Debbie and David Handkins of Cincinnati know all too well how stress and pain can take a toll on busy lives.
David, 49, is an engineer whose work schedule recently was ramped up by layoffs at his plant. Often, this avid family man doesn't get home to his pastor wife, 11-year-old daughter and 7-year-old triplets until 10 or 11 p.m. Exercise is a rare luxury, and the osteoarthritis in his knees makes it so painful that it's nearly impossible. As a result, he's added on 30 pounds that he'd rather be without.
As associate pastor of the 1,800-member Montgomery Community Baptist Church, Debbie, 41, has an equally demanding schedule, ministering to her congregation as well as caring for her family. When stress wells up for her, it often leads to a debilitating migraine headache.
Like their father, two of the three Handkins triplets suffer from asthma, which is controlled well by medication. The oldest Handkins child, Bridget, has had a clean bill of health since rib surgery at age 8 for a rare disease.
I chose the Handkinses for the second family in my five-part "house call" series in USA WEEKEND Magazine because millions of Americans have chronic pain and asthma -- maybe someone in your family is suffering today. But if properly managed, these problems don't have to rule your life. The Handkinses have learned how to make these unwelcome disruptions less intrusive and debilitating, and your family can, too.
Managing migraines
Debbie Handkins has suffered from migraine headaches since she was 11 years old. More than 26 million people have migraines, according to the American Medical Association, with some having just a few a year and others being disabled by recurrences every week. Family history is often significant; Debbie's parents and brothers had migraines.
Migraines start with a "prodrome" phase, which gives warning signs: mood change, sudden fatigue, even yawning. Next, there often is an aura, which can range from loss of vision to seeing sparkles or bright lights. Tingling or numbness may hit the face or upper body. Then comes the throbbing headache, typically on one side of the head, lasting from a few hours to a few days. It may be accompanied by nausea, vomiting and sensitivity to light and sound. The next phase is the end of the headache, which usually requires sleep if not treated. In the past, lying in a dark room was the only way to get rid of a migraine. In the final, "postdrome" phase, the headache is over, but the sufferer may be tired, unable to concentrate and generally unwell.
Migraines are associated with hormonal shifts, making women particularly susceptible. They also have a strong association with stress, and Debbie has noticed her migraines have been triggered by periods of unpredictable, and often unavoidable, stress.
Fortunately for Debbie and other migraine sufferers, today there are medications that treat an attack and others that prevent attacks from taking place.
A few years ago, the Food and Drug Administration approved an over-the-counter combination of acetaminophen, aspirin and caffeine as a pain reliever for mild to moderate migraines. And old-line prescription medications such as ergotamine and isometheptene are effective, but they don't have immediate results, although a nasal spray can speed up ergotamines' action.
Luckily, migraine sufferers got a major breakthrough in treatment in 1993, when sumatriptan was approved by the FDA. This medication is taken in pill, nasal spray or injection form and stops a headache right away without the lingering hangover effects associated with other medications. "[It's] a miracle drug," says Debbie, who has an acute episode every three weeks; she used to get migraines weekly. "[After an injection,] it's gone in 30 minutes. In my job, I have to be functional. If I've got to preach, I've got to get up and do my job."
To keep migraines from recurring, doctors may prescribe beta blockers, calcium channel blockers and some medications also used for seizures.
Understanding trigger points can help reduce the frequency of spells. Foods that bring on migraines include those that contain tyramine (aged cheeses, sour cream, yogurt), other dairy products, chocolates and foods with additives such as nitrates, MSG or aspartame. Alcohol -- especially red wine -- should be avoided by migraine sufferers. Caffeine can be good or bad, depending on the individual. It helps Debbie's migraines, so, to make it have more impact when she needs it medicinally, she rarely has caffeine in her daily life.
Changes in weather and altitude, light, and even loud noises and odors all have been implicated in the onset of migraines.
Finally, your own habits can make a difference; ongoing stress, changes in sleep habits and fatigue all put you at risk. As I noted, stress is a key factor for Debbie.
