to listen to rather fast music through a headset or earphones. To help keep your attention on the music, tap out the rhythm. You can adjust the volume to match the intensity of the pain, making it louder for very severe pain. This technique does not require much energy, so it may be very useful when you are tired.

After using a distraction technique, some people report that they are tired, irritable, and feel more pain. If this is a problem for you, you may not wish to use distraction or to be careful about which distraction methods you use and when you use them.

Hypnosis

Hypnosis is a trance-like state of high concentration between sleeping and waking. In this relaxed state, a person becomes more receptive or open to suggestion. Hypnosis can be used to block the awareness of pain, to substitute another feeling for the pain, and to change the sensation to one that is not painful. This can be brought on by a person trained in hypnosis, often a psychologist or psychiatrist. You can also be trained to hypnotize yourself.

During hypnosis, many people feel similar to the state we experience when we begin to awaken in the morning. We can't quite open our eyes, but are very aware. We can hear sounds inside or outside our house. Our eyes remain closed, and we feel as though we either can't or don't want to wake up and open our eyes.

People can easily be taught, by a hypnotherapist, to place themselves in a hypnotic state, make positive suggestions to themselves, and to leave the hypnotic state.

Choose a hypnotherapist who is licensed in the healing arts or who works under the supervision of someone who is licensed. To locate a therapist skilled in hypnosis, contact the behavioral medicine department at a cancer center near you.

Skin Stimulation

In this series of techniques, the skin is stimulated so that pressure, warmth, or cold is felt, but the feeling of pain is lessened or blocked. Massage, pressure, vibration, heat, cold, and menthol preparations are used to stimulate the skin. These techniques also change the flow of blood to the area that is stimulated. Sometimes skin stimulation will get rid of pain or lessen pain during the stimulation and for hours after it is finished.

Skin stimulation is done either on or near the area of pain. You can also use skin stimulation on the side of the body opposite the pain. For example, you might stimulate the left knee to decrease the pain in the right knee. Stimulating the skin in areas away from the pain can be used to increase relaxation and may relieve pain.

• If you are having radiation therapy, check with your doctor or nurse before using skin stimulation.
• If you are receiving chemotherapy, check with your doctor before using hot or cold packs.
• You should not apply ointments, salves, or liniments to the treatment area, and you should not use heat or extreme cold on treated areas.

Massage

Using a slow, steady, circular motion, massage over or near the area of pain with just your bare hand or with any substance that feels good, such as talcum powder, warm oil, or hand lotion. Depending upon where your pain is located, you may do it yourself or ask a family member, friend, or a massage therapist to give you a massage. Some people find brushing or stroking lightly more comforting than deep massage. Use whatever works best for you.

Precaution:

• If you are having radiation therapy, avoid massage in the treatment area as well as over red, raw, tender, or swollen areas.

Pressure

To use pressure, press on various areas over and near your pain with your entire hand, the heel of your hand, your fingertip or knuckle, the ball of your thumb, or by using one or both hands to encircle your arm or leg. You can experiment by applying pressure for about 10 seconds to see if it helps. You can also feel around your pain and outward to see if you can find "trigger points," small areas under the skin that are especially sensitive or that trigger pain. Pressure usually works best if it is applied as firmly as possible without causing more pain. You can use pressure for up to 1 minute. This often will relieve pain for several minutes to several hours after the pressure is released.

Vibration

Vibration over and near the area of the pain may bring temporary relief. For example, the scalp attachment of a hand-held vibrator often relieves a headache. For low back pain, a long, slender battery-operated vibrator placed at the small of the back may be helpful. You may use a vibrating device such as a small battery-operated vibrator, a hand-held electric vibrator, a large heat-massage electric pad, or a bed vibrator. Do not use a vibrator on the stomach. Avoid vibration over red, raw, tender, or swollen areas.

Precaution:

• If you are having radiation therapy, avoid vibration in the treatment area.

Cold or Heat

As with any of the techniques described, you should use what works best for you. Heat often relieves sore muscles; cold lessens pain sensations by numbing the painful area. Many people with prolonged pain use only heat and have never tried cold. Some people find that cold relieves pain faster, and relief may last longer. Also, you can alternate heat and cold for added relief in some cases.

