Minister calls for pain indicators in QOF (Quality

From the FMS Global News Desk of Jeanne Hambleton (UK)

Courtesy of PulseToday.com

By Nigel Praities -21 Apr 09

A Government minister has invited applications for new pain management indicators for the QOF in a parliamentary debate held yesterday.

Health minster Ann Keen said the inclusion of pain in the QOF was a ‘key issue’ and that she hoped organisations would submit proposed indicators for the next review.

The debate was proposed by Anne Begg MP, the chair of the recently formed All-Party Parliamentary Group on Chronic Pain, who said pain should be considered as a ‘vital sign’ for PCTs and incentivised through the QOF.

‘The inclusion of pain assessment in the QOF would strongly encourage health professionals to be proactive and to ask a patient about their pain, treat it promptly and reassess it to ensure that the treatment given is effective, rather than expecting the patient to raise it first,’ she said.

Ms Begg also criticised the complete withdrawal of co-proxamol by the MHRA, and quoted figures revealed in Pulse earlier this year that showed an increase in morphine and tramadol prescriptions as a result of the withdrawal.

In response, Ann Keen said Ms Begg had made a ‘persuasive and eloquent case’ for pain indicators in the QOF and she hoped pressure groups, such as the Chronic Pain Policy Coalition – would press for its inclusion.

‘I understand that the next opportunity to submit suggestions for new indicators to NICE will be this summer. I hope that the chronic pain policy coalition will take the opportunity to suggest specific indicators at that stage,’ she said.

A spokesperson from the Chronic Pain Policy Coalition confirmed it would submit a proposal for new QOF indicators for the routine management and assessment of pain to NICE later this year.

‘Given the important role GPs have to play in the early identification, diagnosis and management of patients with pain, we strongly believe that this is an area in which greater incentivisation through inclusion within the QOF indicators would have a considerable positive impact,’ he said.

(http://www.pulsetoday.co.uk/story.asp?sectioncode=23&storycode=4122478&c=2&cid=pain042209#)

IN THE HOUSE OF COMMONS 20 April 09 (Hansard source/TheyWorkForYou.com)

In the House of Commons on April 20 MP Anne Begg spoke about the Pain Management Services (England) as reported by Hansard and TheyWorkForYou.com

She said, “In the United Kingdom, 7.8 million people live with pain, day in and day out; that is the equivalent of about one in seven people in every single parliamentary constituency. I have asked for this debate in order to draw attention both to their problems and, more importantly, to some solutions that would not only improve the quality of life of so many of our constituents, but also reduce public expenditure on health, social care and incapacity benefits.

“If anyone is wondering why I, as a Scottish MP, am raising the issue of pain management services in England when health is a devolved issue, it is because I am the chairman of the recently set up all-party group on chronic pain. I suppose I should also declare an interest: I am one of the 7.8 million people in the UK who live with chronic pain.

“There could not be a better opportunity to consider the problem and suggest solutions. People in pain and the health professionals helping them have been pushing at a closed door for many years now. They have argued for early recognition of the needs of people in pain, early access to expert advice and treatment, and referral to a specialist pain clinic when necessary. That door was closed until recently; suddenly, it looks as though it is opening, and I am grateful to the chief medical officer for beginning that process.

MAJOR INITIATIVE

“His latest annual report, only just published, includes a chapter called “Pain: breaking through the barrier”. Sir Liam Donaldson looks at the issue of people living with pain in a sensitive and comprehensive way, and concludes with this statement:’A major initiative to widen access to high-quality pain services would improve the lives of millions of people.’ “

Ms Begg also said, “The evidence suggests that although pain services do exist in most secondary care NHS trusts, they are patchy, and variable in their resources and in the services that they provide. Crucially, the CMO’s report makes this point: each year, more than 5 million people in the United Kingdom develop chronic pain, but only two thirds will recover. Clearly, much more needs to be done to improve outcomes for patients. He reminds us that pain affects 7.8 million people, and that more than a third of households have someone in pain at any given time. Those figures are rising. Indeed, recent surveys suggest that chronic pain is more common now than it was 40 years ago.
Pain is becoming more common, but the effect that it has on individual lives is immense.

“The CMO highlights the fact that pain has a major impact on people’s lives, causing sleeplessness and depression, and interfering with normal physical and social functioning. That often leads to unemployment. He points out how it affects all age groups. Perhaps most worryingly, he states that 8 per cent. of children experience severe pain, that back pain alone costs the economy £12.3 billion per year and that early intervention may prevent pain from becoming persistent. In fact, it has been shown that the cost of chronic pain is greater than that of heart disease or diabetes.

“Looking at the limited number of specialist pain clinics, the CMO points out that systems and infrastructure do not meet need or demand, and that better co-ordination of services, and services designed around patients’ needs, are essential. Pain needs to be considered in its own right, because it is often the pain that dominates the patient’s life, not the illness or condition that causes the pain.

As one patient has said: ‘At first I presumed the pain would eventually go away and I would get better. I didn’t expect to develop chronic pain, or that it would stop me working and lead me to consider suicide. I just want my life back.’

Another said: ‘I am in constant and debilitating pain, often unable to do even the most simple activity such as making myself a cup of tea. I have daily bad headaches, and have no quality of life. It is making me very depressed and life is hell.’

Clearly, we have a duty to ensure that the individual has access to the right treatment as early as possible. That treatment has to come from a properly trained professional, and a multidisciplinary team if needed.

“I was surprised by the amount of interest that this debate has generated. I have been contacted by a number of organisations wishing me to raise their concerns. Age Concern and Help the Aged have particular issues relating to the elderly.

AGEING PROCESS

“They say that pain is not a normal part of the ageing process, and we should not accept it as such. We should challenge discrimination and ageist attitudes with regard to pain in older people. They say that constant pain can lead to a loss of dignity. Some 90 per cent. of calls to Arthritis Care’s helpline concern pain, most of them from people in severe pain. In the UK, pain crises account for 60 to 80 per cent. of emergency presentations in hospital admissions for sickle cell disorder.

CO-PROXAMOL WITHDRAWAL AND NAMED PATIENTS

“This is not the first time I have had an Adjournment debate on the issue of pain. Ever since the Government first indicated that they intended to withdraw the analgesic co-proxamol, I have been trying to persuade Ministers that it should not be completely withdrawn as a small group of people still has not been able to find an alternative and certainly not anything so effective. These are all people who suffer chronic pain, who are saying that only co-proxamol works not because they want to be awkward but because it allows them to carry on with their life.

“One person in that position has said: ‘With co-proxamol I had pain but it was bearable, now I can walk only a few steps before being forced to rest; before I managed to tend my flower garden, now I can only sit and feel depressed with pain and frustration’.

“I have several constituents who depended on co-proxamol but cannot now get access to it. While the Government say that co-proxamol is available on a named patient basis, that is of cold comfort to those whose GPs are refusing to prescribe the drug at all. GPs are not comfortable prescribing off licence as they do not always feel that they have the specialist knowledge. But consultants at pain clinics do.

“The main reason the Government gave for withdrawing co-proxamol was the suicide statistics. As it is now extremely difficult for even those who need the drug to access it, the incidence of suicide attributed to co-proxamol is now tiny. However, the use of stronger pain relief and particularly opiates has grown. A recent Pulse article says that there has been a 44 per cent. rise in prescriptions for morphine and a 61 per cent. rise in tramadol prescriptions. That cannot be good pain management, so I ask the Minister to look at this issue again.

“I have not, however, sought this debate to lay blame at the Government’s door on this matter: rather, I hope to encourage the Minister to consider the recommendations laid out in the chief medical officer’s report and to give due regard to their feasibility. I do not have time to discuss them all, but I do want to take this opportunity to bring some to the Minister’s attention.

PAIN TRAINING SHOULD BE EXTENDED

“First, training on chronic pain should be included in the curriculum for all health professionals who deal with patients. However, it is vital that this core training is extended to all health professionals, and in particular to GPs who, at the very least, should have pain training as part of their standard undergraduate education.

“Secondly, consideration should be given to the inclusion of the assessment of pain and its associated disability in the quality and outcomes framework—QOF—in primary care. That is an extremely important point, because the inclusion of pain assessment in the QOF would strongly encourage health professionals to be proactive and to ask a patient about their pain, treat it promptly and reassess it to ensure that the treatment given is effective, rather than expecting the patient to raise it first.

“A recent report on osteoarthritis found that 50 per cent. of people said that they would need to be in frequently unbearable pain before considering seeing their GP—clearly this is a significant barrier.

FIFTH VITAL SIGN – PAIN SCORE

“Another recommendation was that a pain score should become part of the vital signs monitored routinely in hospital. Indeed, the Chronic Pain Policy Coalition has been campaigning for some time now for pain to be adopted as the fifth vital sign. If implemented, this recommendation would ensure that health professionals become proactive in asking their patients about pain. People would recover faster and reduce the burden of care on others.

MODEL PAIN SERVICE OF PATHWAYS OF CARE

“The final recommendation I want to highlight relates to the development by experts of a model pain service of pathways of care with clear standards. The work could build on the excellent 18-week cross specialty chronic pain pathway developed by patients and clinicians that has been supported by the Department of Health.

“It is an important step forward and should be extended to ensure that all patients are offered comprehensive treatment options. That would improve rapid access and reduce the current variability in treatment that patients receive. Patients need to be confident that they can be offered effective options wherever they live.

