Book Review: Arthritis

A Fair Trade Book (but there's a new edition)

Title: Arthritis: What Works

Author: Dava Sobel with Arthur C. Klein

Author's web site: http://www.davasobel.com/

Date: 1989

Publisher: St. Martin's Press

ISBN: 0-312-03289-7

Length: 455 pages plus 15-page index

Quote: “This is...a detailed report of what's out there, with a painstaking analysis of what works.”

First the bad news:

(1) 1989. That doesn't mean that what works has changed a great deal, but it does mean that what's out there has changed. The patients' reviews of medications are obviously no longer as complete and accurate as they were when the authors took their survey. You didn't need to be told that; you just wanted to be reassured that I had noticed.

(Actually, as I saw when I looked up the book on Amazon, newer editions exist...the very newest have shifted the focus to "what exercises work," though.)

(2) The publishers' blurb on the back of the jacket is a bit of a commercial come-on. “[Y]ou'll find a documented, step-by-step nutritional formula that could end arthritis pain forever...A formula that works!” Inside the book, although the authors have carefully analyzed the responses of patients who were helped by improving their diets, and have produced a sample menu plan with recipes that will meet a lot of people's dietary needs, they admit that no nutritional formula is going to end everyone's arthritis pain forever. The number of variables in the equation is so immense...

I'm not saying this to rain on anyone's parade. It's a solid fact that, for masses of people with arthritis, there is a diet plan that can help to relieve, and may cure, their bone and joint pain. Another solid fact is that no single diet plan is going to work for everybody. If, for example, stubborn non-rheumatoid arthritis is the primary symptom of your celiac disease, Sobel's menu plan (which features lots of whole wheat) won't help you. If you already know that you are or are becoming lactose-intolerant, you can substitute soy, rice, or nut “milk” products for cows' milk products, but if you don't have that information, any menu plan that expects everyone to use cows' milk as a primary source of calcium is not going to work for you. And so on.

Many doctors (though not our faithful correspondent John McDougall) hesitate even to discuss a nutritional approach to medical treatment. The subject is complex; it's outside their specialty, and unless their partners happen to be nutritionists they may not even know where to send you to start exploring nutritional treatment options. Doctors don't want to be scolded, they don't want to be sued, they don't want patients to say “Dr. X just gave me a menu plan that didn't do me a bit of good”...so they tend to tell arthritis patients things more like “Either you have one of the temporary kinds of arthritis that will go away all by themselves, or you'll be totally disabled and in unbearable pain in a few years. When the pain becomes intolerable we can start with the heavy painkillers, dangerous injections, or surgical replacements of your ruined joints. Meanwhile, try to ignore the pain and enjoy the short time you have to live. Have a nice day.”

I got a version of that speech in 1989, when I did, luckily, happen to have one of the temporary kinds of arthritis that go away all by themselves—the kinds caused by minor infections that attack joint tissue. Within eight weeks an immune-boosting diet regimen would have me feeling so good I was downright annoying, bounding out of bed to go jogging at dawn, losing flab while gaining healthy weight...I was very young, but perkiness is a side effect of a successful immune-boosting regimen at any age. And yes, those do help, although they don't completely cure, some people with rheumatoid arthritis.

Anyone who's been through the ups and downs of viral arthritis, the bordering-on-bipolar bounce between “I'm getting better! Life is glorious!” and “With arthritis in my neck, shoulders, knees, toes, and fingers, I'll be a quadriplegic in five years. Why don't I just lie down and die right now?”, will agree that it's cruel to publish anything that claims that nutrition can cure all arthritis patients. Nutrition will help some arthritis patients. Results will vary. Even if there is a diet plan out there that will cure you, the one presented in this book may not be it. Appropriate exercise, rest, weight control, etc., will still be as important as food choices are. Medication or surgery may still be necessary. Damage already done may or may not be reversible. Sobel and Klein actually emphasize these points in the book; it's outrageous that a publicist was allowed to generate a salesmanly blurb that ignores them.