After an attack, think about what you had been eating or drinking, or where you had been. By really analyzing these details, you will see a pattern develop. By understanding this pattern, you can make the necessary changes to minimize this particular kind of headache.
But you can't do it alone: It's critical to partner with your doctor so you can receive one of today's effective medicines.
David's joint pain
David, who'll turn 50 this year, faces an uphill battle. Finding time to spend with his family and take care of himself is difficult enough, but his options for activity are limited by joint pain. Although he twisted his ankles several times playing basketball as a youth, he never thought wear and tear on his joints would limit him later. One clue David overlooked, as do so many other young men, was a family history of arthritis. Both his father and grandfather suffered from arthritis in their lower extremities.
David now finds himself in a situation where his spare time is limited by work, and exercise is limited by pain. Fortunately, he expects his work schedule to lighten up by spring, giving him more time at home. Unfortunately, his knee and ankle joints require ongoing attention. In February, he had arthroscopic surgery to repair knee damage.
David has osteoarthritis, the most common joint disease in the United States. This involves the loss of the cartilage that covers the ends of bones, providing the "padding" for joints. It's usually seen after age 40 and is a leading cause of disability for people over 65. It occurs in men and women at equal rates and typically involves the larger joints of the body, such as the back, hips, knees and ankles. It also can occur in the hands, causing joint enlargement. Symptoms include pain following the use of a joint, stiffness and, over time, a decreased range of motion of the joint. Tenderness, redness and swelling in the joint are much less common with osteoarthritis; they're more common with a condition called rheumatoid arthritis. It is important that chronic joint pain be evaluated by your doctor so the correct diagnosis can be made.
Dr. Tedd Tip
Talk to your doctor about specific ways
to lessen your chronic pain.
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How does someone get osteoarthritis? Well, if you think about what it is -- the loss of cartilage padding on the ends of bones -- you'll get an idea. The lost cartilage is the result of long-term overload to the tissue, particularly in areas that had inflammation.
"Long-term" indicates that the first risk factor is increasing age. Some studies done looking at X-rays have suggested that most people over 65 have evidence of osteoarthritis, although not all feel its painful symptoms.
"Overload" in most cases means excessive weight was put on the joint. For patients who are significantly obese (not David), osteoarthritis can be a major problem.
Joint sprains and other athletic injuries cause "inflammation" and increase chances of developing osteoarthritis. David's twisted ankles in his youth probably increased his risk.
The diagnosis of osteoarthritis usually is made by clinical history and physical exam. X-ray studies can show changes consistent with osteoarthritis, but sometimes these changes take a while to occur, so early X-ray studies actually can be normal.
Once you've been diagnosed as having osteoarthritis, several things become important. First and foremost: weight loss, to literally get the stress off the joints involved. The trick is to make sure the activity program put in place to promote weight loss doesn't aggravate the joint problem. That means high-impact exercises are out of the question. David has to avoid court sports (tennis, basketball, racquetball, etc.), running and even jogging. Lower-impact activities such as walking or using a stair stepper or elliptical trainer would be acceptable. My personal preference for people with osteoarthritis in their lower extremities is to have them do exercises that are no-impact -- that is, the weight of their bodies is supported by something other than their legs. No-impact exercises include cycling (either outdoors or stationary) and swimming.
In addition to developing aerobic training to lose weight, strength training needs to be part of an osteoarthritis treatment program. It is important to strengthen the tissues that support the joint, acting as shock absorbers around the worn-out cartilage. Strength-training an injured joint can be tricky, so I strongly recommend guidance from a qualified personal trainer. David, like most of us who grew up 30-plus years ago, probably was exposed to weight lifting as part of a PE class. But the techniques we were taught often were incorrect. We may have gotten away with it when we were young, but using those same techniques now to begin a strength-training program can be downright painful and even dangerous.
Dr. Tedd Tip
If you have osteoarthritis, stick with no-impact exercises such as cycling and swimming
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I often tell my patients that although I have sports medicine certification, my primary training is in internal medicine, not orthopedics. So my main interest in your joints is that they don't get in the way of my heart program! For that reason, patients must exercise their joints not only consistently and moderately, but appropriately.