“Commitments have already been made both in Scotland with the ‘Getting to GRIPS with Chronic Pain’ report and in Wales under the ‘Designed for Life’ programme to assess and improve the services available for patients with chronic pain. I hope I have shown the Minister that there are patients, third sector organisations such as Arthritis Care and health professionals in England anxious to get hold of these recommendations and take them forward. They will need encouragement and flexibility in the way in which integrated services are funded and in how outcomes are measured.

PAIN CHAMPION DEMANDED

“Above all, people in pain need a champion. Tsars such as Mike Richards for cancer and Roger Boyle for cardiology have shown how such champions can make a difference. Pain affects cancer patients and heart patients as well as millions of others with back pain, arthritis, pelvic pain and a multiplicity of conditions. Surely the numbers involved and the importance of early intervention demand a pain champion.

“I know that the concerns I have raised in this debate are shared by a number of my hon. Friends and indeed by many of their constituents. I thank the Minister for hearing me out, and I hope that she can give consideration to the points I have raised.

REPLY

Replying Ann Keen (Parliamentary Under-Secretary (Health Services), Department of Health; (Hansard source) congratulated Miss Begg on securing this Adjournment debate on a “most important topic, which Professor Sir Liam Donaldson chose to highlight recently in the 150th report of the chief medical officer.”

She said, “The report of the chief medical officer is an independent report to Government on aspects of the nation’s health and, as such, draws attention to a number of different major health challenges. In his annual report for 2008, the chief medical officer called for a major initiative to widen access to high-quality pain services to improve the lives of millions.

NATIONAL PAIN DATABASE

“I am delighted to inform my hon. Friend and the House that I received a letter from Professor Black, the chair of the advisory group, just before the Easter recess, and it recommended that the national pain database, run jointly by the Royal College of Anaesthetists and the British Pain Society, should be funded as part of the national clinical audit programme.”

EDITOR’S NOTE: On behalf of the fibromyalgia community living with chronic pain, numbering around two million, mainly women, me included, and those of us who survived thanks to co-proxamol, I would like to thank Anne Begg MP publicly for speaking out on our behalf.

Had I known Miss Begg was to initiate this debate I would, of course, have asked her to include fibromyalgia in her chronic pain list. Hopefully she will read this somewhere, sometime, and might think kindly of us when next raising chronic pain and co-proxamol.

For many of us co-proxamol, when it was £2.79 for 100 tablets, was an inexpensive painkiller. Had we known this it would have been cheaper than the prescription charge if we had been able to buy it. This was before the Government got involved. It was a life saver for those with fibromyalgia, and many others. In those days we had some relief…now it is pain 24/7 thanks those who meddled against the wishes of many doctors, consultants, a number of MPs and the patients. They did not give a jot about us at the ‘coal face’ living with pain for the rest of the life. Yes I have tried the alternatives and they disagreed with me and my IBS and gastric problems. They should have tightened the rules allowing those who really need it to be able to get it, prescribed without litigation problems.

Today albeit your GP knows you are in pain and you should be a named patient, after years of safely taking co-proxamol without a hint of any problems, he will not prescribe it due to the risk of litigation involved with prescribing an unlicensed drug. Mr. B. sitting comfy in his armchair (free of pain) with all found, at No.10, your Government has a lot to answer for…….. the loss of co-proxamol is most certainly one of them.

Letters to Anne Begg at begga@parliament.uk would I am sure be much appreciated by her especially if you make reference to her debate in the House of Common on 20 April 200 and give her more ammunition about your problems with co-proxamol and fibromyalgia. Maybe you will send a copy to me please -fmsglobalnews@me.com. Thanks.

For the background to the Co-proxamol debate and MP Anne Begg.
SEE: http://fmsglobalnews.wordpress.com/2009/03/13/co-proxamol-a-controlled-drug/

http://fmsglobalnews.wordpress.com/2009/03/24/prescriptions-for-opioids-jump-following-co-proxamol-ban/

http://jeannehambleton77.wordpress.com/2008/01/03/no-u-turn-on-co-proxamol-withdrawal/

http://jeannehambleton77.wordpress.com/2007/12/05/co-proxamol-bungled-withdrawal-is-a-farce/

http://jeannehambleton77.wordpress.com/2007/11/26/co-proxamol-withdrawal-debate/

SEE: http://jeannehambleton77.wordpress.com for more health stories

Why You Must Protect Your Knees

From the FMS Global and UK News Desk of Jeanne Hambleton

Courtesy of WebMD – Feature from “Redbook” Magazine

By Jeannette Moninger

Women are the weaker-kneed sex – really! Ease the pain with these tips.

Years of stooping, kneeling, and running around really takes a toll on your knees, and women have it especially bad: Studies show we are up to six times more likely than men to suffer from knee injuries like ACL tears. Got an achy, creaky, or weak knee? We will help you find the cause — plus, we have got ways to fix your bad knees for good.

Creaky knees

Your knees pop, grind, and ache while climbing stairs or after prolonged sitting.

The cause: Though it is commonly called “runner’s knee,” patellofemoral syndrome afflicts even couch potatoes. The creaking you feel is a result of a misaligned kneecap grating over the lower end of your thighbone. Women are particularly susceptible to this syndrome because our naturally wide pelvises cause our thighs to slant inward, creating a wider quadriceps, or Q, angle than men have.

“This Q angle places extra force on a woman’s knees,” says Kathy Weber, M.D., director of women’s sports medicine at Rush University Medical Center in Chicago.

The fix: If you regularly do high-impact workouts such as running or playing tennis, cut back (but do not stop altogether or the muscles that support your knees will weaken) and add gentler activities such as swimming and yoga to your routine. Also, buy new workout shoes when your shoes’ soles are worn so that your arches and joints are adequately cushioned.

Achy knees

During physical activity, you feel a sharp pain between your kneecap and shinbone. The pain persists as a constant, dull ache.

The cause: tendonitis, which occurs when the tendons connecting your kneecap to the shinbone become inflamed due to repeated stress and overuse. Symptoms flare up when you increase the frequency or intensity of your workouts.

The fix: To ease pain and reduce swelling, take a nonsteroidal anti-inflammatory drug (NSAID) like ibuprofen, and ice, rest, and elevate your throbbing knee, especially following a workout. Also, ask your doctor about patellar tendon straps, Velcro bands placed just under your kneecap, which relieve pain by taking pressure off the tendon. If the pain persists or worsens, see your doctor.

Stiff knees

Your knee is swollen and puffy, and you have trouble straightening or bending it.

The cause: osteoarthritis. The cartilage that cushions your joints breaks down due to use, age, or excess weight, and makes your body produce more joint fluid in the knee. When the cartilage wears down completely, you are left with bone rubbing on bone and painfully swollen joints, says Tamara Martin, M.D., an orthopedic surgeon at Brigham and Women’s Hospital in Boston.

The fix: Losing just 11 pounds can take pressure off your knees and reduce arthritis pain by 50 percent, according to one study. In addition, taking NSAIDs, resting, and using ice can alleviate pain and swelling. If your knee becomes red or feels warm to the touch, see your doctor, who may drain the excess joint fluid with a needle. About 25 percent of people with osteoarthritis need knee-replacement surgery.

©2005-2009 WebMD, LLC. All rights reserved
(http://www.webmd.com/pain-management/knee-pain/features/why-you-must-protect-your-knees?ecd=wnl_art_040609)

Knee replacement surgery

Joint replacement involves surgery to replace the ends of bones in a damaged joint. This surgery creates new joint surfaces.

In knee replacement surgery, the ends of the damaged thigh and lower leg (shin) bones and usually the kneecap are capped with artificial surfaces lined with metal and plastic. Usually, doctors replace the entire surface at the ends of the thigh and lower leg bones. However, it is increasingly popular to replace just the inner knee surfaces or the outer knee surfaces, depending on the location of damage. This is called unicompartmental replacement. People who are good candidates for unicompartmental surgery have better results with this procedure than with total joint replacement. 1 Doctors usually secure knee joint components to the bones with cement.

In knee replacement surgery, doctors remove the damaged cartilage and replace it with new joint surfaces in a step-by-step process.

Joint changes caused by osteoarthritis may also stretch and damage the ligaments that connect the thighbone to the lower leg bone. After surgery, the artificial joint itself and the remaining ligaments around the joint usually provide enough stability so that the damaged ligaments are not a problem.

Doctors most often use regional anesthesia for joint replacement surgery. That means you cannot feel the area of the surgery and you are sleepy, but you are awake. The choice of anesthesia depends on your doctor, on your overall health, and, to some degree, on what you prefer.

Your doctor may recommend that you take antibiotics before and after the surgery to reduce the risk of infection. If you need any major dental work, your doctor may recommend that you have it done before the surgery. Infections can spread from other parts of the body, such as the mouth, to the artificial joint and cause a serious problem.

What To Expect After Surgery – Right after surgery

You will have intravenous (IV) antibiotics for about a day after surgery. You will also receive medications to control pain, and perhaps medications to prevent blood clots (anticoagulants). It is not unusual to have an upset stomach or feel constipated after surgery. Talk with your doctor or nurse if you do not feel well.

When you wake up from surgery, you will have a bandage on your knee and probably a drain to collect fluid and keep it from building up around your joint. You may have a catheter, which is a small tube connected to your bladder, so you do not have to get out of bed to urinate. You may also have a compression pump or compression stocking on your leg, which squeezes your leg to keep the blood circulating and to help prevent blood clots. Some surgeons recommend that you spend time in a continuous passive motion machine (CPM) to help keep your knee flexible. The machine has a cradle for your leg and is fitted to your leg length and joint position. The amount it bends your knee is adjustable. You may already have a CPM slowly bending and straightening your knee when you wake up after surgery.

