A Patient’s Guide to Rehabilitation for Arthritis

Introduction

Arthritis is the most common cause of chronic disability. There is no cure for most forms of arthritis. But with some effort, you don’t need to lose all the movement in your joints. A rehabilitation program can help you maintain and even improve your joints’ strength and mobility. With some help from specialists and special equipment, arthritis won’t always stop you from doing the things you enjoy or the things you need to do.

Rehabilitation is a hands-on form of care and relies on your participation and effort. It involves exercising, learning how to care for sore and swollen joints, and figuring out ways to minimize the stress on your joints. In the early stages of arthritis, the goal of rehabilitation is to maintain or improve your joint strength and range of motion. If your joint is severely damaged, rehabilitation will focus on managing your pain and finding special equipment to help you with necessary tasks. Rehabilitation also helps people recover from joint surgery. Your rehab program will involve managing your symptoms, exercise, and lifestyle changes.

Rehabilitation requires patience. It takes time to strengthen your joints and learn how to do familiar tasks in new ways. But the result can be a greatly improved quality of life.

Most doctors refer their patients to physical or occupational therapists for rehabilitation. Many other types of medical professionals are involved in caring for people with arthritis; rehabilitation nurses, vocational rehab counselors, recreational therapists, and sometimes even medical social workers, speech therapists, and psychologists. No matter what kinds of specialists you see, rehabilitation is a team effort–you, your doctor, and your therapists.

Your First Visit

What happens on the first visit to the therapist’s office?

The first step in your rehabilitation is for your therapist to learn more about you and your joint problems.

History of the Problem

Your therapist will ask questions about your disease history, your day-to-day activities, and what you have problems doing. You may be asked to rate your pain on a scale from one to ten. Your answers will help guide your therapist’s examination. Below are some other questions your therapist may ask you.

• What makes your pain or symptoms better, and what makes them worse?
• How do your symptoms affect your daily activities?
• What treatments have been helpful for you?

Physical Examination

After reviewing your answers, your therapist will do an examination that may include some or all of the following checks.

Posture and Joint Alignment

By checking your overall posture and joint alignment, your therapist can see if you have swelling or other signs of inflammation. Your therapist will also look to see if you have any nodules or other changes around a joint that may be present with various forms of arthritis.

Range of Motion (ROM)

Your therapist will check the ROM in your sore joints. This is a measurement of how far you can move the joint in different directions. Your ROM is written down to compare how much improvement you are making with the treatments.

Strength

Your strength is tested by having you hold against resistance as your therapist tests the muscles around the sore area. Weakness and pain with these tests may be expected due to the presence of arthritis.

Manual examination

Carefully moving the joint in different positions can give your therapist an idea of the stiffness in your joints.

Palpation

Your therapist will feel the soft tissues around the sore areas. This is called palpation. Through palpation, the therapist checks for changes in skin temperature and any swelling. The therapist also pinpoints sore areas and looks for tender points or spasm in the muscles around the sore area. Palpation is important in helping your therapist decide which treatments to recommend.

Planning Your Care

What goes into a rehabilitation plan?

All the information you give the therapist, along with the results of the manual exam, will be used to create a rehab program especially for you. Your therapist will put together a treatment plan that describes the goals you and your therapist have for the treatment. The plan lists the exercises and treatments that will be used, and it includes an estimate of how many visits you will need over what period of time. Your therapist will also let you know what results to expect from the program.

Therapy Treatments

What kind of treatments and activities might the therapist recommend?

Controlling Your Symptoms

Rehabilitation therapy, combined with drugs and other treatments prescribed by your doctor, can help you manage the pain and swelling in your joints. Your therapist’s recommendations will depend on your specific symptoms and needs and may include one or more of the following treatment choices.

Rest

Knowing when to rest painful joints can help ease arthritis pain. Rest is especially important during flare-ups. As a common sense rule, if a certain activity or movement causes severe pain, avoid doing it. If you can’t avoid it, do it less, or take breaks that let your joints rest.

Your therapist may make you a special resting splint to support your sore joint when you’re not using it. A resting splint keeps the joint properly aligned, which limits pain and prevents joint deformity.

Heat

Heat makes blood vessels expand, which is called vasodilation. Vasodilation helps flush away chemicals that make your joints and muscles hurt. It also helps your muscles relax. Moist hot packs, heating pads, and warm showers or baths are the most effective forms of heat therapy. Heat treatments usually involve applying heat to the sore area for fifteen to twenty minutes. Paraffin baths or warm whirlpools can be especially helpful for joints of the hands or feet. You may find you have less pain and better mobility after applying heat.

Be cautious when using heat. While heat can be very helpful at times, heat can make serious inflammation worse. And even when heat is the best treatment for your discomfort, hotter is not better. Your skin can overheat and even burn. Sleeping with an electric hot pad is a bad idea. The prolonged heat can actually burn your skin.

Electrical Stimulation

Gentle electrical currents through the skin can help ease pain and decrease swelling. Electrical stimulation eases pain by replacing pain impulses with the impulses of the electrical current. Once the pain lets up, the muscles begin to relax, making movement and activity easier.

Topical Creams

Certain creams rubbed on the skin can give temporary relief to sore joints. The rubbing is relaxing, and the creams create feelings of warmth or coolness that are soothing. Capsaicin, a cream derived from the common pepper plant, has been shown to effectively relieve arthritis pain. With all creams, you need to wash your hands after using them. What feels good on your sore joint does not feel good in your eyes.

Therapeutic Exercise and Functional Training

Whether at work, home, or play, your capabilities depend on your physical health and function. Specialized treatments and exercises can help maximize your physical abilities, including movement, strength, and general fitness. Therapists also use functional training when you need help doing specific activities with greater ease and safety.

Exercise is safe for arthritis patients. In fact, it’s necessary if you want to improve or maintain joint function. Avoiding exercise just makes your arthritis worse. The less a joint is used, the weaker and stiffer it becomes. This leads to even more pain. Even if you don’t have much range of motion in a joint, your therapist can help you find ways of stretching and moving that can help strengthen your joint. There are some specific types of exercises that therapists recommend especially for people with arthritis.

Stretching

Gentle stretching lengthens muscles and helps the joint maintain its shape and mobility. Therapists teach specific stretches for different types of joints.

Strengthening

Your therapist will teach you exercises that have been adapted especially for arthritic joints. Isometric exercises involve tightening muscles without moving joints. This allows you to keep the muscles strong without stressing your joints. Isometrics can often be done even during flare-ups.

Muscles themselves are not part of joints. But strong muscles around a joint help joints move with less pain. Toned muscles act as shock absorbers in protecting the joint.

Stabilizing

There are also specific stabilization exercises to help keep your joints aligned. When your joints are positioned correctly, there is less rubbing or overstretching, and therefore less pain. Correct alignment also helps prevent joint deformities.

Pool Therapy

When you exercise in a swimming pool, the water bears some of your weight. This puts less stress on the joints of your feet, ankles, knees, and hips. The water’s buoyancy lets you move easier, and the water’s warmth can relax your muscles. You will probably start pool therapy in a group led by an instructor. If it is helpful, you may continue the exercises on your own. The warmth of the water can help relax muscles, improve circulation, and ease soreness.

Aerobic Exercise

Your therapist and doctor will probably also recommend that you do some kind of aerobic exercise. Doctors generally recommend thirty minutes of moderate activity, at least five days a week. People with arthritis can safely try exercises such as walking, swimming, stationary biking, and low-impact aerobics. Your doctor or therapists can suggest an exercise program based on your condition and your overall health. Keeping your body fit is important for your general health and can help keep your arthritis under control.

Aerobic exercise also helps you manage your weight. Weight control is especially important for people with arthritis in the hips, knees, feet, and spine. Keeping your weight down can do a lot to help you control your symptoms.

No matter what type of exercise you do, you should not feel extra pain in the joints while you exercise. Your joints may be sore after exercising, but the soreness should be mild and go away within a short period of time.

Lifestyle Management and Functional Training

It is important that you be very open with your therapist about the ways your disease affects your daily activities. Your therapists can suggest ways to help you reduce the effort it takes to do difficult tasks.

Special Devices

There are many different kinds of equipment available to help you minimize the stress on your joints while you do daily tasks around the house or at work. What kind of equipment you need depends on which joints are affected. Canes and walkers help ease the stress on your weight-bearing joints. Raising the height of chairs and toilet seats can make it easier for you to sit down and stand up. Reachers or grabbers can help you pick up items from the floor without having to bend or stoop. There are devices to help with buttoning, putting on socks, or using zippers. A rolling cart is easier to haul around with arthritic fingers than a hand-held briefcase.

Your therapist may also suggest special splints or braces. A working splint keeps the joints aligned as you go about your daily activities. Splints are made for specific joints and specific activities.

Your therapist may also recommend simple changes in equipment. For example, a good pair of shoes can help reduce shock. If you walk or stand for long periods of time, you should try to do it on soft surfaces. As another example, women may choose a shoulder bag or a small backpack to take the place of a clutch purse or brief case if they have problems with the joints in their hands.