I realize not everyone can run down to the local gym and acquire the ongoing services of a Fabio look-alike, but most communities now have fitness facilities, some even connected to hospitals, where personnel will evaluate your needs and help you launch a program that's right for you.
In addition to losing a few pounds and sticking to a well-rounded exercise program, David also can use any number of effective medications for pain relief. Acetaminophen (the main ingredient in Tylenol) is one of the drugs of choice for this. Other over-the-counter medications, such as non-steroidal anti-inflammatory drugs (Advil, Aleve, etc.), also are effective.
Prescription drugs, which last longer, are available, but they generally are reserved for people who have daily pain not relieved by other means.
A big no-no is to fall into the trap of using narcotics, which can become habit-forming. Their use should be very limited, only for acute episodes of significant pain.
Other osteoarthritis treatments have included injections of steroids into larger joints, which seem to help with acute flare-ups, but they can't be used often. Capsaicin cream, which is a topical, over-the-counter remedy, can relieve pain, but it's typically used in small joints, such as those of the hand.
And there is always good old aspirin, a painkiller that works well for those who can tolerate it.
Be sure to let your doctor know whether you are using any of those over-the-counter agents; each has its own unique side-effect profile that needs to be monitored by your doctor.
Asthma in the family
David's joints aren't his only nuisances when it comes to exercising. A life-long history of asthma has made it important for him to have ongoing follow-ups with his family doctor. He has found, as have millions of others, that using medication to stay ahead of asthma is the best bet for feeling well.
Asthma occurs when the bronchial airways become inflamed and constricted, "trapping" air in the alveoli, which are small spaces in the lungs. The condition affects more than 15 million Americans; nearly one-third of the cases occur in children.
A typical asthma attack can leave a person breathless, with an unpleasant feeling of suffocation. If an attack intensifies, with more compromise to the airways, wheezing can be heard as the person tries to force air past the constricted passages. At that point, breathing is not only uncomfortable, but also difficult. In extreme situations, an asthma attack is a medical emergency, requiring intensive intervention.
Fortunately for David and millions of others like him, effective medical therapies are widely available.
Asthma sufferers have airways that overreact to stimuli that don't bother the rest of us. Those can be environmental agents (such as pet dander, cigarette smoke or even cold air). They also can be internal (such as an allergy to peanuts). Whether environmental or internal, the stimuli are known as triggers. These triggers precipitate a series of cellular responses, which culminate in shrinking airways, leading to the syndrome I described above.
Dr. Tedd Tip
Always keep asthma drugs available -- not only at home, but also on the playground and on vacation.
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For folks who have asthma, a work-up normally involves looking for the things that trigger the problem so they can be avoided. In some instances, triggers are either unavoidable or undiagnosed, but treatment must proceed anyway.
Doctors typically make the diagnosis by looking for some classic symptoms, which include episodes of shortness of breath, coughing and wheezing. The diagnosis can be confirmed by tests that measure airflow.
Once the diagnosis is made, the treatment can vary significantly, depending on the frequency and severity of a patient's symptoms. Some people have attacks on a regular, even daily basis. Others have symptoms that are either so mild or so sporadic that it doesn't make sense to have them use medicine on an ongoing basis. David, who has had asthma all his life, has learned to manage it and takes daily medicine. He knows what triggers the problem: For him, cold air can do it. If he has an attack, he uses an inhaler, but in general he has kept the situation stable.
Two of the three Handkins triplets, Gavin and Elliot, have asthma attacks, but only rarely. Their problems tend to be seasonal, triggered by pollens and sometimes temperature extremes. They have used inhalers on an as-needed basis and have done quite well. They, like the millions of other children who have asthma, should expect normal development and normal childhoods. Although it is necessary to take precautions, such as making certain that medications for asthma attacks always are available (not only at home, but also at school, on the playground and on vacations), both boys should do well. Because Dad has asthma and knows the symptoms, his children can learn from him. He can be a great resource for them and give them support.