Your health professional may teach you to do simple breathing exercises to help prevent congestion in your lungs while your activity level is decreased. You may also learn to move your feet up and down to flex your muscles and keep your blood circulating.

The first few days

You will probably still be taking some medication. You will gradually take less and less pain medication. You may continue anticoagulant medications for several weeks after surgery.

Most people who have knee replacement surgery start to walk with a walker or crutches the day after surgery and can bear weight on the knee if it is comfortable.

A physical therapist will help you gently bend and straighten your knee. Your therapist will also begin some simple exercises to help strengthen your leg muscles.

Rehabilitation (rehab) after a knee replacement is intensive. The main goal of rehab is to allow you to bend your knee at least 90 degrees-enough to do daily activities, such as walking, climbing stairs, sitting in and getting up from chairs, and getting in and out of a car. Most people can get considerably more bending than 90 degrees after surgery. However, one of the factors that affects how much bend you get after surgery is how much bend you had before surgery. To get the most benefit from your surgery, it is very important that you take part in physical therapy both while you are in the hospital and after you go home from the hospital.

Most people go home within a few days to a week after surgery. Some people who need more extensive rehab or those who do not have someone who can help at home go to a specialized rehab center for more treatment.

Continued recovery

Once you go home, monitor the surgery site and your general health. If you notice any redness or drainage from your wound, notify your surgeon. You may also be advised to take your temperature twice each day, and to let your surgeon know if you have a fever over 100.5F.

Rehabilitation generally continues after you go home from the hospital until you are able to function more independently and you have recovered as much strength and range of motion in your knee as you can. You will continue to work on increasing the amount you can bend your knee and on building strength and endurance. Total rehabilitation after surgery will take several months.

You will have an exercise program to follow when you go home, even if you are still having physical therapy. You should also take a short walk several times each day. If you notice any soreness, try a cold pack on your knee and perhaps decrease your activity a bit, but do not stop completely. Sticking to your walking and exercise program will help speed your recovery.

Your doctor may recommend that you ride a stationary bicycle to strengthen your leg muscles and improve your knee bending. Swimming is also a good exercise after knee surgery, once your sutures or staples are removed and you are able to go in the water.

Living with a knee replacement

Your health professional may want to see you periodically for several months or more to monitor your knee replacement. Gradually, you will return to most of your presurgery activities.

Controlling your weight will help your new knee joint last longer.

Stay active to help maintain strength, flexibility, and endurance. Your activities might include walking, swimming (once your wound is completely healed), dancing, golf (do not wear shoes with spikes, and use a golf cart), and bicycling on a stationary bike or on level surfaces.

Your health professional may want you to take antibiotics before dental work or any invasive medical procedure for the rest of your life. This will help prevent infection around your knee replacement.

Why It Is Done

Doctors recommend joint replacement surgery when knee pain and loss of function become severe, and medications and other treatments no longer relieve pain. Your doctor will use X-rays to look at the bones and cartilage in your knee to see whether they are damaged and to make sure that the pain is not coming from somewhere else.

Doctors may not recommend knee replacement for people who:

Have poor general health and may not tolerate anesthesia and surgery well.

Have an active infection or are at risk for infection.

Have osteoporosis (significant thinning of the bones).

Have severe weakness of the quadriceps muscles at the front of the thigh.

Have a knee that appears to bend backward when the knee is fully extended (genu recurvatum), if this condition is due to muscle weakness or paralysis.

Are severely overweight (replacement joints may be more likely to fail in people who are very overweight).

Some doctors will recommend other types of surgery if possible for younger people and especially for those who do strenuous work. A younger or more active person is more likely than an older or less active person to have an artificial knee joint wear out. People who are very overweight are also more likely to have an artificial knee joint wear out from the extra stress on the joint.

Doctors usually do not recommend knee replacement surgery for people who have very high expectations for how much they will be able to do with the artificial joint (for example, people who expect to be able to run, ski, or do other activities that stress the knee joint). The artificial knee allows a person to do ordinary daily activities with less pain. It does not restore the same level of function that the person had before the damage to the knee joint began.

How Well It Works

Most people have much less pain after knee replacement surgery and are able to do many of their daily activities more easily.

The knee will not bend as far as it did before you developed knee problems, but the surgery will allow you to stand and walk for longer periods without pain.

After surgery, you may be allowed to resume activities such as golfing, riding a bike, swimming, walking for exercise, dancing, and cross-country skiing (if you did these activities before surgery).

Your doctor may discourage you from running, playing tennis, squatting, and doing other things that put a lot of stress on the joint.

The younger you are when you have the surgery and the more stress you put on the joint, the more likely it is that you will eventually need a second surgery to replace the first artificial joint. Over time, the components wear down or may loosen and need to be replaced.

Your artificial joint should last longer if you are not overweight and you do not do hard physical work or play sports that stress the joint. If you are older than 60 when you have joint replacement surgery, the artificial joint will probably last the rest of your life.

Risks

Risks from knee replacement surgery include:

Blood clots. People may develop a blood clot in a leg vein after knee joint replacement surgery. Blood clots can be dangerous if they block blood flow from the leg back to the heart or move to the lungs. Blood clots occur more commonly in older people, people who are very overweight, people who have had blood clots before, and those who have cancer.

Infection in the surgical wound or in the joint. Infection is rare in people who are otherwise healthy. Only about 1 to 4 out of 200 people develop an infection after knee replacement surgery. 2 People who have other health problems, such as diabetes, rheumatoid arthritis, or chronic liver disease, or those who are taking corticosteroids are at higher risk of infection after any surgery. Infections in the wound usually are treated with antibiotics. Infections deep in the joint may require more surgery, and in some cases the doctor must remove the artificial joint.

Nerve injury. In rare cases, a nerve may be injured around the site of the surgery. It is more common (but still unusual) if the surgeon is also correcting deformities in the joint. A nerve injury may cause tingling, numbness, or difficulty moving a muscle. These injuries usually get better over time and in some cases may go away completely.

Problems with wound healing. Wound healing problems are more common in people who take corticosteroids or who have diseases that affect the immune system, such as rheumatoid arthritis and diabetes.

Lack of good range of motion. How much you can bend your knee after surgery depends a lot on how much you could bend your knee before surgery. Some people are not able to bend their knee far enough to allow them to do their regular daily activities, even after several weeks of recovery. If this happens, the doctor may give you a medication to relax your muscles and then gently force your knee to bend further. This may loosen tissues around the joint that are preventing you from bending it.

Dislocation of the kneecap (patella). This is an uncommon complication of knee replacement surgery. If this happens, the kneecap may move to one side of the knee, and it will “pop” back when you bend your knee. This may not be painful, but it may make the knee feel unstable, and it may be uncomfortable. Dislocation of the kneecap interferes with the way your thigh muscles (quadriceps) work, and it usually needs to be treated with surgery. In some cases, the knee replacement surgery must be completely redone if the dislocation is caused by a problem with the way the components in the knee line up.

Fracture of the kneecap (patella). The kneecap could fracture either because of a fall or while you are using the knee normally. This complication is very uncommon. It may be seen in people who can bend the knee almost normally and can easily climb stairs and get up from chairs. Doctors usually can treat a fractured kneecap without surgery.

Instability in the joint. The knee may be unstable or wobbly if the replacement components are not properly aligned. You may need a second surgery to align the components correctly so that your knee is stable.

The usual risks of general anesthesia. Risks of any surgery are higher in people who have had a recent heart attack and those who have long-term (chronic) lung, liver, kidney, or heart disease.

What To Think About

Continued exercise (swimming, walking) is important to your general well-being and muscle strength. Discuss with your doctor what type of exercise is best for you.

You may donate your own blood to use during surgery if needed. This is called autologous blood donation. If you choose to do this, start the donation several weeks before the surgery so that you have time to donate enough blood and rebuild your blood volume before surgery.

If you need more than one joint replacement surgery, such as both knees or a knee and a hip, there are some general guidelines that may help you and your doctor decide in which order to do the surgeries.

Should I have knee replacement surgery? Guidelines for multiple joint replacements

Some people may need to have more than one joint replaced-for example, a shoulder and an elbow, a shoulder and a knee, both knees, or a hip and a knee. Doctors have different opinions about what is best, based on their experience and your specific situation. Your doctor will consider many factors, but the following are some general guidelines.

If you need both a shoulder and an elbow replaced, your doctor will probably replace the more painful and disabling joint first.

If you need a shoulder and either a hip or knee replaced, your doctor usually cannot replace the hip or knee until at least 3 months after the shoulder. This is to give the shoulder time to heal before you need to use crutches or a walker after the surgery on your hip or knee.

If you need both a hip and a knee replacement, and you are not sure how well you will tolerate rehabilitation (rehab), most doctors will recommend having surgery on the hip first. Recovery after hip surgery does not require as much rehab, so if you do well, you may also do well with the more intensive rehab required after knee surgery.1

If both knees or both hips need replacement, some doctors recommend doing both knees or hips at the same time during the same surgery. Others may recommend doing two separate surgeries during a single hospital stay.

If you need hip and knee replacement surgery on the same leg, doctors will usually replace either the most painful joint or the hip first. There are two reasons for this:2

Pain from arthritis in the hip joint can spread to the knee (referred pain). Replacing the hip first gives you a better idea how much of your knee pain is actually from arthritis in your knee.