Ergonomics

When they hear the word ergonomics, most people think of the way their desk and computer are set up at work. The meaning is larger than that. Ergonomics considers the way you use your body when you take part in certain activities.

Rehabilitation therapists examine your workstation to help determine if you need to make changes. Your therapist will pay special attention to your posture, the repetitions involved in your work, rest times, the amount of weight you are working with, and which activities seem to cause you the most problems. Your therapist will look at the heights of your chair and desk, alignment of computer monitors, lighting, and any special equipment you use.

After evaluating your work site, your therapist will make recommendations. If changes are suggested, they are usually small and inexpensive, such as changing the height of your chair or standing in a different position. But even these minor changes can make big differences in your discomfort on the job.

The ideas behind ergonomics can also be applied to the tasks you do at home. If you have problems with specific jobs or hobbies, talk to your therapist. Together you may come up with a plan or some simple devices that can help.

Pacing Yourself

Plan to take breaks. Pace your activities so that you don’t get too tired or have to force your joint to function through pain.

Taking Care of Your Mind

Not all your work will be physical. Dealing with the pain and loss of function of arthritis can be emotionally draining. Make sure you take care of yourself mentally, and try to bolster your coping skills. Breathing exercises, naps, visual imagery, and meditation can all help you relax. Learning more about your condition can help you feel more in control of your disease. Many people find support groups helpful.

Home Program

Your therapist’s goal is to help you figure out ways to keep your pain under control and improve your strength and range of motion. When you are well under way, your regular visits to the therapist’s office will end. Your therapist will continue to be a resource for you, but you will be in charge of your own ongoing rehabilitation program.

A Patient’s Guide to Medications for Arthritis

Doctors have only a few kinds of drugs to help treat the many different kinds of arthritis. The three classes of arthritis medications doctors prescribe are nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and disease-modifying antirheumatic drugs (DMARDs).

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Uses of NSAIDs

The most commonly used drugs are NSAIDs. The over-the-counter drugs aspirin, ibuprofen, and naproxen are NSAIDs. Your doctor must write a prescription for other NSAIDs. Almost all of the NSAIDs are taken in pill form. Your doctor will probably prescribe only one form of NSAID at a time.

Inflammation is your body’s response to an injury. In normal circumstances, inflammation is the process that helps the injury heal. In arthritis, the inflammatory response gets out of control and actually causes damage to the tissues. NSAIDs help reduce inflammation. They also decrease pain and fever. However, they are short-acting drugs. After NSAIDs have passed through your body, inflammation, pain, and fever can return quickly.

NSAIDs can be very effective against inflammation, but they do not prevent tissue damage. Even when NSAIDs are controlling the inflammation, the joint or organ damage of arthritis can continue to get worse. NSAIDs only lessen your pain and discomfort. They do not affect your underlying disease.

Complications of NSAIDs

NSAIDs are safe drugs. However, they have many side effects. The side effects happen more often when they are used over long periods of time, which is common in arthritis patients. Some of the side effects can become very serious. It is important to use the lowest doses possible to control your symptoms.

GI Effects

NSAIDs irritate the gastrointestinal (GI) tract (the digestive system–your esophagus, stomach, and intestines). They increase the production of gastric acid, and they harm the gastric lining. NSAIDs aggravate ulcers and GI bleeding. Up to 5 percent of people who use NSAIDs for a year develop ulcers, bleeding, or tears in the GI tract. The risks are higher for older patients, patients with a history of GI problems, and patients with heart disease.

Blood Effects

NSAIDs make it harder for the platelets in your blood to clump together at the site of an injury. This can cause bleeding problems. Aspirin especially has this effect. Before you have surgery, you should stop taking aspirin for two weeks to prevent bleeding problems.

Liver Effects

NSAIDs can be toxic to your liver. You will not feel this, but elevated levels of certain liver enzymes can easily be seen in blood tests. Liver function almost always returns to normal when you stop taking NSAIDs.

Kidney Effects

NSAIDs can make it hard for your kidneys to get rid of some kinds of wastes. If you have a history of kidney problems, or if your disease may affect your kidneys, your doctor will use NSAIDs with caution.

Other Effects

Some people get skin reactions and rashes from NSAIDs. Some get a combination of runny nose, polyps in the nose, and asthma. Different kinds of NSAIDs can have different side effects. Salicylates can cause problems with hearing. Other kinds of NSAIDs can cause headaches and confusion, especially in elderly patients. Many of the possible side effects depend on your health and the disease for which you are being treated.

Individuals can react very differently to the same NSAIDs. You and your doctor must work together to find the type and dose of NSAID that controls your symptoms without causing unwanted side effects.

Corticosteroids

Uses of Corticosteroids

Corticosteroids are chemical copies of hormones that occur naturally in your body. The most commonly used corticosteroids are prednisone, prednisolone, and methylprednisolone. Corticosteroids can be given orally or put directly into the bloodstream through an intravenous needle. They can also be injected directly into an inflamed spot. Corticosteroid cream can be rubbed on the skin.

Corticosteroids are powerful drugs. They drastically decrease inflammation. But they are also highly toxic. Doctors have different opinions about how corticosteroids should be used.

Corticosteroids can’t cure your disease. But they do seem to affect the development of some diseases, including rheumatoid arthritis (RA).

Complications of Corticosteroids

Corticosteroids can have many unwanted effects on your body. Whether or not you develop these complications depends on many factors: what type of corticosteroid you take, your dose, the length of time you are on it, and how sensitive your body is to these hormones. The most common side effects are.

Osteoporosis

All corticosteroids slow bone growth and create conditions that lead to osteoporosis, a disease process that results in reduction of bone mass. Compression fractures of the vertebrae can happen with long-term corticosteroid use. Men and women past menopause are most likely to develop osteoporosis. Your doctor may recommend that you take calcium and vitamin D pills while you take corticosteroids.

Infections

High levels of corticosteroids hinder your body’s ability to fight bacterial infections. High-dose corticosteroids can even mask the symptoms of some types of infections, such as abscesses and bowel tears. Most viral infections are not a problem, except for herpes.

Adrenal Insufficiency

This means that your pituitary and adrenal glands can’t produce enough of certain kinds of hormones. This can happen after taking corticosteroids in moderate doses for only a few days. Adrenal insufficiency is most likely to happen as you are reducing the dosage. It can be a problem if you need surgery or if you get an infection or serious injury.

Withdrawal

When you stop taking corticosteroids, the doses will be slowly reduced over a period of days or weeks. Even if you have only been taking steroids for a few weeks, you will still need to taper off. Corticosteroid withdrawal can be very difficult for your body. In many patients, the disease symptoms become worse. Some people experience a sickness that includes fevers, nausea, vomiting, low blood pressure, and low blood sugar. Others have withdrawal symptoms that include muscle and joint pain, weight loss, fever, and headaches. If you have problems coming off corticosteroids, your doctor will have you taper off the drug more slowly.

Different people, and different diseases, react very differently to corticosteroids. You and your doctor will need to find a dose that controls your symptoms but minimizes unwanted effects.

Disease-Modifying Antirheumatic Drugs (DMARDs)

Uses of DMARDs

DMARDs are primarily used to treat rheumatoid arthritis (RA) and other systemic diseases. In the past twenty years, DMARDs (which are also called slow-acting antirheumatic drugs) have become much more widely used.

The idea behind using DMARDs is to prevent joint damage. This means you start using them early on, and you switch drugs or doses when your current drugs stop working. Using DMARDs requires you to be alert for possible side effects. You also need to be patient. DMARDs take some time to work. But they can be very effective at slowing the course of your disease.

DMARDs do not cure disease. Very few patients see their disease go into a complete remission. Most patients find that their symptoms come back after months, or sometimes years, of improvement on DMARDs.

Doctors often prescribe DMARDs, corticosteroids, and NSAIDs at the same time. The DMARDs affect the underlying disease, and the corticosteroids and NSAIDs give relief from pain and inflammation. Sometimes doctors prescribe two or more DMARDs together. There are few studies to prove how well these combinations work. However, using more than one DMARD does not seem to cause problems with higher toxicity. This means that taking more than one DMARD isn’t any harder on your body than taking just one.

Types and Complications of DMARDs

There are many different types of DMARDs, with different effects and complications. Some are used only for specific types of diseases.

Antimalarial Drugs

Hydroxychloroquine and chloroquine have been used since the 1950s for rheumatic diseases. They have been used against malaria for much longer. These drugs are mostly used for RA and lupus (which is also called SLE). Chloroquine has more side effects. Side effects include indigestion, rash, and eye problems. Antimalarial drugs take three to four months to show results.

Penicillamine

This drug affects the way your immune system functions. Almost 25 percent of patients who take it experience bad side effects within the first year. The most common side effects are rashes, blood and protein in the urine, low numbers of platelets in the blood, and autoimmune problems including drug-induced lupus. Taking penicillamine requires regular blood and urine tests.

Sulfasalazine

This fairly new drug is used primarily in RA and spondyloarthropathies (arthritis of the spine). It may slow down erosions of bone. Almost half of patients develop side effects in the first four months, but most of the reactions are minor. Side effects include rashes, nausea, abdominal pain, liver and blood disorders, low sperm counts, and discolored urine and sweat. You will need liver and blood tests for the first months on this drug.