Avoiding kidney stones
As if migraines weren't enough, Debbie also has had several bouts with painful kidney stones. She had a major incident last July; her doctor had to perform a procedure to retrieve a stone. Like her migraines, Debbie also has a family history of kidney stones.
Kidney stones are deposits of salts, normally calcium salts, in the kidneys. When these stones hit the ureter (the tube that connects the kidneys to the bladder), the trouble begins. Even tiny stones can wreak havoc as they try to traverse this narrow passageway. These stones are brought on by an accumulation of the salts, and they usually indicate a problem with the way the kidneys shift and clear these substances from the system. As with migraine headaches, the basic approach to treatment involves taking care of an attack once it's there and then preventing another one from occurring.
When a kidney stone tries to "pass," you have three options. First, you can tank up on fluids to help it pass on its own. Second, you can retrieve it surgically. Third, you can pulverize it with sound waves (a procedure called lithotripsy). The best option depends on several factors, including the size and location of the stone. Your doctor will make the choice, so seeing him or her is the most important thing you can do at the onset of kidney stone pain.
After the treatment of an acute attack, your doctor often will look at the composition of the stone to decide whether you need to treat your system with chemicals that alter the way your body produces urine, decreasing the likelihood of developing future stones. Because the most common stones are calcium stones, one approach in medicine has been to employ a low-calcium diet. But a recent study in the New England Journal of Medicine challenged that approach. Italian researchers found that, after five years, those on a low-calcium diet had more recurrences than those who restricted animal protein and salt.
Dr. Tedd Tip
To prevent kidney stones, avoid apples, cheese, chocolate, oranges, broccoli, spinach, beer, soda, coffee and tea.
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What can you do to prevent kidney stones? For some predisposed people, there's not a lot you can do. But the most important thing is to maintain a high intake of fluid -- enough to produce about half a gallon of urine a day for those with a history of stones. You need to keep your urine diluted (clear) so your system is more than adequately hydrated and your body is clearing the extra water. If you don't drink water throughout the day and your urine looks dark yellow or amber, you are not "tanked up" and getting enough fluid.
Food also may precipitate the most common kidney stone (calcium oxalate). For those with recurrent stones, it's a good idea to cut back on a long list of foods and drinks, including apples, asparagus, beer, berries, black pepper, broccoli, cheese, chocolate, coffee, colas, milk, oranges, peanut butter, pineapples, spinach, tea and yogurt.
A rare disease
The oldest Handkins child, Bridget, underwent surgery on a rib when she was 8 to remove a tumor caused by Langerhans cell histiocytosis. Now 11, Bridget has done extremely well in ongoing follow-ups.
But such an illness can affect the entire family for years. Although her health evaluations have shown no evidence of other problems, Mom and Dad now fear the worst every time Bridget has an ache or pain. Their situation is like that of any other concerned parents with a child who has dealt with a serious illness. Remember, a positive mental outlook is important in any situation, particularly one involving children, where ongoing medical follow-up is required. That helps raise not only Mom and Dad's spirits, but the child's as well. Keep this in mind: "The best medicine is laughter; the best healer is time."
Lessons learned from this family
A lot can be learned from my house call with the Handkins family.
Pain syndromes, while varied in their causes, have as a common thread the fact that they detract from the quality of your life. The Handkinses have learned to handle these unwelcome disruptions nicely. Using the information here, so can you and your family.
Almost without exception, pain syndromes are aggravated by things we do to ourselves, so pay attention to your behavior. Problems that cause chronic pain need to be discussed with a physician, because many of them have identifiable risk factors that can be brought to your attention. Furthermore, your doctor can help you develop strategies for minimizing the frequency and intensity of episodes.
Like millions of other baby boomer families, the Handkinses have too many good things going on in their lives to be shackled by pain. This requires effort, and the Handkinses are willing to do the things they need to do to enjoy a healthy quality of life. But remember, it's not always easy.
There is nothing worth having that is not worth working for. Down here in Texas, we say there is a lot more to riding a horse than just sitting in the saddle and letting your feet hang down. The Handkinses have learned that, and with time, you can, too.