The hip surgery usually is done first because a painful knee will not interfere too much with successful rehab after hip surgery. On the other hand, a painful hip may interfere with successful rehab after knee replacement surgery.

If you do have two surgeries at the same time or very close together, your recovery is likely to take longer than if you had a single surgery. However, it is still likely to be shorter than the total recovery time for one surgery and recovery followed by a separate surgery and recovery.

(http://www.webmd.com/hw-popup/guidelines-for-multiple-joint-replacements)

Citations
Sledge CB (2005). Principles of reconstructive surgery for arthritis: The knee. In ED Harris Jr et al., eds., Kelley’s Textbook of Rheumatology, 7th ed., vol. 2, pp. 1890–1900. Philadelphia: Elsevier Saunders.

Moore KD, Cuckler JM (2005). Surgical treatment of knee arthritis. In WJ Koopman, LW Moreland, eds., Arthritis and Allied Conditions: A Textbook of Rheumatology, 15th ed., vol. 1, pp. 1067–1076. Phildelphia: Lippincott Williams and Wilkins.

Author Robin Parks, MS – Editor Kathleen M. Ariss, MS – Associate Editor Pat Truman, MATC
Primary Medical Reviewer E. Gregory Thompson, MD – Internal Medicine -Specialist Medical Reviewer Stanford M. Shoor, MD – Rheumatology
Last Updated April 20, 2007

To view the slideshow on Knee Replacement to see what happens during this surgery log on to http://arthritis.webmd.com/knee-replacement-surgery.

©2005-2009 WebMD, LLC. All rights reserved. © 1995-2008 Healthwise, Incorporated

Fear Keeps Many From Fighting RA Pain

From the FMS Global and UK News Desk of Jeanne Hambleton

Courtesy of WebMD.com
By Bill Hendrick – WebMD Health News- Reviewed by Louise Chang, MD

March 25, 2009 — Many people with rheumatoid arthritis may have barriers that hinder optimal management of their pain, a study suggests.

Barriers to pain reduction, Canadian researchers say, include fear of medication side effects, fear of drug interactions, worry about drug addiction, concerns that the effects of medication might mask the disease, and aversion to taking too many pills.

McGill University scientists studied 60 patients with rheumatoid arthritis, all of whom were being treated by specialists. Of the rheumatoid arthritis sufferers, 53% described their pain as moderate to severe.

Forty-seven percent reported that pain was mild or absent. And 65% of all patients, including about half of those with moderate to severe pain, were satisfied with current methods to control suffering, the researchers report in the March issue of The Journal of Pain.

Although 87% of the patients reported that they expected to have “some” pain to “much” pain from their rheumatoid arthritis, only 13% didn’t expect any pain or only slight pain.

The researchers, led by Mary-Ann Fitzcharles, MD, of Montreal General Hospital at McGill University, were interested in the potential barriers to reducing pain that kept some people hurting.

The top barriers to optimal pain management found in the study participants included:

Worry of medication side effects (80%)

Not wanting to take “too many pills” (63%)

Worry about medication interactions (57%)

Worry of addiction (35%)

The researchers found that more than half of the patients had at least three barriers.

The researchers conclude that people with rheumatoid arthritis should be questioned vigorously about their pain, and that clinicians should explore potential barriers to effective pain control.

News release, McGill University.
Fitzcharles, M. The Journal of Pain, March 2009; vol 10: pp 300-305.
© 2009 WebMD, LLC. All rights reserved.
(http://www.webmd.com/rheumatoid-arthritis/news/20090325/is-fear-keeping-you-from-fighting-ra-pain?ecd=wnl_cbp_040209)

Hand Exercises Aid Rheumatoid Arthritis

Muscle-strengthening exercises may ease pain and help individuals with RA improve their quality of life

By Gina Shaw -WebMD the Magazine – Feature Reviewed by Michael W. Smith, MD

For 25 years, New Yorker Carol Solomon, 69, ran a knitting store. In 2006, a few years into retirement, she was diagnosed with rheumatoid arthritis (RA) in both hands.

“I have movement in my thumb and in my pointer finger, but my other three fingers are pretty stiff,” she says. Solomon did not want to give up the knitting and sewing she loves, so she sought help from her doctor and physical therapists at New York’s Hospital for Special Surgery.

There is a saying about exercise and RA: Use it, but do not abuse it.

“Studies have shown that strengthening the muscles around the joints leads to overall improved function and better quality of life,” says Heather Williams, DPT, a physical therapist in the Hospital for Special Surgery’s Joint Mobility Center.

“Patients can be afraid to exercise those joints because of pain, but they really benefit from strengthening exercises.”

RA is an autoimmune disease in which the body attacks its own tissues. It is a chronic disease, but when diagnosed and treated early with a combination of medication and physical therapy, joint damage can be limited.

When it affects the hands or wrists, like Solomon’s, some helpful exercises include squeezing small exercise balls or putting the hand out flat, palm up, and bending each finger one by one into the palm. Take it slowly, advises the physical therapist. She says Solomon should try three sets of five repetitions of each exercise instead of 10 or 12 reps — and then work up to more as she builds her strength.

People with RA go through phases called “flare-ups,” with extremely swollen and painful joints, and then “subacute” phases when the disease is less active. Modifying activity depending on what phase you are in is important, says Theodore Fields, MD, clinical director of the Gosden-Robinson Early Arthritis Center at New York’s Hospital for Special Surgery.

“When you have a significant flare-up, the joints need more rest.”

Whatever kind of exercise you do, be sure to discuss your exercise plan with a physical therapist who understands RA.

“Have your physical therapist work out a home-exercise program that fits your needs and respects the joints you have trouble with,” says Fields.

Solomon knows her knitting needles will never fly like they used to, but she has started to work with yarn again and can even sew with a needle and thread, an impossible feat when she first was diagnosed.

“I am just seeing what I can do every day, and trying to adjust the way I do things to give myself as much function as possible,” she says.

Hand Exercise for Rheumatoid Arthritis

The Exercise:
Fill an empty box with small items such as nuts, screws, and bolts. Reach in and, handful by handful, pick the screws and bolts out of one box, place them in your other hand, and place in a second box.

The Benefit:
This exercise helps strengthen muscles around joints for improved finger mobility and helps prevent future joint damage.

Originally published in the September/October 2007 issue of WebMD the Magazine. © 2007 WebMD, Inc. All rights reserved.
(http://www.webmd.com/rheumatoid-arthritis/features/hand-exercises-aid-rheumatoid-arthritis?ecd=wnl_cbp_040209)

Health Benefits of Intravenous Nutrient Therapy – Myers Cocktail

From the FMS Global News Desk of Jeanne Hambleton

Courtesy HealthNotesNewswire

By Darin Ingels, ND

EDITOR’S NOTE: While I appreciate this was written in 2003 I do know that many fibromites are regularly given the ‘Myers Cocktail’ to relieve pain. I felt the background would be interesting. However I would recommend you read the Consumer Alert written May/June 2007 on the FM Net News website (http://www.fmnetnews.com/resources-alert-product8.php) for another view point. Please do not shoot the messenger I am merely reporting what I have found. I have a good friend who has these injections from time to time and she believes they do her the world of good. See the FM Net News report. Without prejudice. JH)

Healthnotes Newswire (January 16, 2003)

Administering a vitamin and mineral formula (known as the Myers cocktail?) intravenously may be useful in treating a variety of medical problems, according to a report in Alternative Medicine Review (2002;7:389?403). Although few studies have been published on this therapy, many physicians have observed its benefit in treating migraine headaches, fatigue, allergies, heart disease, acute asthma attacks, fibromyalgia, infections, and other conditions.

The Myers cocktail was pioneered by John Myers, MD, a physician from Baltimore, Maryland, who developed this treatment more than 30 years ago. The doses of the various nutrients were subsequently modified, based on more recent information, by Alan R. Gaby, MD, the author of the report.

The vitamin-mineral combination includes magnesium, calcium, vitamin B12 (hydroxocobalamin), vitamin B6 (pyridoxine), vitamin B5 (dexpanthenol), vitamin B complex, and vitamin C. Intravenous therapy can raise blood levels of nutrients to a considerably greater extent than oral therapy can, and some doctors believe that achieving these high blood levels has therapeutic benefits in certain clinical situations. The benefits of the Myers cocktail may be due to the drug-like (pharmacological) effects of some nutrients (for example, high concentrations of vitamin C kills viruses), or to improved transport of nutrients from the blood into the cells. More research is necessary to clarify this issue.

Some physicians who use the Myers cocktail report that it is particularly useful in treating acute asthma attacks and acute migraine headaches. Relief of symptoms usually occurs within minutes of administering the concoction. It is not clear whether the benefits are due to one nutrient or to the combination of nutrients, but other studies have shown that intravenous magnesium alone can reduce the symptoms of asthma and migraines. However, the author?s observation is that the Myers cocktail is more beneficial for acute asthma attacks than is magnesium alone.

The author and other physicians have found that the Myers cocktail is also useful in treating angina, chronic fatigue syndrome, bronchitis, sinusitis, fibromyalgia, hayfever, chronic hives, narcotic withdrawal, hyperthyroidism, muscles spasms, tension headaches, and some cases of mild to moderate depression. While many people improved after the first treatment, others required several treatments to achieve the maximum benefit, suggesting this therapy may have a cumulative effect. The number of treatments needed varies by person and condition. Some individuals obtain long-lasting relief after a few treatments, while others require ongoing treatments to maintain the benefit. The risk of serious adverse reactions is said to be low and the treatment is usually well tolerated.