Gold

Gold compounds have been used for eighty years to treat RA. They are also used in juvenile chronic arthritis and psoriatic arthritis. Gold is injected into your muscles, usually once a week. Most patients only use gold compounds for one to five years. After about a year, most patients stop seeing benefits from using gold therapy. And most patients also start having complications. Unwanted side effects include diarrhea, rashes, low levels of platelets and other blood disorders, protein in the urine, lung problems, and sores of the mucous membranes, especially in the mouth. Using gold compounds requires regular blood and urine tests.

Methotrexate

Methotrexate shows results in one to two months. Most patients stay on it longer than other DMARDs. In the short term, methotrexate causes nausea, loss of appetite, and high levels of certain liver enzymes. As with all the other DMARDs, there are serious complications with long-term use. It can cause liver damage and lung disease.

Infliximab

Infliximab is a type of disease-modifying medication in a class called anti-tumor necrosis factor (TNF) agents. The anti-TNF agents are a special type of antibody referred to as human monoclonal antibodies. They specifically target (and inhibit) tumor necrosis factor. Tumor necrosis factor (TNF) promotes the inflammatory response, which in turn causes many of the clinical problems associated with autoimmune disorders such as rheumatoid arthritis.

Azathioprine

This drug is most often used in RA, lupus, and other connective tissue diseases. It can also help offset the bad effects of steroids. Azathioprine is as effective as other DMARDs, but it does have more side effects. It can cause nausea, vomiting, diarrhea, bone marrow suppression, and hepatitis. The most troubling long-term side effect is cancer of the lymph system.

Nitrogen Mustard Alkylating Agents

Chlorambucil and cyclophosphamide are the main alkylating agents used as DMARDs. Chlorambucil is usually used to treat RA, juvenile chronic arthritis, vasculitis, systemic sclerosis, and ankylosing spondylitis. However, it can damage the chromosomes. This creates a higher risk for leukemia and other kinds of cancers. Cyclophosphamide can be taken by mouth or intravenously. It is usually used to treat severe RA, lupus, and systemic vasculitis. Bad side effects are common. They include inflammation and bleeding of the ulcer, suppression of the immune system, reproductive problems in men and women, and cancer that may show up long after the drug is stopped.

Cyclosporine

Cyclosporine can be very effective against RA, but most people who take it develop kidney problems and high blood pressure. Kidney function goes back to normal when you stop taking the drug.

As with NSAIDs and corticosteroids, you and your doctor will need to work together to find the best type and dose of DMARDs for your disease.

Oral medications (pills taken by mouth) are under investigation that might be available in the future for the treatment of a specific type of arthritis called psoriatic arthritis (PsA). These include ustekinumab, apremilast, and tofacitinib. Each of these medications works in a slightly different way to regulate the immune system.

A Patient’s Guide to Psoriatic Arthritis

Introduction

Psoriasis is a disease that most people think of as primarily a skin disease because the condition causes a persistent rash in various areas of the body. Psoriatic arthritis is a type of joint disease that occurs in roughly seven percent of people who have psoriasis. Psoriatic arthritis affects people of all ages, but most get it between the ages of 30 and 50. Usually a patient has psoriasis (the skin rash) for many years before the arthritis develops, and the arthritis comes on slowly. But this is not always the case. No matter what, patients with psoriatic arthritis must manage both the outbreaks of itchy, scaly skin and the pain and stiffness of arthritis.

This guide will help you understand

• how psoriatic arthritis develops
• how doctors diagnose the condition
• what can be done for the problem

Anatomy

Where does psoriatic arthritis develop?

Psoriatic arthritis can affect any joint. Its symptoms often seem like the symptoms of rheumatoid arthritis (RA) or degenerative arthritis of the spine. X-rays can be used to show the difference between psoriatic arthritis and other diseases. In psoriatic arthritis, X-rays show a very distinctive type of bone destruction around the joint and certain patterns of swelling in the tissues around the joints.

Patients with psoriatic arthritis fall into three groups. Many patients have what is called asymmetric arthritis. This means that only a few joints are involved and that it does not occur in the same joints on both sides of the body. (For example, only one wrist and one foot are affected.)

An equal number of patients suffer from symmetric polyarthritis. This means that arthritis occurs in several corresponding joints on both sides of the body. (For example, both elbows, both knees, and both hands are affected.) The polyarthritis type of psoriatic arthritis is much like RA.

A third group has mostly axial disease. This refers to arthritis of the spine, the sacroiliac joint (where the pelvis and bottom of the spine meet), or the hip and shoulder joints. Patients do not necessarily stay in the same category. Over time, the pattern may change. Doctors use these categories to better understand the disease and to follow the progression of the arthritis. The treatment is basically the same.

Causes

Why do I have this problem?

The exact cause of psoriatic arthritis is not known. Many factors seem to be involved in its development. Heredity–your genes–plays a major role. People who are closely related to someone with psoriatic arthritis are 50 times more likely to develop the disease themselves. Recent studies have located genetic markers shared by most people who have the disease.

Sometimes injuries seem to set off psoriatic arthritis. Infections also contribute to the disease. It is known that strep infections in children can cause psoriasis. Some researchers think that the arthritis may be an immune system response to bacteria from the skin lesions.

Symptoms

What does psoriatic arthritis feel like?

All people who suffer from psoriatic arthritis have psoriasis (the skin rash). Some patients have very few areas of rash. Other patients have psoriasis over a large portion of their bodies. The skin lesions of psoriasis are reddish, itchy, and have silvery scales. These areas can range in size from the size of a pencil dot to the large areas the size of your palm. Psoriasis usually shows up on the elbows, knees, scalp, ears, and abdomen, but it can appear anywhere. In people with psoriatic arthritis, the psoriasis most often affects fingernails or toenails. The nails may have pits or ridges, or they may be discolored or appear to be separating from the skin.

Psoriatic arthritis can affect any joint. Symptoms often seem like those of any other type of arthritis–joint swelling and pain–but patients generally describe less pain. Some joint symptoms are unique to psoriatic arthritis:

• The joints nearest to the fingernails and toenails are affected more. (These joints are called distal interphalangeal, or DIP, joints.)

• The affected fingers and toes take on a “sausage-like” appearance.
• The bones themselves become inflamed (called dactylitis).
• The tendons and ligaments become inflamed where they attach to bones. (This is called enthesitis and is especially common in the heels.)
• Bony ankylosis of the hands and feet develops. (This means that the joints stiffen and become frozen in awkward positions.)
• The joints grow inflamed where the bottom of the spine meets the pelvis. (This is called sacroiliitis.) Patients often notice no symptoms, but the inflammation can be seen on X-rays.
• The vertebrae of the spine become inflamed. (This is called spondylitis.)
• The eyes become inflamed.

About five percent of patients with psoriatic arthritis will develop a form of arthritis called arthritis mutilans. This type of arthritis affects the small joints of the hands and feet. It is especially severe and destructive. The destruction caused by arthritis mutilans can result in deformity of the hands and fingers.

Rare symptoms include problems with the aortic heart valve, extra tissue formation in the lungs, and metabolic disorders that affect the tissues.

Diagnosis

How do doctors identify the condition?

A detailed medical history, with questions about psoriasis in your family, will help your doctor make a diagnosis. Patients with psoriasis may have other forms of arthritis, and the symptoms of psoriatic arthritis often look like other types of joint disease. This means that your doctor will probably do tests to rule out other diseases.

Blood studies will help rule out RA. (The RA test is usually not positive in patients with psoriatic arthritis.) Efforts are being made to find ways to identify psoriatic arthritis through a blood test. The presence of specific biologic elements called biomarkers (biologic evidence of disease) would make it possible to look for evidence of this disease before it progresses – or even before it starts. Psoriatic arthritis is common in people who test positive for HIV, the AIDS virus. As a precaution, your doctor may test your blood for HIV, especially if your symptoms are severe.

Physicians must also use other diagnostic tools such as X-rays, ultrasonography, and MRIs. Each one of these tests provides a little different information. For example, X-rays of affected joints will be studied both to rule out other diseases and to identify characteristics of psoriatic arthritis.

Ultrasonography, the use of sound waves to create a picture of what’s going on inside, provides a better look at the whole package: bones, joints, and soft tissues. This diagnostic test is also noninvasive and does not expose the patient to any radiation. Ultrasound also has the ability to show small changes in the nails and early signs of inflammation in tendons and small joints.

MRIs can show bone marrow edema, tenosynovitis, and early joint erosion. Tenosynovitis is the inflammation of the fluid-filled sheath (called the synovium) that surrounds a tendon. But reliability is a problem with MRIs because what one examiner sees may not be the same as another observer. Changes in the small joints of the hands and feet don’t show up well on MRIs like they do with ultrasonography.

One advantage MRIs do have over ultrasonography is the availability of whole body MRI. By scanning the entire body, it is possible to identify areas of inflammation undetected by clinical exam.

Until blood studies are able to find biomarkers indicating the presence of psoriatic arthritis, physicians will probably have to use a combination of different tests to diagnose the problem. The information these tests provide is important in determining treatment.</p.