Arthritis actually presents, on page 249, a table of which foods different patients report to be reliable pain triggers for them. All patients with gout need to avoid sardines; most patients with other kinds of arthritis do not. For most diseases that cause joint pain there's not even that kind of clear, though confusing, pattern. More than 10% of Sobel's and Klein's respondents found it helped to avoid red meat, avoid simple sugars, and/or limit fat intake. Almost 10% felt a need to avoid salt. Chocolate, which contains simple sugar, saturated fat, and caffeine, may also contain lactose, and may also be a specific allergy trigger, might be the single food arthritis patients were most likely to find it helpful to avoid. Several, but fewer than 5 percent, of patients were aware of needs to avoid “the nightshades” (potatoes, tomatoes, aubergines), alcohol, refined grain products, wheat products, various chemical additives in commercial foods, acidic foods, citrus fruit, processed meat, cow's milk products, soda pop, the “purine” foods that specifically trigger gout, spicy foods, fermented foods, or eggs. “Someone else could be allergic to peanuts,” one patient reminded the researchers, though none of the patients who completed their survey seemed to have that allergy.

Several patients also identified types of food that seemed to help them. Almost 20% specified that they felt better when they ate more fresh vegetables, almost as many specified fresh fruit, and several patients mentioned benefits from “fiber” and water. The common denominator here...Jethro Kloss didn't sing it as a jingle, actually, but he discussed it at length...constipation triggers inflammation. The only specific vegetable mentioned, other than the general category of “greens,” was garlic. Some patients mentioned benefits from eating “whole grains,” fish, fowl, and lean meat, and about 5% mentioned that they got good results from diets that featured milk or “calcium-rich” foods. Sobel and Klein don't count honey and vinegar as foods, but do discuss them as quack remedies later.

Working with these specifications, Sobel and Klein enlisted a nutritionist to offer a diet based on “less fat, more vegetables, less red meat, more fish, more (skinned) poultry, less salt, less sugar, lots of fiber, a good breakfast, lots of liquids,” while continuing to warn readers to “Learn your own food sensitivities.” The menu plan was specifically designed around recipes that “serve four—so your family or friends can enjoy sharing these meals with you.” Why not? There's nothing radical about this meal plan. Although it requires some home cooking, it's mainstream U.S. cuisine with familiar ingredients. If you can cook, you can try it. It might help.

A few new readers may not be aware that our own sporadic contributor, Grandma Bonnie Peters, was one of the arthritis patients who've been helped by a nutritional approach. Even people who've only recently met her in real life probably don't guess...GBP is more active, energetic, and cheerful at 82 than she was at 32. As a young woman she was sickly, chronically fatigued, chronically overweight, with major PMS and problem pregnancies, and then she started waking up in the middle of the night with acute pain in her shoulders, and some doctor told her “It's arthritis of the spine; you'll be in a wheelchair in about five years; nothing can be done.” What it was, was an allergic reaction triggered by the primary arthritis trigger suspects listed above (red meat, sugar, fat, and “the nightshades”) and caused by undiagnosed celiac disease—she was one of the fat celiacs. GBP eliminated her allergy triggers from her diet and avoided becoming disabled, then, after several years, eliminated wheat gluten from her diet and became positively healthy for the first time in her entire conscious life. She can be evangelical about this. It's a powerful experience, for those who have specific food intolerances, to discover that we too can be healthy if we're willing to become rigid picky eaters. In her adventurous life GBP has used wheelchairs after injuries, but she still walks a mile before breakfast. For her, the diet Sobel and Klein recommend isn't radical enough. She's a “McDougaller.” And while she'll allow that pretending to promise that any one diet plan is a cure for arthritis can be cruel, she says that denying the potential benefit of the right diet plan for an individual patient is at least equally bad.

It would also be unethical to tout, as the blurb writer did, nutrition as the only treatment the arthritis patients rated helpful...and that's not what Sobel and Klein do. This was, in its time, a comprehensive study of all the treatments arthritis patients were trying, from copper bracelets to orthopedic surgery. For each category of medical care providers, medications, etc., there's a chart showing the percentage of patients who mentioned “Dramatic long-term relief; moderate long-term relief; temporary relief; no relief; made participant feel worse.”

Orthopedists and rheumatologists, not surprisingly, got high ratings, while massage therapists got low ratings for arthritis relief. Occupational therapists, physical therapists and exercise coaches, nutritionists and dietitians, and (for some patients) psychotherapists, got good ratings.