The most common side effect of the Myers cocktail is a sensation of warmth, particularly if the injection is given rapidly. This effect is primarily due to magnesium, although calcium may also be a contributing factor. People with low blood pressure may be more prone to this side effect than those with normal or high blood pressure. People taking digoxin (Lanoxin®) and medications that deplete potassium should be cautious in using this treatment, since giving magnesium intravenously to such individuals could induce an irregular heart beat. The Myers cocktail can be prescribed only by a medical doctor, osteopath, or, in some states, a naturopath.

Although most of the reported benefits of the Myers cocktail are anecdotal, doctors who use this treatment are convinced that it often produces results not achievable by any other means. Controlled studies are needed to verify these clinical observations.

Darin Ingels, ND, MT (ASCP), received his bachelor?s degree from Purdue University and his Doctorate of Naturopathic Medicine from Bastyr University in Kenmore, WA. Dr. Ingels is the author of The Natural Pharmacist: Lowering Cholesterol (Prima, 1999) and Natural Treatments for High Cholesterol (Prima, 2000). He currently is in private practice at New England Family Health Associates located in Southport, CT, where he specializes in environmental medicine and allergies. Dr. Ingels is a regular contributor to Healthnotes and Healthnotes Newswire.

Copyright © 2003 Healthnotes, Inc. All rights reserved. Healthnotes Newswire is for educational or informational purposes only, and is not intended to diagnose or provide treatment for any condition. If you have any concerns about your own health, you should always consult with a healthcare professional. Healthnotes, Inc. shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon. Healthnotes and the Healthnotes logo are registered trademarks of Healthnotes, Inc.

(http://www.thevitaminservice.com:healthnotes.asp%3Forg=vitaminservice&page=newswire:newswire_2003_01_16_2.cfm..webarchive)

Consumer Alerts Myers’ Cocktail
Courtesy Fibromyalgia Network

Many treatment centers for fibromyalgia are heavily promoting the use of intravenous (IV) Myers’ nutrient therapy, or what many call a modified Myers’ cocktail. The advertisements often boast that you can receive up to 60% reduction in pain and an 80% reduction in fatigue. They also claim that you will notice these symptom improvements within two days of receiving the Myers’ IV cocktail.

Myers was a physician who believed that an IV infusion of the ingredients below would help jump-start symptom improvements (especially fatigue) in people with chronic illnesses, but never published data to substantiate his theory. So why is it that treatment centers are claiming you can reap amazing improvements in pain and fatigue with the Myers’ cocktail? They are basing it on a report of seven women with fibromyalgia (and no control subjects for comparison) by Patrick Massey, M.D., Ph.D., of Elk Grove Village, IL.*

Although Massey is to be commended for trying to evaluate a nutrient treatment for fibromyalgia patients, the results of his study are being taken out of context for the promotional use of this expensive therapy ($200 – $300 a shot). Massey selected seven fibromyalgia patients who were already under his care and tried to help them with eight weekly Myers’-type IV infusions. He asked the seven patients to rate their pain and fatigue prior to the first IV, and then to rate these symptoms as a weekly average when they returned to his office for the next infusion. The seven patients knew that they were being given something new to help ease their fibromyalgia symptoms, which could understandably lead to high expectations for health improvements. This was not a blinded or placebo-controlled study.

Massey states in his report that the eight-week therapy reduced pain by 60% and fatigue by 80%. However, due to the lack of a placebo comparison group, the small number of patients in the study, the power of suggestion (the “white coat” effect because doctors often wear white lab coats), and the fact that all seven patients knew they were receiving the nutrient therapy and not a placebo, patients cannot bank on these results. The mere power of suggestion by the person in the white coat (even if it is not intended) may produce phenomenal results from a placebo or sugar pill.

In the discussion part of the report, Massey comments that the therapy is short-lived-lasting between 24 and 48 hours. Yet he provides no data to substantiate this claim. Promoters of the IV Myers’ cocktail may reference the 24-48 hour time frame to imply the speed at which patients should notice symptom improvements, but it is actually the estimated duration of the relief. If you have received IV nutrient therapies before, only to find that they do not produce long-lasting symptom benefits (if any at all), this could be the reason why. Yet, regular infusions of this nature are not practical and they are expensive (approximately $250 per infusion).

Why is the Myers’ cocktail so expensive? Any treatment approach that includes an IV is costly. The ingredients in this IV therapy are relatively cheap when taken orally as nutritional supplements. If one were to take the nutrients in the IV dose over 48 hours as an oral supplement, then the cost per month would be less than $15, as compared to four IV treatments a month totaling about $1,000. (See the third column in the table above for the daily equivalent oral doses.) Patients who are concerned that their diet is deficient in these essential nutrients have little to lose by trying this oral supplementation approach. All you need to do is purchase three supplements: 1) vitamin B complex, 2) vitamin C, and 3) magnesium. The vitamin C formula should be buffered and the magnesium should be chelated so these supplements are gentle on your stomach.

* Massey PB. Alternative Therapies 13(3):32-34, May/June 2007.

Modified Myers’ IV Formula (may provide up to 48 hours of relief) includes the following:
Magnesium chloride hexahydrate, Calcium gluconate, Vitamin C , Hydroxocobalmin (B12) , Pyridoxine hydrochloride (B6), Dexpanthenol (B5) Riboflavin (B2), Thiamine (B1), Niacinamide (B3).
Estimated Costs $250/IV Dose, $15/Month. For quantities please log on to the Fibromyalgia Network website as below.

(http://www.fmnetnews.com/resources-alert-product8.php)

All information on this site is copyrighted by Fibromyalgia Network, P.O. Box 31750, Tucson, AZ 85751 (800) 853-2929.
This site is provided for informational purposes only. To remain unbiased, we do not accept endorsements, advertisements, or pharmaceutical industry grants. Patients should always consult their physician for medical advice and treatment.

Chili Pepper Compound Can Bring Pain Relief

From the FMS News Desk of Jeanne Hambleton

COURTESY usnews.com Health Day – Monday March 16

Capsaicin works on nerves to ease joint discomfort, scientists say

(HealthDay News) – University of Buffalo scientists say they have found how capsaicin, the compound that gives chili peppers their fiery flavor, also works to relieve joint and muscle pain.

In a study appearing Tuesday in the journal PLoS Biology, researchers found that capsaicin flips on nerve-ending receptors that sense both pain and heat.

“The receptor acts like a gate to the neurons. When stimulated it opens, letting outside calcium enter the cells until the receptor shuts down, a process called desensitization,” study leader Feng Qin, an associate professor at the university’s School of Medicine and Biomedical Sciences, said in a news release issued by the institution.
The flood of calcium changes the levels at which the receptors detect pain signal. “In other words, the receptor had not desensitized per se, but its responsiveness range was shifted,” Qin said.

While capsaicin has been used in folk medicines for generations, knowing how it works in relation to PIP2 may lead to developing other analgesics that ease pain without first causing irritation on their own, the team said.

More information

The U.S. National Institute of Neurological Disorders and Stroke has more about capsaicin .
(http://health.usnews.com/articles/health/healthday/2009/02/25/chili-pepper-compound-can-bring-pain-relief.html)

Finding Effective Treatment for Your Chronic Pain

Studies are underway to look into the effectiveness of alternative ways of delivering pain medications

By January W. Payne

Chronic pain is a problem that—when healthcare, lost income, and lost productivity are taken into account—is estimated to cost about $100 billion in the United States each year. More than a quarter of Americans age 20 or older, or about 76.5 million people, say they’ve experienced pain that lasted longer than 24 hours, according to the American Pain Foundation—and 42 percent have endured pain lasting longer than a year. Nobody keeps good long-term national stats, but if North Carolina’s experience is any guide, the numbers are on the rise.

A just-published study in the Archives of Internal Medicine found that the prevalence of chronic low-back pain in the state more than doubled, to 10.2 percent, between 1992 and 2006. Paul J. Christo, assistant professor and director of the Multidisciplinary Pain Fellowship at the Johns Hopkins University School of Medicine, calls undiagnosed, untreated, or undertreated pain a “significant public-health problem.”

Chronic pain encompasses a multitude of ills, from back pain, headaches, neck pain, and conditions like arthritis and fibromyalgia to pain that develops as a result of cancer treatment and lingers for months or even years. Low-back pain, migraines, and joint pain (particularly in the knees) are among the most common complaints, according to the National Center for Health Statistics. knee pains,

Still, while it may have different origins, chronic pain “can be viewed as an illness in its own right because of its effect on function,” says Russell Portenoy, chairman of the department of pain medicine and palliative care at Beth Israel Medical Center in New York City.

Studies have shown that some people with chronic pain have brain abnormalities, though the connection between that and pain is not well understood. One recent study, for instance, showed that women with fibromyalgia had blood flow abnormalities in a region of the brain known to discriminate the intensity of pain that were not observed on CT scans done in healthy women.

Another study showed that chronic pain may harm the wiring of the brain, as demonstrated on functional MRIs. Chronic pain may also be caused by a problem with the “fight or flight” response, Christo says. “We believe that in certain pain conditions . . . the stress response can worsen pain because that stress response releases a chemical called noroepinephrine. . . . And noroepinephrine binds to certain receptors in the body that trigger pain.”

“Pain is essentially an alarm system that is designed to grab your attention, and when it works properly, it signals harm or healing,” says Scott Fishman, professor and chief of the division of pain medicine at the University of California-Davis School of Medicine. When the body heals, the pain should dissipate, but “the nervous system can become injured,” Fishman says. “That’s when the symptom of pain becomes the disease of chronic pain.”