Treatment

What can be done for the condition?

Dealing with psoriatic arthritis involves treating both the skin lesions and the joint pain. Many lotions and creams are made for skin affected by psoriasis. If the skin involvement is especially severe, your doctor will most likely prescribe a drug called methotrexate. Methotrexate can also help with the arthritis.

PUVA therapy may be helpful for both the skin and joint problems. PUVA therapy uses topical cream medications that are rubbed on the skin lesions. Following application of the cream, the skin area is placed under a lamp that emits a special ultraviolet light. The light triggers chemicals in the medication cream that treat the rash lesions.

Treatment of arthritis symptoms depends on which joints are affected and the severity of the disease.

The first drugs most doctors prescribe are nonsteroidal anti-inflammatory drugs (NSAIDs). Aspirin and ibuprofen are NSAIDs, as are many prescription pain relievers. Other medications known as disease-modifying antirheumatic drugs (DMARDs) are used in patients with high levels of pain or especially bad arthritis. These medications work in different ways to regulate the immune system and thereby control the arthritis.

One of the most commonly used disease-modifying medication for the treatment of psoriatic arthritis (PsA) is methotrexate. DMARDs like methotrexate not only control symptoms, they also slow the progression of disease. That’s what makes them “disease-modifying”. For some patients, it may be necessary to combine methotrexate with another drug (e.g., infliximab) to get the desired results (decreased joint pain, swelling, and stiffness).

Infliximab is a type of disease-modifying medication in a class called anti-tumor necrosis factor (TNF) agents. The anti-TNF agents are a special type of antibody referred to as human monoclonal antibodies. They specifically target (and inhibit) tumor necrosis factor. Tumor necrosis factor (TNF) promotes the inflammatory response, which in turn causes many of the clinical problems associated with autoimmune disorders such as rheumatoid arthritis.

Oral medications (pills taken by mouth) are under investigation that might be available in the future for the treatment psoriatic arthritis (PsA). These include ustekinumab, apremilast, and tofacitinib. Each of these medications works in a slightly different way to regulate the immune system.

Doctors will sometimes prescribe a combination of drugs. Cortisone injections into sore joints can help relieve pain. Surgery may be called for in the rare cases of unmanageable pain or loss of joint function.

Related Document: A Patient’s Guide to Medications for Arthritis

Warm water soaks and applying heat to joints gives pain relief to many patients. Your doctor may ask you to see a physical therapist to maximize the strength and mobility of your joints. Stress does make your symptoms worse, so your doctor may encourage you to exercise and find ways to reduce the stress of your daily life.

Your psoriatic arthritis will not go away. But there are many treatment options. Together, you and your doctor should be able to find treatment that will work for you.

A Patient’s Guide to Osteoarthritis

Osteoarthritis (OA) is the most common form of arthritis. In fact, more than 75 percent of people older than fifty-five show the joint deformations of OA on X-rays. But most of these people have no symptoms. For people who do have the joint pain and stiffness of OA, it can become a crippling disease. Some people suffer from OA in just one joint, while others have it in several joints. It affects more women than men, and most OA patients are over 45.

This guide will help you understand

• how OA develops
• how doctors diagnose the condition
• what can be done for OA

Anatomy

Where does OA develop?

OA is most common in the small joints of the hands, the spine, the knees, the hips, and certain toe joints. OA primarily affects the articular cartilage, the slippery, cushioned surface that covers the ends of the bones in most joints and lets the bones slide without rubbing. Articular cartilage also functions as a shock absorber.

In OA, the articular cartilage becomes damaged or worn away. As this happens, the joint no longer fits together well or moves smoothly. In the early stages of OA, the cartilage actually becomes thicker as your body tries to repair the damage. The repaired areas are more brittle than the original cartilage, and these brittle areas begin to wear away and become thin. They may even wear away entirely. This eventually leads to a condition called eburnation, in which the bones become thick and polished as they rub together. X-rays can show these changes in the cartilage and bones.

But OA is not just a disease of the cartilage. The damage to the cartilage seems to start a sort of chain reaction that involves all the parts of the joint. Bone spurs, or outgrowths, often begin to form around the edges of the joint. The joint capsule (the watertight sack around the joint) can become thickened and lose its stretch. The synovial membrane that lines the inside of the joint capsule may become inflamed (swollen, red, hot, and painful), and crystals may form in the synovial fluid. The tendons and ligaments around the joint can also become inflamed.

Even the muscles around the joint can lose their strength. This usually occurs as a result of under-use of the muscles due to pain in the joint. When something hurts we subconsciously change the way we use the joint to avoid the pain. This causes the muscles to become weakened. Because cartilage itself does not have nerves to feel pain, the pain of OA probably comes from these other changes in and around the joint.

Causes

Why do I have this problem?

The exact cause of OA is not known. There are probably different causes in different people. Doctors think of OA in two different categories, primary OA and secondary OA. Primary OA refers to breakdown of a joint from a disease process. Secondary OA means that something else was wrong–an infection in the joint or a fracture for instance–that caused damage to the joint. Even when the original problem clears up, the chain reaction effect of OA can cause the disease to progress.

Major injuries and repetitive stress both seem to cause OA. A person who breaks an ankle is likely to develop OA in that same ankle. Just like any machine, a joint that is damaged and unbalanced wears out faster. People who consistently put heavy stress on the same joint, such as jackhammer operators or baseball pitchers, are more likely to develop OA in that joint.

OA of the knee and hip occurs much more often in people who are seriously overweight. A study that followed overweight young adults for thirty-six years found that being overweight at a young age was closely related to developing OA later in life. The same study also showed that losing even small amounts of weight decreased the odds of developing OA.

Heredity–your genes–may also play a role for some people, especially women. OA in the fingers, which affects ten times more women than men, shows up much more often among women in the same family. Researchers do know that some genes cause problems with cartilage formation.

In some cases, rare metabolic disorders or other problems with the bones or joints can lead to OA. But the primary factor in most patients with OA seems to be age. If you’re lucky enough to live a long life, you are much more likely to develop OA.

Symptoms

What does OA feel like?

Patients with OA have one or more joints that are painful and stiff. The pain is a deep, dull ache that usually comes on gradually. Pain gets worse when the joint is used and gets better with rest. The joint is stiff after waking up or after not being used for some time, but the stiffness usually goes away fairly quickly. Over time the pain and the stiffness become almost constant.

No matter which joints are affected, OA patients report many of the same symptoms

• Most patients say that the pain is worse in cool, damp weather.
• Many OA patients feel or hear crackling or popping in the affected joints (called crepitus). This is most common in the knees.
• Joints enlarge or change shape. The enlarged areas are often tender to the touch.
• In most cases the affected joints can’t move through a normal range of motion.
• In other cases the joints have become so unstable that they can actually move too much or in the wrong direction.

Some symptoms depend on the affected joint. Patients with knee OA may have problems with the joint locking up, especially when they are stepping up or down. Patients with OA of the hip often limp. OA of the hands can affect the strength and movement of fingers and make simple tasks such as getting dressed very difficult. OA of the spine can cause neck and low back pain as well as weakness and numbness.

Diagnosis

How do doctors identify the condition?

It may seem that diagnosing OA would simply involve a few X-rays. However, it is very important that your doctor rule out other forms of arthritis. Your doctor will also need to figure out if your OA was caused by another problem (secondary OA). And even if OA is the main problem, the breakdown of cartilage may have caused problems in other parts of the joint that need to be addressed.

Your doctor will ask you many detailed questions about your health history. Explaining the nature of your pain will be important. Following the history the doctor will thoroughly examine the affected joints. X-rays will most likely be taken. Blood samples and samples of the synovial fluid in the joint may be taken to try to identify other problems.

Treatment Options

What can be done for the problem?

There is no cure for OA. It is a chronic but very treatable disease. The goals of treatment are to relieve your pain and to improve or maintain the movement of the joint.

Nonsurgical Treatment

Much of the treatment for OA involves no prescriptions at all. Your doctor will encourage you to take some steps to help manage your symptoms:

• Get aerobic exercise.
• Do strengthening and range of motion exercises. These are most often taught and monitored by physical or occupational therapists.
• Lose weight.
• Use heat and cold packs.
• Tape the knee, if it is affected.
• Wear wedged insoles in your shoes, if the hip or knee is affected.
• Receive massage.
• Use equipment to help take pressure off your joints, such as a cane or special gadget to open jars.
• Participate in education programs or support groups.

Drugs are available to help alleviate your pain. Your doctor will probably start with an over-the-counter pain reliever, such as acetaminophen (Tylenol). If this doesn’t work, nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and aspirin, may be prescribed. The main problem with NSAIDs is that they can be very hard on your stomach and kidneys over time, and you will be probably be taking these drugs over many years. In rare cases of extreme pain doctors may prescribe stronger pain medications, but these can be addictive and must be used with caution.

Related Document: A Patient’s Guide to Medications for Arthritis

All these medications can interact with other drugs. You must let your doctor know what other medicines you are taking, and you must work closely with your doctor to set up dose amounts and schedules.