For cold, try gel packs that are sealed in plastic and remain soft and flexible even at freezing temperatures. Gel packs are available at drugstores and medical supply stores. They can be used again and stored in the freezer. You may want to wrap the pack in a towel to make it more comfortable. An ice pack, ice cubes wrapped in a towel, or water frozen in a paper cup also work.

Precaution:

• If you start to shiver when using cold, stop right away. Do not use cold so intense or for so long that the cold itself causes more pain.

To use heat for pain relief, a heating pad that generates its own moisture is convenient. You can also try gel packs heated in hot water, hot water bottles, a hot, moist towel, a regular heating pad, a hot bath or shower, or a hot tub to apply heat. For aching joints, such as elbows and knees, wrap the joint in a lightweight plastic wrap (tape the plastic to itself). This retains body heat and moisture.

Precautions:

• Do not use a heating pad on bare skin. Do not go to sleep for the night with the heating pad turned on. Also, be very careful, if you are taking medicines that make you sleepy or if you do not have much feeling in the area.
• Do not use heat over a new injury because heat can increase bleeding — wait at least 24 hours.
• Avoid heat or cold over any treatment area receiving radiation therapy and for 6 months after therapy has ended.
• If you are receiving chemotherapy, check with your doctor before using a cold pack.
• Do not use heat or cold over any area where your circulation or sensation is poor.
• Do not use heat or cold application for more than 5 to 10 minutes

Menthol
Many menthol preparations are available for pain relief. There are creams, lotions, liniments, or gels that contain menthol. When they are rubbed into the skin, they increase blood circulation to the affected area and produce a warm (sometimes cool) soothing feeling that lasts for several hours.

How to Use Menthol

To use menthol preparations, test your skin by rubbing a small amount of the substance in a circle about the size of a quarter in the area of the pain (or the area to be stimulated). This will let you know whether menthol is uncomfortable to you or irritates your skin. If the menthol does not create a problem, rub some more into the area. The feeling from the menthol gradually increases and remains up to several hours. To increase the strength and length of the feeling, you can open your skin pores with heat (e.g., shower, sun) or wrap a plastic sheet over the area after the menthol application. (Don't use a heating pad because it may cause a burn). If you are concerned about the odor, you can use the menthol when you are alone, or perhaps in the evening or through the night.

Precautions:

• Do not rub menthol near your eyes, over broken skin, a skin rash, or mucous membranes (such as inside your mouth, or around your genitals and rectum).
• Make sure you do not get menthol in your eyes (wash your hands after applying menthol).
• Do not use menthol in the treatment area during radiation therapy.
• If you have been told not to take aspirin, do not use these preparations until you check with your doctor. Many menthol preparations contain an additional ingredient similar to aspirin. A small amount of this aspirin-like substance may be absorbed through the skin.

Transcutaneous Electric Nerve Stimulation (TENS)

This is a technique in which mild electric currents are applied to some areas of the skin by a small power pack connected to two electrodes. The feeling is described as a buzzing, tingling, or tapping feeling. The small electric impulses seem to interfere with pain sensations. The current can be adjusted so that the sensation is pleasant and relieves pain. Pain relief lasts beyond the time that the current is applied. Your doctor or a physical therapist can tell you where to get a TENS unit, and how to use it properly.

Acupuncture

In acupuncture, thin needles are inserted into the body at certain points and at various depths and angles. Each point controls the pain sensation of a different part of the body. When the needle is inserted, a slight ache, dull pain, tingling, or electrical sensation is felt for a few seconds. Once the needles are in place, no further discomfort should be experienced. The needles are usually left in place for between 15 and 30 minutes, depending on the condition treated. No discomfort is felt when the needles are removed. Acupuncture is now a widely accepted and proven method of pain relief. Acupuncture should be performed by a licensed acupuncturist. Ask your doctor, nurse, or social worker where to get acupuncture.

Precautions:

• Make sure your acupuncturist uses sterile needles.
• If you are receiving chemotherapy, talk to your doctor before beginning acupuncture.

Emotional Support and Counseling

If you feel anxious or depressed, your pain may seem worse. Also, pain can cause you to feel worried, depressed, or easily discouraged. Some people feel hopeless or helpless. Others may feel embarrassed, inadequate, or angry, frightened, isolated, or frantic. These are normal feelings that can be relieved.

Finding Support

Try to talk about your feelings with someone you feel comfortable with — doctors, nurses, social workers, family or friends, a member of the clergy, or other people with cancer. You may also wish to talk to a counselor or a mental health professional. Your doctor, nurse or the social services department at your local hospital can help you find a counselor who is specially trained to help people with chronic illnesses.