Finding relief can take quite an effort, since the causes are often not immediately clear and there is not a sure-fire treatment. The battle can require a team of experts, so the multidisciplinary pain clinics or pain management programs that have sprouted up at hospitals, rehab centers, and in free-standing facilities over the past decade or so may be of particular help.

The clinics provide an all-in-one setting for care that, in addition to pain management specialists who may be trained as neurologists, psychiatrists, physiatrists, or anesthesiologists, may include physical therapists, family and vocational counselors, and massage therapists, for example. (The American Chronic Pain Association offers advice on selecting a pain clinic.)

After a full assessment, tailored treatment may include medications from anti-inflammatory drugs to antidepressants to opioids. Since commonly prescribed opioid medications such as oxycodone, fentanyl, and morphine can cause addiction, the American Pain Society and the American Academy of Pain Medicine have just released the first comprehensive clinical practice guidelines to help physicians make treatment decisions.

The guidelines, published in the Journal of Pain, suggest that physicians regularly assess people taking long-term opioids and do periodic drug screenings of patients who are considered to be at risk for abuse or addiction. Meanwhile, the Food and Drug Administration announced plans this month to require the brand-name and generic makers of morphine, oxycodone, fentanyl, and methadone to assist with a plan to reduce the risks associated with the drugs.

Other treatment options include injections of steroids or other medications, nerve blocks that interrupt pain signals, physical therapy, alternative therapies, and psychological interventions such as cognitive behavioral therapy, biofeedback, and guided imagery and other relaxation techniques. Acupuncture, which some people with pain find helpful, is thought to ease pain by raising the level of endorphins in the body, Christo says. “Endorphins are sort of like opioids. . . . They are natural pain relievers,” he says.

“They are released when the body experiences pain—when you sprain your ankle, cut your finger, in response to injury.” Still, research offers conflicting conclusions about the pain-relieving effects of acupuncture. A review of 13 studies published last month in British Medical Journal found that acupuncture offered only a small level of pain relief for people with low-back pain, migraines, knee osteoarthritis, and postoperative pain.

Jennifer Phillips, 41, of Providence Forge, Va., saw 54 doctors before the fibromyalgia that caused her pain was diagnosed in 1996. Finally, after seeing an internist whose nurse had fibromyalgia, she found a routine that works for her: a combination of proper sleep (achieved, in part, using the tricylic antidepressant amitriptyline), daily supplements of vitamins, magnesium, and potassium, plenty of water, and a low-carb diet.

The search is on for greater relief. Studies are underway to look into the safety and effectiveness of alternative ways of delivering pain medications, such as an inhaled form of fentanyl that would get the drug into the patient’s system more quickly. For older people who have fractures of the spine, vertebroplasty and kyphotlasty—two minimally invasive techniques in which bone cement is injected into the collapsed bone in the spine—can result in “significant pain reduction,”

Christo says. In the ongoing debate over how best to handle back pain, a study just published in the Journal of the American Academy of Orthopaedic Surgeons finds that the most effective way to treat most degenerative disc disease cases is to combine physical therapy and anti-inflammatory medications, rather than having surgery.
While it may seem counterintuitive, people with chronic pain should try to get exercise. Experts say it is important to keep moving, both for the usual cardiovascular reasons and in order to avoid muscle atrophy. A supervised, individually designed exercise program, incorporating stretching or strengthening, may improve pain and functioning in people with chronic low-back pain, according to a 2005 study published in Annals of Internal Medicine.

A physical therapist or personal trainer can offer the necessary advice. In fact, staying in bed for more than a day or two can make back pain worse, according to the National Library of Medicine’s MedlinePlus.

Jeff Nance of Indianapolis, whose chronic pain is caused by degenerative disc disease and spinal stenosis of his lower back, recalls that he barely wanted to leave his home three years ago. Then he discovered the Meridian Health Group pain clinic in Indianapolis. Now he is working full time again, and he recently participated in an annual bike ride across the state of Indiana. Nance goes back to the clinic every few months for a check of his medications, and he sees a psychologist a couple of times a month.

“What we try to do is really recognize that people can have pain for all kinds of reasons, [and we] find as many of those causes as possible and treat them in the most specific fashion as possible,” says Michael Clark, associate professor and director of the Chronic Pain Treatment Program in the Department of Psychiatry and Behavioral Sciences at Johns Hopkins Hospital. “Ultimately, you’d like to get somebody well.”

(http://health.usnews.com/articles/health/pain/2009/02/10//finding-effective-treatment-for-your-chronic-pain.html?loomia_ow=t0:a41:g2:r2:c0.160667:b22273524&s_cid=loomia:chili-pepper-compound)

Copyright © 2009 U.S.News & World Report LP All rights reserved.

Gene therapy promising for rheumatoid arthritis

From the News Desk of Jeanne Hambleton 

           Monday, February 9, 2009

NEW YORK (Reuters) –- Researchers have successfully used gene therapy to substantially reduce joint pain in two patients with rheumatoid arthritis (RA).    These data “provide the first documented, clinical evidence that local gene therapy can provide symptomatic relief in human RA,” Dr. Christopher H. Evans and co-investigators report in the February issue of Human Gene Therapy.  RA develops when, for unknown reasons, the body’s immune system turns against itself, causing joints to become swollen and inflamed. If the disease is inadequately controlled, the tissues of the joint are eventually destroyed. There is no cure for RA, which is estimated to affect more than 2 million individuals in the U.S. alone.  “RA is an extremely painful condition affecting multiple joints throughout the body. Arthritis is a good target for (gene therapy) because the joint is a closed space into which we can inject genes,” Evans, from Harvard Medical School in Boston, noted in a written statement.  Prior studies have shown that the molecule interleukin-1 plays a key role in the breakdown of cartilage in patients with arthritis. In the current study, tissue was removed from the knuckle joints of two patients with severe RA and a harmless virus was inserted into the tissue cells, in order to serve as a “vector” to shuttle a gene that blocks action of the interleukin-1 protein to the joint. After being placed in culture to grow and replicate, the cells were injected back into the afflicted joints.  One patient who received gene therapy in two joints experienced an 85 percent reduction in pain in one joint within 1 day, and both joints were pain-free from 1 week onward. “Remarkably,” the researchers report, joints receiving the therapy were protected from flares that occurred during the study period.  The second patient also responded to gene therapy, with a 70 percent reduction in pain between weeks 2 and 3.  “Existing treatments for rheumatoid arthritis are costly and need to be administered regularly,” said Evans, adding that in addition to risk of side effects, not all patients respond well. “This paper provides us with the first real evidence that painful symptoms can indeed be lessened through gene therapy.”  Ongoing work will focus on the use of gene therapy for the treatment of osteoarthritis, by far the most common type of arthritis, as well as rheumatoid arthritis, Evans noted.

Courtesy of  The Tehran Times  (http://www.tehrantimes.com/index_View.asp?code=188744)   Info@tehrantimes.com

Dual action

From Jeanne Hambleton’s FMS Global News Desk
By Sandra Flahive (FiftySomething) January 10 2009

Bill and Susan Steffey of Grimes both have seen great physical improvements since they began exercising together at the Wellness Center at Mercy Medical Center.

Susan, 55, first started a regular workout regimen in July on the advice of her rheumatologist. Bill, 60, joined her a couple months later, hoping to lose weight and lower his cholesterol.

Three days a week, the couple attends a low-impact aerobics class that’s especially tailored to older adults. They warm up on the treadmill before class. Afterward, Bill hits the weights while Susan gets on the elliptical machine.

Both have lost weight since they began exercising regularly. Susan, who has arthritis, fibromyalgia and a pulmonary disease, says her muscles and joints are stronger and her lung capacity has improved.

Through weight training, Bill says he has been able to strengthen his bad knee and can now get up stairs without using the handrail to pull himself up.

“Neither one of us will go without the other one,” Susan says of their workouts. “That’s a huge motivator because you feel guilty. And we’ve made great friends.”

It has also given them a chance to spend more together and become closer, she says.

Because his wife’s health and stamina have improved, they are considering taking vacations, Bill says. That includes travelling to Indianapolis for a NASCAR race in July.

“Now that she is working (out) … she has got a little stronger, and we are talking about doing those things again together,” he says.

What a difference a year makes. A year is about how long Ankeny couple Bill Riley Jr. and his wife, Bridget, have been regulars at the Aspen Active Fitness Center in the West Glen Town Center.

With the help of their respective personal trainers, the Rileys say their lives have changed dramatically. The two – who were not regular exercisers – now give each other workout tips, regularly check on one another’s progress and have bought fitness equipment to use at home.

They say they feel better, have replaced body fat with muscle, eat more healthfully and are excited about the future.

“We are enjoying this. We are feeling that we are doing something for ourselves and not just letting ‘old man time’ chip away at us,” says Bill, 51. “We are feeling a lot better about being 60, 65, 70. We plan on being very active … and you cannot do that without your health. We made the decision to start that now, and we are glad we did it.”

In the past, fitness clubs had been intimidating and uncomfortable places for him and his wife, Bill says. Then he met certified personal trainer Mickey Pesek at Aspen Athletic Fitness Center.

“The personal training has made a huge difference in our outlook and opinions of joining a gym,” says Bill, whose triglycerides, cholesterol and blood pressure have decreased.

Bridget, an oncology nurse, says several factors influenced her to join her husband in getting fit: turning 50, her mother having a massive stroke a year ago and seeing how good her husband was feeling.