In recent years, two unique compounds have been used by people with OA. These compounds are gaining greater acceptance among many doctors. Glucosamine and chondroitin sulfate are dietary supplements taken in pill form that have shown benfits of reducing pain and increasing joint mobility. These treatments are controversial. Yet some doctors feel there are enough benefits to encourage their patients to supplement with these compounds.

Related Document: A Patient’s Guide to Glucosamine and Chondroitin Sulfate for Osteoarthritis of the Knee

Steroid injections directly into the joint can help ease the pain in some cases. Capsaicin cream rubbed into the joint sometimes provides pain relief. Occasionally doctors may recommend tidal joint lavage, which involves rinsing the joint with saline. Alternative approaches, such as pulsed electromagnetic fields and electrical nerve stimulation, have been tested.

Surgery

When pain cannot be relieved and joint function cannot be maintained, your doctor may recommend surgery. While this option may sound scary, surgery can be very effective in treating OA.

Many types of surgical procedures have been designed to treat OA of different joints. Perhaps the most well known treatment is artificial joint replacement. Artificial joint replacement is the final answer to OA after the joint is totally destroyed, but other surgical procedures have been designed to treat osteoarthritis in early stages to reduce symptoms and slow the progression of the disease.

It will take some work to manage your OA, but it is possible. OA doesn’t always worsen over time. In many patients the disease stabilizes. In some patients, especially those with OA of the knee, the disease can actually reverse itself. And even when the OA does continue to progress, it often moves very slowly.

A Patient’s Guide to Lyme Disease

Introduction

A Patient’s Guide to Systemic Lupus Erythematosus

Introduction

Systemic lupus erythematosus (also called SLE, or lupus) is an autoimmune disease of the body’s connective tissues. Autoimmune means that the immune system attacks the tissues of the body. In SLE, the immune system primarily attacks parts of the cell nucleus.

SLE affects tissues throughout your body. Five times as many women as men get SLE. Most people develop the disease between the ages of 15 and 40, although it can show up at any age.

This guide will help you understand

• how SLE develops
• how doctors diagnose the disease
• what can be done for the condition

Anatomy

Where does SLE develop?

SLE causes tissue inflammation and blood vessel problems pretty much anywhere in the body. SLE particularly affects the kidneys. The tissues of the kidneys, including the blood vessels and the surrounding membrane, become inflamed (swollen), and deposits of chemicals produced by the body form in the kidneys. These changes make it impossible for the kidneys to function normally.

The inflammation of SLE can be seen in the lining, covering, and muscles of the heart. The heart can be affected even if you are not feeling any heart symptoms. The most common problem is bumps and swelling of the endocardium, which is the lining membrane of the heart chambers and valves.

SLE also causes inflammation and breakdown in the skin. Rashes can appear anywhere, but the most common spot is across the cheeks and nose.

Causes

Why do I have this problem?

Doctors and researchers know quite a bit about the changes in the bodies of SLE patients. But the cause of SLE is a mystery.

Heredity plays a role in SLE. If you have a close relative who suffers from SLE, you are much more likely to develop the disease yourself. However, genes alone do not seem to cause SLE. It seems to be triggered in unknown ways. Not everyone with a tendency toward SLE will develop the disease. Researchers think some of the triggers that set off SLE may be infections, stress, diet, and toxins, including some kinds of prescription drugs. These triggers may also help explain why SLE has a cycle of flare-ups and remissions.

Symptoms

What does SLE feel like?

The symptoms of SLE come on in waves, called flares or flare-ups. In between flares, patients may have almost no symptoms. Almost every SLE patient suffers from general discomfort, extreme fatigue, fever, and weight loss at some point. In addition to these general symptoms, SLE produces different symptoms in different body systems.

Skin

Rashes caused by SLE are red, itchy, and painful. The rash can show up on any part of the body. The most typical SLE rash is called the butterfly rash, which appears on the cheeks and across the nose. SLE also causes hair loss. The hair usually grows back once the disease is under control.

People with SLE tend to be very sensitive to sunlight. Being in the sun for even a short time can cause a painful rash. Some people even get a rash from fluorescent lights at work.

Muscles and Bones

Almost everyone with SLE has joint pain or inflammation. Any joint can be affected, but the most common spots are the hands, wrists, and knees. Usually the same joints on both sides of the body are affected. The pain can come and go, or it can be long lasting. The soft tissues around the joints are often swollen, but there is usually no excess fluid in the joint. Many SLE patients describe muscle pain and weakness, and the muscle tissue can swell.

In its late stages, SLE can cause areas of bone tissue to die, called osteonecrosis.. Osteonecrosis can cause serious disability. It can be caused at least in part by using high doses of corticosteroids over a long time. Corticosteroids help control the symptoms of SLE.

Kidneys

People with SLE usually don’t notice any problems with their kidneys until the damage is severe. Sometimes kidney problems aren’t noticed until the kidneys are actually failing.

Nervous System

SLE can cause headaches, seizures, abnormal blood vessels in the head, and many other problems with the nervous system. SLE can also cause organic brain syndrome. This disorder involves serious problems with memory and concentration, emotional problems, and severe agitation and hallucinations. Any of these symptoms may show up alone, without any other symptoms of SLE.

Membranes

In the body, membranes surround your internal organs. The membranes around your lungs, heart, and the organs in the abdomen become inflamed in SLE. This is called serositis and can be seen on X-rays. Many SLE patients develop symptoms of pleurisy (swelling of the membrane around your lungs). The pericardium, the membrane around your heart, is often affected as well.

Digestive System

Problems with the stomach and intestines are common. Symptoms include abdominal pain, loss of appetite, nausea, and sometimes vomiting. In most cases this is caused by serositis in the membrane around the organs in your abdomen.

Lungs

SLE can cause many lung problems.

• Inflammation of the lungs, called Lupus pneumonitis, can come on suddenly or slowly. It has many of the same symptoms of pneumonia.
• A hemorrhage (burst blood vessel) can occur in the lungs.
• A blood clot can form in the artery going to the lungs.
• The blood vessels in the lungs can begin to contract.
• Shrinking lung syndrome involves scarring of the lungs due to long standing inflammation decreases the lungs’ capacity to take in air. It seems that the lungs can no longer hold normal amounts of air.

Blood

SLE causes very low levels of red and white cells in your blood. SLE often does not directly cause low levels of red blood cells, called anemia. Anemia is instead caused by blood loss, kidney problems, or the drugs taken to control the disease.

You may have few of these symptoms, almost all of them, or any combination in between. The disease affects different people in very different ways. There is even a group of patients considered to have latent lupus. They have some chronic SLE symptoms, but the disease never seems to progress into true SLE.

A few patients have drug-induced lupus. In these cases, SLE symptoms come on suddenly while taking certain kinds of drugs. The symptoms are usually milder than in true SLE, and the symptoms go away when the patients stop taking the drug.

Pregnancy

Because so many SLE patients are young women, pregnancy is a major concern. Women with SLE can get pregnant. The disease can be managed during pregnancy if it has already been brought under control. However, the chances of miscarriage, premature birth, and death of the baby in the uterus are high.

Diagnosis

How do doctors identify the condition?

Your description of symptoms and a detailed medical history will help your doctor make a diagnosis. Your doctor will also do a complete physical exam. You will be asked to give a blood sample.

The exams and tests your doctor will do to diagnose SLE depend on your symptoms. You may be asked to have X-rays taken of joints or organs. You may need to have an ultrasound of your heart or kidneys. Many other tests and exams can help diagnose SLE. Because SLE can develop and change over time, your doctor may ask you to do some of these tests again, to help monitor your disease.

Treatment Options

What can be done for SLE?

Treatment options for SLE have improved dramatically since the 1970s. SLE cannot be “cured” and will most likely be a lifelong disease that will require management and attention. You and your doctor should be able to find ways to manage flare-ups.

Lifestyle Alterations

One of the most important parts of dealing with SLE is learning about your own disease. The more you know, the better you can help yourself. Many patients find support groups helpful, both to learn about the disease and to meet others with SLE.

The skin of many SLE patients is extremely sensitive to sunlight. To avoid painful rashes, avoid going outside during the middle of the day, use sunscreen, and wear hats and long clothing.

Infections are common with SLE. If you come down with a fever, talk to your doctor right away. This is especially important if you are on certain drugs, including high-dose corticosteroids and cytotoxic drugs, those that are destructive to cells.

Birth control is important in women with SLE. It is especially important in women with kidney disease. Many of the drugs used to treat SLE can harm a growing fetus, so any pregnancy must be planned with the help of your doctor.

Medication

Several types of drugs can be used to treat the complications of SLE. What your doctor prescribes for you will depend on your symptoms.