You may also want to join a support group where people with cancer meet and share their feelings about how they have coped with cancer. For information about support groups, ask your doctor, nurse, or hospital social worker. Also, many newspapers carry a special health supplement containing information about where to find support groups.

Other Pain Relief Methods

Some people have pain that is not relieved by medicine or nondrug techniques. In these cases, other treatments can be used to reduce pain.

Radiation Therapy

Treatment with high-energy rays (called radiation therapy) can reduce pain by shrinking a tumor. Often, only a single dose of radiation is needed to relieve pain.

Surgery

Pain cannot be felt if the nerve pathways that relay pain impulses to the brain are interrupted. To block these pathways, a neurosurgeon may cut nerves, which are usually near the spinal cord. When the nerves that relay pain are destroyed, the sensations of pressure and temperature can no longer be felt. Surgeons with special skills and expertise in pain management, preferably in consultation with other pain specialists, should perform the procedures.

Nerve Blocks

Nerve block is a procedure where a local anesthetic, which may be combined with a steroid, is injected into or around a nerve or into the spine to block pain. After the injection, the nerve is no longer able to relay pain so the pain is temporarily relieved. For longer lasting pain relief, phenol or alcohol can be injected. A nerve block may cause muscle paralysis or a loss of all feeling in the affected area.

End of Life Care

The goal of pain control is usually for a person to be as free from pain as possible and still be able to continue with normal life activities, such as work, hobbies and recreation. However, if a person has only a short time to live — less than 12 months — and has pain that is hard to control, comfort becomes the most important goal. Pain control methods that can cause lasting side effects may need to be used to make a patient comfortable. For example, a nerve block may cause a muscle to become paralyzed. Also, a certain medicine or higher dose of a medicine that may cause side effects, such as sleeping or resting more than usual, may need to be used to control pain or relieve restlessness.

Research on Pain Control Methods

Patient studies — clinical studies or clinical trials — have contributed largely to the decrease in cancer death rates in the United States. Clinical studies have also led to better pain control methods, such as continuous pain-medication infusion pumps (patient-controlled analgesia), first developed in the early 1980s.

In cancer research, a clinical trial is designed to show how a given anticancer strategy — for instance, a promising drug, a new diagnostic test, or a possible way to prevent cancer — affects the people who receive it. "Clinical trial" is a research term that refers to medical studies with people. These studies are the final step in the process of developing new drugs and other means to fight diseases. Once a drug has shown promise, first in the laboratory and then in animal studies, it may move on to studies with people if the U.S. Food and Drug Administration (FDA) approves. Only after a drug proves safe and effective for patients in clinical studies does the FDA grant approval for using the drug as standard treatment.

For more information about current research on pain control methods, contact:

NCI's Cancer Information Service (CIS) at 1-800-4-CANCER (1-800-422-6237).

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Tools for Patients

Patient Notes

Doctor's Name:

Address:

Phone:

Nurse's Name:

Address:

Phone:

Pharmacist's Name:

Address:

Phone:

Social Worker/Therapist:

Address:

Phone:

Questions to Ask:

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Pain Control Record

You can use a chart like this to rate your pain and to keep a record of how well the medicine is working. Write the information in the chart. Use the pain intensity scale to rate your pain before and after you take the medicine.

Pain Intensity Scale

0

1

2

3

4

5

6

7

8

9

10

No pain

Worst pain imaginable

Date	Time	Pain scale rating	Medicine and dose	Other pain relief methods	Side effects from pain medicine
June 6 (example)	8 am	6	Morphine 30mg - every 4 hrs	massage	constipation

 

Use this form to record all medicines — not just pain medicines — you are now taking. This information will help your doctor keep track of all the medicines you are taking.

Medicine	Dose	How often taken	How well is it working?	Prescribing doctor

Use this form to record the pain medicines you have taken in the past. It will help your doctor understand what has and hasn't worked.

Pain Medicines Taken in the Past

Medicine	Dose>	How often taken	Side effects	Reason for stopping

Resources

Cancer Information Service (CIS)

Toll-free: 1-800-4-CANCER (1-800-422-6237)

TTY: 1-800-332-8615

http://cancer.gov/

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Source: National Cancer Institute
November 2000

Reviewed by athealth on February 6, 2014.