Bridget works with certified personal trainer Trista Manikowske. “She makes me feel confident and accomplished,” she says. “It is probably the best I have felt health-wise since I was 20.”

She says she feels healthier, has a better attitude about herself and sleeps better. The couple rarely eats out anymore, she says, and have added more fish and protein to their diet.

“We talk about growing old together and walking together and being outdoors. We talk about doing vacations that involve a lot of walking … and keeping our hearts healthy and blood pressure good,” Bridget says.

Setting goals together helps the two individuals be supportive of, and accountable to, each other, says Manikowske, the personal trainer. It is also a good idea to write down those goals.

“People with written goals accomplish five to 10 times as much as people who have never taken the time to actually write them down. It helps you remember what they are,” she says.

7 Tips for Exercising in Tandem
Certified trainers Trista Manikowske and Mickey Pesek offer these suggestions for couples working together toward physical fitness.

• Make a plan together and stick to it. Devise a workout schedule and, if you are working out separately, ask each other questions about your progress.

• Decide on a reward for meeting your goals. Looking forward to a vacation, for example, can motivate and encourage you.

• Find fun physical activities you can do together.

• Plan healthful meals, shop for groceries and cook as a couple.

• When going out to eat, split portions with each other.

• Get the whole family involved in eating more healthfully and exercising.

• For a spouse or significant other reluctant to get more physically active, give a gym membership as a birthday or anniversary gift or invite the person to work out with you. Some personal trainers offer “buddy sessions,” where two people get personal training together for an hour.

Good advice….My thanks to the Desmoine Register http://www.desmoinesregister.com/article/20090110/FIFTYSOMETHING/301110005/-1/SPORTS12

NEW DATA ON THERAPIES FOR PAIN AND INFLAMMATION FROM PFIZER

By Jeanne Hambleton © Fibromite NFA Leader Against Pain

While I am a great believer in positive thinking, I have to accept that medication can be the only way that allows some people to live with pain and this impossible invisible condition called fibromyalgia. From this point of view I must say I am pleased that the drug companies are continuing to find ways of easing our pain and hopefully one day will find a cure.
This morning I received a press release from Pfizer who are working to help those of us with fibromyalgia and arthritic problems. I wanted to share this with you and the full report is listed below.

Having read this one of my greatest hopes is that the UK medical authorities will, in the near future, give its blessing to Lyrica, Cymbalata and now Esreboxetine.

Let us hope if these new drugs are approved in the UK that there will be no ‘post code lottery’ by the NHS for the prescription of these medications. Currently British fibromites are victims of the lack of approval of any specific fibromyalgia drugs. While American patients are able to gain relief from the new drugs, it seems the UK fibromites must suffer in silence.

In recent years I have read and signed numerous epetitions appealing to the Prime Minister Gordon Brown to bring some relief to those of us with fibromyalgia. The epetitions have asked for research, better education of doctors and specialists, fibromyalgia clinics and much more – but all have met with lame excuses. This has nothing to do with the current financial crisis. We have been writing to Prime Ministers – Tony Blair and Gordon Brown -for years. What do we have to do to get attention – camp out in our wheelchairs outside the Houses of Parliament? We might get more press coverage that way!

I am not surprised that Guy Fawkes chose to blow up the Houses of Parliament on November 5 if this was the only way he could get the attention of those working inside that building. Maybe we need a fictional Gun Powder Plot to enlighten the Government and spur the MPs into allocating funds for research to find a cure for fibromyalgia. But it does appear that nothing seems to stir those in the ‘corridors of power’.

A little correction here – according to Hansard and TheyWorkforYou on October 14 Dr John Pugh MP (Shadow Minister, Treasury; Southport, Liberal Democrat) is reported to have said, “…I was recently approached by someone in my constituency who suffered from a disease called Fibromyalgia, which had to be explained to me. That person found that there was wholesale ignorance of the disease in all parts of the NHS and many parts had been accessed about the condition.”

Hooray for John Pugh. Shall we all write to our MPs and talk about the ‘F’ word? You do know I mean F for fibromyalgia, I hope! I am not into writing about politics but for goodness sake if someone wants to win the next election they should become our champion – do something about the plight and despair of the fibromites. That should get them at least 2 million votes plus their families and friends. I wonder why are we treated as second class citizens? Just because we have an invisible disability it does not mean we have no feelings and do not deserve some respect. What do you say?

As a matter of interest something like 10 years ago the public were ignorant about ME. Today everyone has heard of it? We must spread the ‘F’ word – fibromyalgia. I have banned the other ‘F’ word in my house. Now we all say ‘fibromyalgia’ when we lose our temper and burst into fits of laughter.

Results from Clinical Trials Show Promise for Innovative Therapies in Rheumatoid Arthritis and Osteoarthritis Pain and Fibromyalgia

SAN FRANCISCO–(BUSINESS WIRE)–Pfizer will present data on three investigational compounds that represent potential new mechanisms for targeting pain and inflammation. These data will highlight tanezumab, a molecule designed to target nerve growth factor, a key pain mediator; CP-690,550, a JAK-inhibitor that suppresses immune-related inflammatory response; and esreboxetine, a highly-selective norepinephrine reuptake inhibitor which plays a role in controlling the activity of this important neurotransmitter. These data will be presented at the 2008 American College of Rheumatology Scientific Meeting in San Francisco, California.

“Pfizer has an established track record of bringing innovative therapies to patients suffering with pain and inflammation,” said Martin Mackay, Ph.D., president, Pfizer Global Research and Development. “Data to be presented at ACR confirm our clinical approaches in developing these three compounds – CP-690,550, esreboxetine and tanezumab – as potential new medicines to provide relief from these serious medical conditions.”

Fibromyalgia

Pfizer is a pioneer in the study of fibromyalgia, investing many years of research into treatment options for this complex pain condition. In June 2007, Lyrica (pregabalin) CV became the first FDA-approved treatment for the management of fibromyalgia. Data supporting that approval showed Lyrica patients experienced significant reduction in pain as early as week one in some patients.
While widespread pain is the cornerstone of fibromyalgia, the condition is also characterized by other hallmark symptoms such as fatigue and difficulty concentrating.

Data presented at ACR will highlight the results of a phase 2 proof of concept study with esreboxetine, a highly selective norepinephrine reuptake inhibitor in a fibromyalgia population.
Data from this study showed that esreboxetine may be effective in relieving in key fibromyalgia symptoms, including pain, function and fatigue and was generally well tolerated. In the study, 43 percent of patients receiving esreboxetine reported their condition was much improved or very much improved as compared to 23 percent of placebo-treated patients.

The most common side effects compared to placebo were constipation, insomnia, dry mouth, headache and nausea. The proportion of patients who discontinued as a result of adverse events was 8.2 percent in the esreboxetine group and 2.3 percent in the placebo treatment group.
Fibromyalgia has been recognized by the professional community for over 30 years as a common, chronic widespread pain condition and is now thought to affect up to six million Americans. Recent evidence suggests a neurological basis to fibromyalgia, as demonstrated by brain scans and altered levels of certain neurotransmitters.

Rheumatoid Arthritis

Data is being presented from several clinical trials studying CP-690,550, an oral medication that inhibits the Janus Kinase enzyme (JAK). This enzyme plays a major role in controlling the activation and proliferation of white blood cells, key elements of the immune system, which play a major role in rheumatoid arthritis (RA). CP-690,550 has shown encouraging results for the treatment of rheumatoid arthritis at doses that don’t appear to be associated with excessive immune suppression.

Investigators will present interim results from a late-breaking Phase 2B study evaluating the activity of CP-690,550 in combination with methotrexate, the most commonly-used RA treatment. Approximately 60 percent of patients on doses at or above 3 mg of CP-690,550 responded to treatment as compared to 37.7 percent on placebo. These data confirm and extend the promising data seen in an earlier phase 2A study to this longer, 12 week study, and to patients who are already taking methotrexate to treat their rheumatoid arthritis.

Also being presented is a pharmacokinetic drug interaction study which showed that CP-690,550 and methotrexate can be co-administered without dose adjustment. In addition, preliminary results from an open label extension study will be presented.

In these studies, the most commonly reported adverse events were nausea, headache, dizziness, disorientation, hot flushes, urinary tract infections, diarrhea and liver function tests. Larger and longer phase 3 studies are expected to start in 2009 to help further define the benefits and risks of CP-690,550 as a potential treatment for rheumatoid arthritis.

According to the Arthritis Foundation, 1.3 million Americans live with rheumatoid arthritis, a type of arthritis that can be severe, debilitating, deforming and even shorten life.

Osteoarthritis Pain

Pfizer continues to research new ways of treating osteoarthritis pain. Two studies to be presented highlight a new compound in development and new data for Celebrex (celecoxib) in the treatment of osteoarthritis pain.

Results from a Phase 2 study exploring the safety and efficacy of tanezumab, a novel biologic designed to block nerve growth factor, show that treatment once every eight weeks may significantly decrease pain in patients suffering from moderate to severe osteoarthritis pain in the knee. In the trial, approximately 75 percent of patients in both the tanezumab 100 and 200 μg/kg treatment groups experienced a 50 percent reduction in knee pain as compared to 26 percent of patients in the placebo group. In the study, the most common adverse events associated with tanezumab include headache, upper respiratory tract infection, paresthesia (abnormal sensations), hypoesthesia (decreased sensations) and arthralgia (joint aches).

Another late-breaking study evaluated continuous use of daily Celebrex treatment over a 22-week period compared to intermittent use of the medicine in preventing spontaneous OA flares. The study showed that continuous use resulted in 42 percent fewer OA flare episodes than the intermittent use. The results from the study also demonstrated that there were no significant differences in overall adverse events between the intermittent and continuous use groups.