• Nonsteroidal anti-inflammatory drugs (NSAIDs) are used to treat muscle, bone, and joint pain, and mild cases of serositis (inflammation of internal membranes). They may also be used for fevers.
• Corticosteroids are used in many forms. Creams are rubbed into rashes, and oral or intravenous forms are used to treat flare-ups and to keep the disease under control. Corticosteroids can be injected directly into painful arthritic joints. These drugs are very toxic, however. It is important to use them only when absolutely necessary.
• Antimalarial drugs (hydroxychloroquine, chloroquine, and quinacrine) work to manage the skin problems of SLE. They can also help treat other symptoms. These drugs can hurt your eyes. As a precaution, you may need to get regular eye exams if you take antimalarial drugs.
• Methotrexate in low weekly doses can help manage arthritis, rashes, serositis, and other symptoms.
• Cyclophosphamide, given intravenously, is often used when SLE is affecting the kidneys, heart, and lungs. This is an extremely toxic drug, with many side effects. Patients often experience severe nausea and vomiting and almost total hair loss. The hair does grow back, even when patients must continue taking the drug.
• Azathioprine can be used instead of cyclophosphamide to treat kidney disease. Doctors consider it less effective, but it is also far less toxic. It can also be used instead of steroids.

SLE progressively damages the kidneys over time. In late stages of the disease, kidney failure requires dialysis or kidney transplants.

SLE is a very serious disease. Its effects on the kidneys, heart, and lungs can cause many long-term problems. Although doctors now have better ways to help you live with SLE, there are not many options to help prevent or reverse the damage to your organs.

A Patient’s Guide to Joint Injections for Arthritis

Doctors recommend joint injections of corticosteroids (also commonly known as cortisone) for many arthritis patients. Cortisone is a powerful anti-inflammatory medication that can reduce joint inflammation. Because the medication is injected directly into the joint, the effects of the medication are concentrated on the painful joint. The injected cortisone can bring the inflammation in the joint under better control and decrease the swelling and pain.

These injections involve putting a needle directly into the joint. Through the needle, your doctor can remove excess synovial fluid (the lubricating fluid found in joints) and inject corticosteroid medication to help reduce the inflammation, pain, and swelling.

This process may sound risky. It is actually safe and fast. It involves little or no pain. And therapeutic injections have important benefits. They deliver the medicine to the exact spot that needs it. They also allow you to use lower and fewer doses of oral steroids, which are highly toxic.

Most doctors give only three to four injections per year in large, weight-bearing joints. This includes joints in your knee and hip. However, patients with arthritis pain that cannot be controlled in other ways can get injections more often.

Complications

The most common side effect from injections is a temporary increase in pain and swelling. Rest, cold packs, and anti-inflammatory drugs help this pain go away within four to twenty-four hours. Studies have shown that about 6 percent of arthritis patients who receive injections in their joints experience this passing pain. It is probably caused by the body’s reaction to the corticosteroid crystals in the medicine. If you have problems with pain and swelling after injections, your doctor may want to change the type of corticosteroid in your next injection.

Another fairly common complication is mild, temporary flushing (sudden redness of the skin) and agitation. Injections can also make diabetic symptoms worse.

There is a chance that the injection can introduce an infection into the joint. However, the odds of this are very slight. Studies show infections following injections happen from 1 in 1000 to 1 in 1600 times. Still, infections in the joint can be very serious. It is important to have an experienced professional perform the injection.

Some doctors and patients have wondered if the cartilage and other tissues of the joints are damaged by injections into the joint. Studies have not shown this to happen.

A Patient’s Guide to Gout

Introduction

Gout is a disease that involves the build-up of uric acid in the body. About 95 percent of gout patients are men. Most men are over 50 when gout first appears. Women generally don’t develop gout until after menopause. But some people develop gout at a young age.

This guide will help you understand

• how gout develops
• which parts of the body are affected by gout
• what can be done for the condition

Anatomy

What is gout?

Gout was the first disease in which researchers recognized that crystals in the synovial fluid could be the cause of joint pain. Synovial fluid is the fluid that the body produces to lubricate the joints. In gout, excess uric acid causes needle-shaped crystals to form in the synovial fluid. Uric acid is a normal chemical in the blood that comes from the breakdown of other chemicals in the body tissues.

Everyone has some uric acid in his blood. As your immune system tries to get rid of the crystals, inflammation develops. For the person with too much uric acid, this inflammation can cause painful arthritis.

The first attack of gouty arthritis usually happens in just one joint. Half of the time, gout affects the metatarsophalangeal (MTP) joint. This is the joint at the base of the big toe. Eventually, 90 percent of people with gout will have pain in the MTP joint. Other joints that are commonly affected include the mid-foot, ankle, heel, and knee joints. Less commonly gout affects the fingers, wrists, and elbows.

Over time, patients with gout can develop tophi, or lumps that grow around crystal deposits in joints or near pressure points. Tophi most often occur in the fingers, wrists, ears, knees, elbows, forearms, and heels. Tophi can also grow in the kidneys, heart, and eyes.

Causes

Why does gout develop?

Hyperuricemia

The underlying condition that causes gout is called hyperuricemia. It means that you have high levels of uric acid in your blood. This can happen for two reasons: (1) your body creates too much uric acid, or (2) your kidneys don’t excrete the uric acid effectively. Whether or not you will develop gout is related to how bad your hyperuricemia is over time.

For people who create too much uric acid, the cause is usually genetic. Some rare genetic and metabolic disorders can cause overproduction of uric acid, which can eventually lead to gout. The breakdown of purines in the body also releases uric acid. Purines are ingested through certain types of food such as sweetmeats (e.g., liver, kidney, brain) and seafood. The increased intake of fructose-sweetened soft drinks has also been linked with an increased risk of gout. Usually the excess uric acid is then passed out of the body through the urine.

More than 90 percent of people with gout have kidneys that don’t effectively get rid of uric acid. Sometimes this is caused by certain kinds of drugs, such as diuretics, cyclosporine, and low-dose aspirin. Other medical conditions, such as obesity, hypertension, and diabetes, can also make some people more likely to develop gout.

Many gout patients have a combination of overproduction and under-excretion of uric acid. Their bodies create too much uric acid and have problems getting rid of it. This combination of problems happens with drinking alcohol, especially beer. The more alcohol the patient drinks, the worse the problem is. Alcohol both raises uric acid levels in the body and impairs the kidneys’ ability to excrete the buildup.

Acute Causes

Attacks of gouty arthritis seem to be caused by sudden increases in the amount of urate (a solid form of uric acid) in your synovial fluid. This rapid change can be caused by injury to the joint, alcohol use, or use of certain drugs.

An injury that can trigger gout can be very slight. Even gentle exercise can cause inflammation in the joint, although you may not notice it. Once the joint is at rest, the body absorbs some of the water in the synovial fluid. This leaves the synovial fluid more concentrated with urate, which may allow crystals to grow.

Other Factors

Heredity plays a role in gout. In some families, hyperuricemia tends to develop into gout, while in other families it doesn’t. But genes alone don’t account for gout. The rising number of people with gout since World War II suggests more than just a genetic or hereditary basis for this condition.

Dietary changes may be the major difference over the last 60 years. Food scarcity during the 1940s was followed by an increased intake of carbohydrates and especially carbohydrates containing high-fructose corn syrup. The increase in obesity (another risk factor for gout) during the same time supports this idea.

There are several other risk factors for gout. These conditions do not cause gout, but they are closely related to severe hyperuricemia. The risk factors include metabolic syndrome, kidney problems, high hemoglobin levels, high triglyceride levels, and hypertension (high blood pressure). About 14 percent of hypertension patients have gout. A combination of factors such as eating lots of organ meat, a sedentary lifestyle without exercise, and drinking lots of alcohol increases the risk for symptomatic gout.

It is important to note that hyperuricemia alone doesn’t cause gout. Most people with high levels of uric acid in their blood never develop any symptoms of gout. At least five percent of Americans have at least one period of hyperuricemia as adults without showing any symptoms of gout. And most people can tolerate fairly high levels of uric acid in their bloodstream without damage to their kidneys.

Symptoms

What does gout feel like?

Gout causes attacks of very painful joint inflammation. This pain is often described as burning pain. Early gout attacks usually affect only one joint. This joint is most commonly the MTP joint at the base of your big toe. The joint becomes swollen, warm, and red within eight to 12 hours. Most of the time the attacks happen at night. Patients say the pain is so bad the joint can’t even stand the slightest touch. Even the weight of a sheet causes excruciating pain. Walking and standing are almost impossible if the legs or feet are affected. Many patients have flu-like symptoms, including fever and chills. The pain may go away on its own in a few hours, or it may take a few weeks.

Gouty arthritis attacks come and go. There may be months between attacks. Over time the attacks happen more often, last longer, and involve more joints. Eventually the pain doesn’t ever completely go away. The joints stay swollen and tender even between flare-ups, and the flare-ups start to happen every few weeks. Eventually, some patients develop tophi on joints or pressure points and kidney stones.

Diagnosis

How do doctors identify the condition?

Diagnosis is important because crystals within the joint can lead to joint damage. This can happen without you knowing it. Patients with arthritic episodes that come and go may not seek medical help. Some patients are medically evaluated but complete testing is not done. They are misdiagnosed with rheumatoid arthritis. Either of these situations will delay treatment and increase the risk of erosive damage to the joint.