About massage therapists I can agree with Sobel and Klein. They found that, if arthritis patients had tried massage in 1989, they generally agreed that “Most are bad, some are good, some have done the best they could,” but if massage worked it almost had to be provided by a physical therapist in combination with exercise. I was a novice massage therapist in 1989, and I saw that too. Massage therapists have studied muscle strain. That, we can treat. Very few of us have studied arthritis. Too many of us were, in 1989, too eager to offer some sort of help for everything, including conditions where massage is actually contraindicated. This was not always the result of greed, but of overconfidence, over-eagerness, just being so dang young, and believing that our good intentions would set up healing vibrations even when we couldn't do a patient any good—which was not necessarily the case. A lot of us believed, as I myself did in 1989, something like “It's mostly a social or emotional pleasure for patients to lie back and be touched; we're not doing any medical good or harm.” (Sometimes we were blessed to find that we were doing good, and not harm.) Over the next soon-to-be-thirty years I've seen a wonderful increase of awareness that massage can do medical good or harm, more reluctance to “try and see” whether we hurt someone we shouldn't touch, more specialized studies of how much it's possible for massage to help those whom it does help...but arthritis is a complicated group of diseases. I've generally avoided arthritis patients myself and don't know anyone who's actually helped an arthritis patient with massage. Sometimes muscles tense in reaction to joint pain, and it's possible to relieve the muscle tension while the pain subsides; when the pain returns, so does the tension. The best-case scenario, with arthritis patients and massage therapists, seems to be an emotional bond that doesn't affect the joint pain much but does offer a temporary soothing effect.

Sobel and Klein don't discuss the specific problem “sensual massage” presents for arthritis patients (since it's not actually a health care practice, it merely sounds like one), so I will. “Sensual massage” is not muscle therapy; it offers either to “tease” or to “release” clients' erotic feelings. I'm not sure how anyone can guarantee such things but, when the clients would otherwise be participating in prostitution and spreading AIDS, I think cities should salute the practitioners of “sensual massage” rather than trying to banish them. But sexual pleasure triggers a prostaglandin surge, so when “sensual massage” has its advertised effect on arthritis patients, five minutes later those patients are likely to be much more conscious of pain. If that prostaglandin surge arrives on its own in the middle of the night, it's more likely to begin to subside by the time the patients need to work, drive, or talk to people...

After reviewing different types of medical practice, Sobel and Klein review the medications that were commonly prescribed in 1989, from aspirin by the handful through Motrin and Prednisone. Motrin generally got the best ratings in the anti-inflammatory category, “but as we said earlier, they don't predict the way the drugs will behave for you,” Sobel and Klein warn. Prednisone got even higher ratings, but still got very mixed ratings for having lots of nasty side effects.

Of non-prescription drugs, “more than half of our 1,051 survey participants rely on” aspirin and “give aspirin...the highest [rating] on our scale.” “Aspirin is not only good medicine. It's cheap,” Sobel and Klein affirm. However, heavy users of aspirin (some arthritis patients take literally dozens of aspirin tablets daily) seem to be more likely than the general population to develop allergy reactions: “[A]bout one person in five hundred is truly allergic to the drug...In our group of 1,051 survey participants, however, 8 individuals (about 4 in 500) say they do not use aspirin because they are allergic to it.” The chapter on non-prescription medicines compares ratings not only for aspirin, Tylenol, and other non-prescription painkillers, but also for topical counterirritants. Majorities of users of all the rub-on pain treatments “found [each one] (somewhat) effective,” with Myoflex and Mineral Ice outscoring cheaper formulas like Icy Hot, Ben-Gay, and Heet. (Biotone, which I used to offer to patients with acute inflammation for the traditional reason—free samples—came out later and is not discussed.)

Most people who've been diagnosed with arthritis never need surgery to fuse or replace a damaged joint, but enough respondents did for the book to include a chapter charting the percentage of patients who reported good results from different types of surgery. Here more than ever, results vary. While some treatments' ratings clustered in the middle, ratings for surgical procedures clustered at the ends, with a majority of patients for whom the surgeries were recommended raving over the results they got—and a minority ranting that the surgeries did more harm than good.

Of the “Additional Orthodox Treatments,” Sobel and Klein summarize: “Exercise is the best, provided it's tailored to your needs...Hydrotherapy feels great while you're wet...but the effects are temporary. Heat is an effective treatment...Cold works even better than heat for some people's pain...Psychological Counseling is a worthwhile adjunct to arthritis care...Massage is at least soothing,” if not really helpful, but “Traction can relieve some kinds of pain by taking pressure off pinched nerves. In the wrong hands, this treatment can hurt as much as help.” Finally, somewhat obviously: “Biofeedback requires your own finely honed powers of concentration to help you achieve relaxation and pain relief.”