According to the Arthritis Foundation, osteoarthritis affects 27 million Americans. Recent data show that one in two Americans are at risk for knee osteoarthritis over their lifetime. Loss of joint function as a result of osteoarthritis is a major cause of work disability.

About Celebrex

CELEBREX is indicated for the relief of the signs and symptoms of osteoarthritis, rheumatoid arthritis in adults and ankylosing spondylitis, and for the management of acute pain in adults.

Cardiovascular Risk
All prescription NSAIDS, including CELEBREX, may cause an increased risk of serious cardiovascular (CV) thrombotic events, myocardial infarction, and stroke, which can be fatal. All NSAIDs may have a similar risk. This risk may increase with duration of use. Patients with CV disease or risk factors for CV disease may be at greater risk.

All prescription NSAIDs, including CELEBREX, are contraindicated for the treatment of perioperative pain in coronary artery bypass graft surgery.

Gastrointestinal Risk

All prescription NSAIDs, including CELEBREX, cause an increased risk of serious gastrointestinal adverse events including bleeding, ulceration, and perforation of the stomach or intestines, which can be fatal. These events can occur at any time during use and without warning symptoms. Elderly patients are at greater risk for serious gastrointestinal events.

About Lyrica

LYRICA is indicated for the management of Fibromyalgia, neuropathic pain associated with Diabetic Peripheral Neuropathy, Postherpetic Neuralgia, and as adjunctive therapy for adults with Partial Onset Seizures. There have been post-marketing reports of angioedema and hypersensitivity. Treatment with Lyrica may cause dizziness, somnolence, peripheral edema or blurred vision. Other most common adverse events include dry mouth, weight gain, constipation, euphoric mood, balance disorder, increased appetite and thinking abnormally.

About Pfizer’s Investor Briefing at ACR (American College of Rheumatology)
On Tuesday, October 28 at 6:00 p.m. PCT, Pfizer will host a briefing for analysts and investors to review data presented at the meeting on candidates in Pfizer’s pain and inflammation portfolio

EUROPEAN FIBROMITES ARE DENIED CYMBALTA/DULOXETINE

By Jeanne Hambleton © 2008

News that the drug Cymbalta/Xeristar, a medicine containing the active substance duloxetine, will not be approved in Europe as the first official drug to treat fibromyalgia has been announced, causing grave concern to those who suffer with pain 24/7. This has led to fears that the decision may lead to more delays in a UK approval of new drugs to bring relief to fibromyalgia patients. There are currently no approved drugs for the treatment of Fibromyalgia available to UK patients.

This follows news that the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency have adopted a negative opinion, recommending the refusal of a change to the marketing authorisation for the medicinal product Cymbalta/Xeristar 30 mg and 60 mg gastroresistant capsules for treatment of Fibromyalgia.

Cymbalta is the first medication for Fibromyalgia treatment that has been filed in Europe by Eli Lilly for the treatment of this invisible disability. The medicine was approved by the US Food and Drug Administration (FDA) for Fibromyalgia in June 2008.

The European Network for Fibromyalgia Associations suspect that the misperception, even among some medical professionals in Europe, that fibromyalgia is not a real medical condition may have contributed to the decision. Despite the fact that the World Health Organisation (WHO) has recognized Fibromyalgia as a disease in 1992, and several well respected medical organizations including the European League Against Rheumatism (EULAR), the American College of Rheumatology and the American Pain Society (APS) have developed criteria and guidelines for the classification and treatment of fibromyalgia, some medical professionals and some governments in Europe have been slow to recognise Fibromyalgia as a disease.

Cymbalta/Xeristar is a medicine containing the active substance duloxetine. It is available as gastroresistant capsules. Cymbalta/Xeristar was authorised for this purpose in December 2004. It is also used for adults with major depression; pain due to diabetic peripheral neuropathy (damage to the nerves in the extremities that can occur in patients with diabetes); and generalised anxiety disorder (long-term anxiety or nervousness about everyday matters).

In the European Medicines Agency press release from Canary Wharf, London, it states the major concerns that led the committee to recommend the refusal of the change to the marketing authorisation, came from concern that the effectiveness of Cymbalta/Xeristar in treating fibromyalgia had not been shown sufficiently. The results of five studies involving a total of 1,718 adults with fibromyalgia were submitted to the CHMP. Four of these were short term and one long term involving 307 patients.

In the short-term studies, the CHMP considered that the effect of Cymbalta/Xeristar was too small to be relevant for patients. There was no clear demonstration of improvement in symptoms and the modest effects of Cymbalta/Xeristar could be due to the medicine’s effect of improving the patients’ mood. The CHMP also concluded that the long-term study was insufficient to show the effectiveness of the medicine and that a long-term study comparing Cymbalta/Xeristar with placebo would be needed.

The CHMP was of the opinion that the benefits of Cymbalta/Xeristar in the treatment of fibromyalgia did not outweigh its risks and recommended that the change to the marketing authorisation be refused.

Mr. Robert Boelhouwer, President of the European Network for Fibromyalgia Associations (ENFA), expressed his concern following months of work in Brussels with the European Parliament to raise awareness, establishing a declaration for acceptance by the ENFA countries and promoting a petition for the recognition of Fibromyalgia.

He said, “The ENFA encourages the regulatory agency and its professional committee members to recognise the sufferings that the patients have been enduring and approve other effective and safe treatment options as soon as possible. This negative recommendation has put the 14 million Fibromyalgia patients in Europe in despair. They have been hoping to have access to the first innovative medicine to treat their disease. I cannot believe that Fibromyalgia patients in Europe cannot have an access to the medicine that has been helping the patients in the US and other countries in the world.”

The latest ENFA press release suggests that the misperception even among some medical professionals in Europe that fibromyalgia is not a ‘real’ medical condition may have contributed to the decision. Despite the fact that the World Health Organisation (WHO) has recognised Fibromyalgia as a disease in 1992, and several well respected medical organisations including the European League Against Rheumatism (EULAR), the American College of Rheumatology and the American Pain Society (APS) have developed criteria and guidelines for the classification and treatment of fibromyalgia, some medical professionals and some governments in Europe have been slow to recognise Fibromyalgia as a disease.

The ENFA claim it is estimated that about 12-14 million people in Europe suffer from fibromyalgia and the epidemic is more prevalent with women (87% of total prevalence). Due to the complex pathology of the disease, a comprehensive diagnosis requires multi-disciplinary approach. A recent global survey showed that healthcare professionals lack confidence in diagnosing and managing Fibromyalgia. Educating healthcare professionals, patients and the public to promote better understanding and management of Fibromyalgia will benefit patients, healthcare providers and the society. Some scientists believe that there is an abnormality in how the body responds to pain, and particularly a heightened sensitivity to stimuli.

Currently, two medicines have been approved in the US to treat Fibromyalgia. The US Food and Drug Administration, the equivalent of the EMEA in Europe, has approved the first medicine Lyrica (pregabalin) in June 2007 for specifically treating fibromyalgia and Cymbalta (duloxetine hydrochloride) in June 2008. Both Lyrica and Cymbalta are proven to reduce pain and to improve function in people with Fibromyalgia.
Fibromyalgia imposes large economic burdens on the society as well as on affected individuals. A study shows that an average patient in Europe consults up to seven physicians and takes multiple medications over 5-7 years before receiving the correct diagnosis. The debilitating symptoms often result in lost work days, lost income and disability payments. In fact, a Dutch study in 2005 estimates that the average annual cost of fibromyalgia is €980 million in the Netherlands. Research in the UK has shown that diagnosis and positive management of Fibromyalgia reduce healthcare cost by avoiding unnecessary investigations and consultations

The ENFA describes Fibromyalgia as a complex disease with chronic widespread pain as the defining symptom and various additional symptoms including fatigue, non-restorative sleep, morning stiffness, irritable bowel and bladder, restless legs, depression, anxiety and cognitive dysfunction often referred to as “fibro fog.” All of these symptoms cause serious limitations in patients’ ability to perform ordinary daily chores and work and severely affect their quality of life.

As with all new medication the patient’s information leaflet and details of potential side effects should be read before taking any medication.

Dear Editor,

This year we are helping to support the mission of the Arthritis Foundation by raising money and participating in the Arthritis Walk.

Our team Looking Good is walking in honor of Nancy Clay, BSN RN. She has taught us through experience and expertise. In addition Nancy has brought resources and speakers to us to help us learn how to help ourselves positively while living with our illnesses. We will be walking together at Freedom Park in Morganton, NC on September 22, 2007. Registration at 9:00am and walk at 10:00am. We’d love to have you join us!

Did you know that arthritis is the nation’s leading cause of disability and affects 66 million people? One in three adults and 300,000 children have arthritis or chronic joint pain, costing the U.S. economy more than $86.2 billion annually.

We have decided to make a difference. We are committed to raising $_ 1000_ to help prevent, control and cure arthritis. You can also make a difference by joining our team and walking with us or by donating funds to help us reach our goal. If you’d like to donate, please make your check out to the Arthritis Foundation and mail it to me at 118 Torrence Cir. NW, Lenoir, NC. Please note Looking Good Team on the for line. Thank you in advance for your support! Please call Lindy 828 754 2064 or Nancy for information.

Sincerely,

Looking Good Team Captain

Lindy Wilcox

“Love bears all things.” ICor.13:7
“God is good! All the time!”

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