The diagnosis begins with a history of your symptoms and a physical exam. Your doctor will need to look at synovial fluid from the affected joint to identify the needle-like crystals. This is the most important part of the diagnosis. To get a sample of the synovial fluid, the physician performs an arthrocentesis. A long, thin needle is inserted into the affected joint and a small amount of synovial fluid is aspirated or removed. The fluid is sent to a laboratory where it is viewed under a special polarized light microscope to determine if uric acid crystals are present.

If there are uric acid crystals, then you have gout. But only 80 per cent of the tests are positive when the person really has gout, so this test is not completely accurate. In some cases (such as the midfoot), it isn’t easy to aspirate fluid. Without the use of fluoroscopy (a special X-ray imaging) or ultrasound to guide the needle, aspiration isn’t done. In these situations, the diagnosis is made without joint aspiration when the patient responds favorably to therapy.

Ultrasonography may be helpful in the diagnosis because the crystals form into the shape of rosary beads inside the hyaline cartilage and this can be seen in the ultrasound pictures. Hyaline cartilage coats the ends of the bones to protect them. Ultrasonography can also show the double contour sign. This sign looks like a top covering or extra coating of the joint surface when crystals are deposited in the hyaline cartilage. Ultrasound studies do not replace fluid removal and examination under a microscope because ultrasound does not confirm infection.

The diagnosis must rule out the presence of infection, which can be a hidden problem. Your doctor may also get a blood test to look at the levels of uric acid. However, uric acid levels rise and fall depending on many complex factors in your body. It is possible to have a normal uric acid level while you are having severe gout pain.

If you have tophi, your doctor may want to biopsy one of the lumps.

Your doctor will need to rule out other forms of arthritis. Gout can occur with other forms of arthritis, such as septic arthritis and rheumatoid arthritis. There are also other diseases that cause different kinds of crystals to form in the synovial fluid.

X-rays don’t show doctors much in the early stages of gout. X-rays can help monitor your disease, and they may be needed to rule out other problems.

Treatment

What can be done for the condition?

Gout cannot be cured, but it can be very successfully treated. The main goal of treating gout is to reduce the amount of urate in your blood. Joint crystals will not dissolve or go away unless the serum urate concentration is below six mg/dL.

During the acute or early phase of a gouty attack, doctors prescribe medicines called colchicine, certain nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids to decrease swelling and relieve pain. All of these drugs work quickly and are very effective. The sooner they are given after an attack starts, the faster the pain goes away. These drugs may be given by mouth, through an intravenous line into your bloodstream, or injected directly into the joint. There are some potential adverse side effects of these medications. It may take a bit of time to find the most effective drug with the least intolerable side effects for some patients. But it is important to start treatment during the first few days of an attack to get the best results.

Your doctor may also decompress the affected joint. Aspiration of synovial fluid immediately decreases the pressure in the joint. And the needle leaves a pathway or track that acts as a vent for continued drainage after the needle is removed.

Lifestyle changes can help you manage intermittent gout without using drugs every day. Your doctor may ask you to do the following:

• Change your diet. Diets that are lower in meat, shellfish, and some other foods can help decrease the amount of uric acid in your body. Avoid fructose sweetened foods and beverages.
• Quit taking drugs such as diuretics.
• Lose weight.
• Quit drinking alcohol.
• Avoid activities that stress your joints.
• Drink plenty of fluids to help your kidneys work more efficiently.

If your gout is severe, prolonged, or chronic, you may need to take daily serum uric acid-lowering (SUA) medication to reduce your uric acid levels. Your doctor will put you on the lowest dose possible of medications such as uricosuric drugs or xanthine oxidase inhibitors. Doctors usually prescribe allopurinol (Zyloprim, a xanthine oxidase inhibitor) for patients who overproduce urates or have tophi, kidney disease, or kidney stones. Allopurinol is useful in preventing recurrence of gouty attacks. It blocks the production of uric acid and decreases the formation of purine. For patients who have difficulty getting rid of uric acid through the kidneys, medications to help the kidneys remove more uric acid from the blood may be prescribed as well. Probenecid is one of the commonly prescribed drugs that increase the removal of uric acid in the urine.

Another, serum uric acid-lowering (SUA) medications that has been shown to
reduce the risk of occurrence is Uloric (Febuxostat). Febuxostat has been approved by the FDA for patients with mild to moderate kidney disease. It lowers uric acid slowly enough to avoid flaring up the gout. It isn’t processed by the kidney, so it’s possible patients with kidney disease may be able to take it. But it is metabolized by the liver. Anyone with a liver problem or who abuses alcohol may not be able to take this drug.

As with all medications, you should report any side effects to your doctor right away. Watch for skin rashes, itching, fever, nausea, vomiting, diarrhea, or other new symptoms not present before taking the serum uric acid medications.

Sometimes patients experience a flare-up after taking urate-lowering agents. This reaction can come as a surprise, since you expect your pain and swelling to get better. Flares of this kind mean that old deposits of crystals stored in the tissues are being released. The increase in symptoms is not a sign that new crystals are forming. Don’t stop taking your medication without first checking with your doctor. Getting rid of the old crystals can help protect the joint from further damage.

Doctors seldom treat hyperuricemia without symptoms of gout. However, if hyperuricemia is at least moderately bad over several years, it is more likely to lead to gout. In this case, a doctor may begin treatments to prevent gout. This is called prophylaxis.

A program to control uric acid levels and manage symptoms often includes daily colchicine and allopurinol or probenecid (usually both are not taken at the same time) along with dietary restrictions. Regular follow-up with your physician and blood tests to detect serum uric acid concentration that are above the six mg/dL target level are important in maintaining good control and preventing joint erosion.

So far, there are no drug treatments to prevent the formation and deposit of these crystals in the joints. Researchers continue to look for pharmacological and other biologic therapies that might prevent, if not cure, gout for those who suffer from symptomatic outbreaks.

A Patient’s Guide to Arthritis

What Is Arthritis?

Arthritis means inflammation of the joints. Inflammation generally includes symptoms of redness, heat, swelling, and pain. Many different diseases can result in inflammation of the joints. Arthritis is therefore a general term that describes more than one hundred different diseases of the joints of your body.

In some types of arthritis, the cause of the disease is known, but in others it is still unknown. Some types of arthritis come on suddenly, and others develop slowly. Any joint can be affected, including your knees, hips, neck, shoulders, and fingers.

The diseases that cause arthritis can also attack muscle and connective tissue around joints. Some diseases may even damage other organs of the body, such as the kidneys, intestines, and heart. Because the diseases inflame the joints, most arthritic conditions and related diseases involve chronic (long-term) pain. Over time, they may cause increasing damage to the joints or soft tissues of your body.

Your joints are beautifully designed to minimize stress and damage while you move. Nearly all joints of the body are synovial joints. Most synovial joints occur where two bones come together and must rub against one another to allow motion. Smooth, slick articular cartilage covers the end of the bones so they don’t rub together. Synovial fluid lubricates the joint. Around the joint, connective tissue forms a watertight sack that is called the joint capsule. Small, fluid-filled sacks, called bursae, cushion parts of the joint. Ligaments connect the bones together and tendons connect the muscles to bones. A problem with any one of these parts can lead to joint pain and inflammation–arthritis.

Many people of all ages suffer from arthritis. It is estimated that forty million Americans–that’s one in seven of us–have arthritis. Almost two-thirds of arthritis patients are women, but for some types of arthritis most sufferers are men.

Arthritis and related diseases are often painful to live with and difficult to treat. But your doctor can help you find treatment and pain management strategies that work for you. The method of treatment will vary depending on the specific disease.

A Patient’s Guide to Fibromyalgia

Introduction

Fibromyalgia, a common painful disorder among women in their middle years (40 to 60 years old) is no longer considered a “disease” but rather a syndrome. The term “syndrome” is used to represent a group of symptoms that tend to occur together either at the same time or in close proximity to one another. Sometimes fibromyalgia is referred to as fibromyalgia syndrome (FMS).

The most common symptom is widespread pain throughout the body, with especially tender spots near certain joints. The pain stops people with fibromyalgia from functioning normally, partly because they feel exhausted most of the time. Fibromyalgia is a chronic (meaning long-lasting) condition that usually requires many years of treatment. It can occur along with other forms of arthritis or all by itself. It can occur after an injury or out of the blue.

This guide will help you understand

• how doctors diagnose fibromyalgia
• what can be done for the condition

Anatomy

Where does fibromyalgia develop?

Pain in fibromyalgia is present in soft tissues throughout the body. Pain and stiffness concentrate in spots such as the neck, chest, shoulders, elbows, knees, buttocks, and lower back. The tender spots don’t seem to be inflamed. Most tests show nothing out of the ordinary in the anatomy of people with fibromyalgia.

Causes

Why does fibromyalgia develop?

The causes of fibromyalgia are unknown, but one thing is for sure: you’re not making it up. Many sufferers have been told that it’s all in your head by family members or other doctors. It is true that people with fibromyalgia are often depressed, and that stress worsens symptoms. But depression and stress don’t seem to be the driving forces behind the disease.

Scientists haven’t been able to unlock all of the secrets behind fibromyalgia syndrome (FMS). Right now, the main theory is that FMS occurs when something goes hay wire in the nervous system. That something may be what’s called central sensitization syndrome. It means your nervous system is ramped up to react too soon, too often, and for too long.