(I've known exactly one person for whom elaborate biofeedback equipment was really useful—not an arthritis patient, but a cerebral palsy patient who was unable to speak. Biofeedback was that patient's primary means of communication. For other people, hooking up to a lot of monitoring devices can help us learn to control body processes, but it's not necessary.)

Then there's an “Uncensored Look at Arthritis Quackery,” which begins with a complaint that the Arthritis Foundation included legitimate, reasonable, merely unverified home remedies in its too-broad, somewhat paranoid definition of quack remedies, and goes on to investigate the genuinely quacky treatments. “Rating copper bracelets...shows the jewelry to have less than a placebo effect” since a lot of people were annoyed by the sight of copper oxide on their skin, and some patients seemed to get good results from a treatment designed to flush copper out of the body. Eight patients told Sobel and Klein they'd tried spraying WD-40 on an inflamed joint; four thought it helped, four didn't. No points for guessing why Sobel and Klein withhold recommendation from “bee sting therapy.”

Chiropractic manipulation, acupuncture, and yoga get a separate chapter. All three are controversial, rated highly by some respondents but carrying some inherent dangers. Many have been helped, many have been harmed, and many have been cheated, by practitioners and teachers of these treatments. Just by being “alternative” practices they seem to attract a few shameless charlatans, and yet, when practiced honestly and competently, they can work.

The chapter on experimental treatments is obviously the chapter that aged fastest in this book. By now the results of what was experimental in 1989 are beginning to be fully collected.

There's even more information, of the evergreen variety, about emotional self-care (for those who didn't guess, a flare-up of arthritis is generally accompanied by a flare-up of unhappy thoughts), adaptive devices, exercises, and quick fixes for sudden bursts of pain. There's also a reasonable amount of “back matter,” information about the survey, books and publications cited.

One omission now seems to need to be filled in. Norman Cousins' experience with “arthritis of the spine” (Anatomy of an Illness) seems to be deliberately ignored. Even when people feel that “maintaining a positive mental outlook” is likely to help, laughing out loud at pain can seem incongruous. In the 1990s more research explained how Cousins and other people were able to use laughter as pain medicine: we ho-ho-ho by exercising the diaphragm muscle, so laughing has the same endorphin-boosting effect that yoga breathing, Lamaze breathing, singing,  chanting, and aerobic exercise have. Sobel and Klein discuss yoga and aerobic exercise separately but don't discuss the role of the diaphragm in pain management at all.

Finally, another short section that's become incomplete is the table of known drug interactions. Some readers may remember how The PillBook expanded in the 1990s, as new drugs came on the market and more interactions and side effects were documented. The more a promising medication (even aspirin) is used, the more we learn about its shortcomings, so in one edition there might be one paragraph of warnings about a drug and in the next edition ten pages. By and large I think Arthritis is still likely to be a useful first book for anyone diagnosed with any of the diseases that cause chronic joint inflammation, but readers need to know that they cannot rely on pages 437-448 for all the warnings arthritis medications should carry today. By now a really reliable list of interactions and side effects for arthritis medications alone might well have reached the size of older editions of The Pill Book (which tried to list all the prescription medications).

Some things haven't changed since 1989. “Arthritis” is still a category of symptoms that can be caused by more than a hundred known diseases. A few of those diseases are better understood than they were thirty years ago. Many remain incurable. Many people still “have to live with” arthritis, but at least understanding is growing that diet, exercise, and self-care can reduce the pain most of them feel.

Given that there's a 2005 edition, I'm not sure whether Sobel actually wants you to buy the 1989 edition as a Fair Trade Book. Buying the new book as a new book would show even more respect. If, however, you can afford to buy both for comparison purposes, a first edition of Arthritis will cost...$15 per book, plus $5 per package (two books of this size should fit into one package), plus $1 per online payment. This was truly a groundbreaking book in 1989, a massive improvement over what was available in public libraries at the time, so it's an historic achievement and it's become collectible. So the first edition costs about the same as the updated edition does. If you buy it here we'll send $2 to Sobel or a charity of her choice. If you buy the updated edition as a new book she'll probably get more than that.

(But there's also a 1991 paperback edition, poor little orphaned thing, that's still available as a Fair Trade Book for $5 per book. If you buy that one, Sobel or her charity gets $1...as this web site discussed when we tried to support Laura Ingraham last year, some people's favorite charities don't even bother with donations of $1.)