With a dysregulation of the central nervous system like this, there appears to be some kind of mistake within the nervous system in how it recognizes and transmits pain messages. Somehow, the nervous system seems to think even the simplest touch is a noxious (painful) stimuli.

Nervous system dysregulation of this type is likely caused by biochemical abnormalities, altered brain blood flow, and problems with the pain processing mechanisms. Sufferers have lower pain thresholds and lower levels of serotonin, a brain chemical involved in pain, sleep, and mood.

Sometimes FMS occurs as a result of an injury or some other medical condition. For example, patients with rheumatoid arthritis or Lyme disease (inflammatory diseases), metabolic dysfunction (e.g., thyroid problems), or cancer often develop a type of FMS referred to as reactive fibromyalgia. It’s important to identify whether or not the FMS is primary (the main problem) or secondary (caused by other problems).

Folks who have fibromyalgia syndrome (FMS) often have certain triggers that seem to bring on (or increase) symptoms. The triggers vary from person to person but may include degenerative (spinal) disc disease, headaches (all kinds), irritable bowel syndrome, reflux (heart burn), trigger points of the muscles, and poor posture. Anxiety, depression, and post-traumatic stress disorder also seem to be linked with FMS. Having a bipolar illness increases the risk of developing fibromyalgia syndrome (FMS) dramatically.

About 80 percent of all fibromyalgia patients report serious problems sleeping. Because fibromyalgia is so strongly connected to sleep disturbance, in some cases it is possible that the sleep disturbance may be a major contributing factor. In fact, studies have produced fibromyalgia-like symptoms in healthy adults by disrupting their sleep patterns.

New evidence suggests that fibromyalgia is really caused by a dysregulation of the central nervous system. There appears to be some kind of mistake within the nervous system in how it recognizes and transmits pain messages. Somehow, the nervous system seems to think even the simplest touch is a noxious (painful) stimuli. It’s like a ten-alarm fire signal is sent to the brain when a breeze blows by the barn. Nervous system dysregulation of this type is likely caused by biochemical abnormalities, altered brain blood flow, and problems with the pain processing mechanisms. Sufferers have lower pain thresholds and lower levels of serotonin, a brain chemical involved in pain, sleep, and mood.

Symptoms

What does fibromyalgia feel like?

The symptoms of fibromyalgia are long lasting and intense. However, they can vary from day to day. Some of the most common symptoms include

• pain and stiffness throughout the body, with especially tender points along the back of the neck, top of the shoulders, center of the chest, elbows, knees, low back, and buttocks
• a feeling of exhaustion that sleep often does not help
• sleep problems
• tension headaches
• numbness or tingling in the arms and hands
• a feeling of swelling in the hands, although this is not confirmed in physical exams
• constipation and diarrhea along with abdominal pain (known as irritable bowel syndrome)
• intense PMS pains in women
• depression

Diagnosis

How do doctors identify fibromyalgia?

Blood tests and X-rays don’t show fibromyalgia in your body. However, your doctor may do these tests to rule out other conditions. Doctors have only two tools to diagnose fibromyalgia. One is your history of symptoms. The other involves putting pressure on eighteen tender point sites. If you feel pain in eleven of these eighteen sites, you are considered to have fibromyalgia. (However, it is still possible that you can have the disease with pain in fewer sites.)

In some patients, doctors may recommend X-rays to look at the bones near painful spots. The X-rays will not show fibromyalgia but are used to make sure there are no other causes of your pain. Other special tests such as electromyograms, which measure the contraction of muscles, may be used to try to determine if the muscles show abnormalities. Most of the time these tests are negative. A sleep history, and possibly a sleep study, could be important to the diagnosis.

Other conditions can occur along with fibromyalgia that can confound the diagnosis. In some cases, other problems such as Lyme disease, Epstein-Barr virus, viral hepatitis, HIV infection, and thyroid problems mimic fibromyalgia making the diagnosis more difficult. Chronic fatigue syndrome (CFS) may need to be ruled out. CFS is another disease that is difficult to diagnose and has puzzled doctors for many years. CFS and fibromyalgia share many symptoms, especially the severe exhaustion. The major difference is that CFS causes flu-like symptoms, such as low-grade fevers, sore throats, and swollen lymph nodes.

Treatment

What can be done for the condition?

There have been some significant breakthroughs in our understanding (and therefore treatment) of fibromyalgia syndrome (FMS). Today’s modern approach is multimodal, meaning many different treatment options are pursued at the same time. Combining medications with exercise, behavioral counseling, and alternative medicine have made it possible to live a more normal life for those who suffer with this condition.

Usually the first step in the treatment of fibromyalgia is to help patients understand this complex and frustrating disease. Many patients are relieved to learn that the disease is not all in their head. After that, the task is to manage the pain and exhaustion.

Until the exact pathologic pathways are understood, treatment will be more of a management approach. The first-line treatment for fibromyalgia includes medications and a variety of other nonpharmacologic (nondrug) treatment. There isn’t one magic pill patients can take to wipe away the pain, improve sleep, or restore energy. Instead, a wide range of medications are available that can act on the nervous system in a variety of ways. These include tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), selective serotonin-norepinephrine reuptake inhibitors (SSNRIs), and anticonvulsants (also known as antiepileptics).

And for the first time, there are some medications now FDA approved from these categories specifically for fibromyalgia (e.g., pregabalin, duloxetine, milnacipran). In the past, many of the medications were used off-label. This means the medications were intended for something else (like seizures or depression) but were found to be effective for fibromyalgia.

Two of these drugs (duloxetine and milnacipran) are antidepressants. Studies have shown that these medications don’t work because they improve the person’s mood (reduce depression). The chemical pathway of the drug seems to impact pain signals directly.

Neither one of these drugs seems to improve sleep. They do improve energy levels, physical functioning, and cognitive function — probably because they reduce pain, a symptom that can bring a person down in all these areas.

Pain relievers, whether over the counter or prescription, are generally not effective by themselves. Many pain medications are addictive and should be used with caution. Mild pain medications may help in combination with other treatments. Opioid (narcotic) pain relievers, corticosteroids,and nonsteroidal antiinflammatories (NSAIDs) are no longer recommended.

Like many chronic diseases, the symptoms of the disease can be controlled or managed. The successful treatment of fibromyalgia is very much a joint effort between doctor and patient. You must be willing to make lifestyle changes as well as give attention to your psychological health to help control the symptoms. Other treatments or lifestyle changes your doctor may recommend include

• exercise (aerobic and strength training)
• biofeedback
• electrical stimulation
• electromagnetic wave tharapy
• nutritional counseling
• meditation
• acupuncture, trigger point injection
• hypnosis
• pain medication
• massage
• heat for temporary pain relief
• behavioral cognitive therapy

All of the research so far confirms the need to treat this problem with a multidisciplinary approach. A multidisciplinary team of professionals includes doctors, nurses, physical therapists, psychologists, pharmacists, nutritionists, and other practitioners in the healing arts.

You’ll notice that exercise is listed first in the list above. That’s because there is a lot of evidence from good scientific studies that any form of exercise but especially isometrics (contract, hold, relax individual muscles) can be helpful. Pilates-based stretching, yoga, and low-impact aerobic exercise have the greatest benefit.

Anyone with fibromyalgia syndrome (FMS) must be very careful when trying weight-lifting, rowing, or jogging. In fact, these are not really recommended during painful flare-ups. Many people with FMS don’t have any real trouble during exercise. It’s the painful joint and muscle “after shock” that is the worst. Some can barely get out of bed the next day after what seems like a mildly strenuous work out.

That’s why it’s important to have a physical therapist evaluate you and prescribe the optimal mode (type), frequency, intensity, and duration of exercise on an individual basis. There isn’t a one-size-fits-all type of program because of the wide range of physical abilities and disabilities among adults with this condition.

Patients must learn as much as they can both about this condition as well as about themselves and what works best for them. That’s easier said than done. Many times the pain and fatigue keep patients from getting the exercise they need. They become deconditioned and weak, which adds to their pain and loss of function.

This is another place where medications can be very helpful. Medications can help get the pain under control so that the person can move and exercise again. Sometimes several medications are combined to get the most relief of symptoms with the fewest adverse effects. Some medications address the pain or sleep issues, while others deal with the anxiety, depression, or other psychologic disorders.

Early recognition, diagnosis, and treatment can provide a faster resolution of symptoms and much improved prognosis. Reducing and managing symptoms, improving quality of life, and decreasing distress are reasonable goals. But the patient must understand that at the present time, there is no one-best treatment that works for everyone with fibromyalgia. In the ideal plan, the patient is really the manager who consults with these other experts to formulate the most effective plan. Treatment (or more accurately, the management plan) will likely last for many years.

Patients do get better. In the ideal plan, the patient is really the manager who consults with these other experts to formulate the most effective plan. In fact, there is new evidence that half of all adults diagnosed with fibromyalgia early in the development of their disease (and who are adequately treated) no longer have this problem two years later. Many others have reduced their pain to tolerable levels.