General Orthopedics

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 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 Rheumatoid Arthritis

Introduction

Rheumatoid arthritis (RA) is a chronic, or long-term, inflammatory form of arthritis. RA is considered an autoimmune disease, in which your immune system attacks the tissues of your own body. In RA, the immune system mostly attacks tissues in the joints, but it can also affect other organs of your body. In some people, RA seems to run its course more or less by itself. In others, RA gets progressively worse and leads to the destruction of joints. RA can greatly affect your ability to move and do normal tasks. RA can appear at any age, but most patients are between the ages of 30 and 50. About two million Americans have RA, and most of them are women.

This guide will help you understand

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

Anatomy

Where does RA develop?

In RA, two things are happening in the joints. First, the immune system causes inflammation in the synovial membrane, called synovitis. The synovial membrane is the thin tissue that lines the inside of all joints. At first this causes extra fluid, swelling, and oozing clots in the joint. The pain and swelling of synovitis can be reversed.

Second, the synovitis itself causes other problems in the joint. The blood cells and the swollen membranes release chemicals into the synovial fluid (the lubricating fluid of the joint) that can break down or damage the tissues of the joint. This breakdown can cause permanent damage to the cartilage, bone, ligaments, and tendons inside and around the joint. The structural damage usually happens in the first to third year of the disease. The synovitis can come and go, but the structural damage progresses. As a result, the joint becomes painful and very difficult to move.

RA usually affects many corresponding joints on both sides of body. (For example, both knees, both ankles, both wrists, and the same joints in both hands may be affected.) Research indicates that almost all the joints that will be affected show symptoms of RA in the first year of the disease. This means that each joint may continue to get worse, but you probably won’t have many more joints that will develop the symptoms of RA.

Most RA patients have inflammation in the tendons around the joint. (Tendons connect muscle to bone.) Nodules, or bumps, may form on the tendons, or the tendon sheath (the membrane that surrounds the tendon) may become inflamed. Inflammation can also occur in other parts of the body, like the lungs. In general, inflammation refers to symptoms of swelling, redness, heat, and pain.

Most people think of RA as a disease of the joints, but it is actually a systemic disease–it affects the whole body. That means that RA can show up in other organs, too, such as the heart, blood vessels, lungs, and eyes. Sometimes RA occurs in joints and other organs, and sometimes it occurs only in other organs. RA works somewhat differently outside the joints, but the underlying problems are still damage to the tissue and loss of function.

Causes

Why do I have this problem?

No one knows exactly what causes RA. There are probably different causes in different people. Many doctors and researchers think that a virus or bacteria might cause RA. So far studies haven’t proved this. However, researchers do know that bacteria can cause swelling in the synovial membrane.

Heredity–your genes–plays a part in RA. The disease tends to run in families. If a close relative has RA, you are 16 times more likely to develop the disease yourself.

Symptoms

What does RA feel like?

The primary symptom of RA is pain in corresponding joints (both elbows, both knees, and so on). In rare cases the pain is only in one joint. Most often the pain develops over several weeks. But the pain can come on suddenly. As the pain spreads to other joints, it becomes more symmetrical, meaning that it shows up in the same places on both sides of your body. The pain is directly related to the amount of swelling in the synovial membranes. When the swelling is at its worst, your joints themselves will feel warm and swollen. The pain can come and go with the swelling.

RA patients also describe severe morning stiffness that can last up to two hours. The stiffness can be so bad that it makes it hard for you to get dressed, make breakfast, or even get out of bed. This stiffness also corresponds to the synovitis. When the synovitis goes away for a time, so does the stiffness.

About half of RA patients have rheumatoid nodules. The nodules are hard knots, from the size of a pea to the size of a golf ball, that grow under the skin in three distinct layers. They are usually found on the outside of the elbow, the Achilles tendon on your heel, the underside of your fingers, the lower abdomen, and certain toe joints. They look like the kind of bump that grows around a splinter. They don’t usually hurt. Over time they tend to shrink or disappear.

Because RA is a systemic disease, most patients feel tired and weak during flare-ups. In patients who test positive for rheumatoid factor (RF) in their blood, other organ systems can also become inflamed when the joints do. About 50 percent of RA patients have systemic inflammation during joint outbreaks of RA.

Conjunctivitis, or inflammation of the eye, is common. It may be related to a disease of the eye called Sjogren’s syndrome, which often occurs along with RA. The main symptom is eye dryness, but patients often can’t even feel it.

RA can affect the lungs. Occasionally it can cause an inflammation of the membrane that surrounds the lungs (called the pleura), which causes pain in the side and sometimes coughing and problems breathing deeply.

RA commonly affects the nervous system, but it can be hard to tell from other symptoms of RA. Damage to the joints in the cervical spine (the neck) can eventually lead to weakness and instability between the cervical vertebrae. This damage can cause problems with the spinal cord as it travels through the neck.

Some symptoms depend on the affected joints:

• Cervical spine (the neck): Symptoms include neck stiffness, weakness, and loss of motion. Other symptoms often can’t be felt or seen in exams. Ligaments are often inflamed, and there may be problems with the spinal cord or nervous system. Neck pain alone tends to get better, even when the joints are damaged. Damage to the nervous system does not usually improve.
• Shoulders: The main symptom is loss of motion. Your body’s unconscious reaction to shoulder pain is simply not to use your shoulders. Since daily life doesn’t require much shoulder use, frozen shoulder syndrome can set in quickly.
• Hands and wrists: Almost everyone with RA has affected wrists. Joints in the middle of your hand and fingers are usually affected. The knuckles at the ends of your fingers usually are not. RA can cause joint deformities that freeze your fingers in unusual positions. Rheumatoid nodules and tendon inflammation can make it hard to bend the fingers. Nodules can cause a locking and catching action as your fingers bend.
• Knees: It is easy to feel the swelling in the knees. A fluid-filled lump called a Baker’s cyst often appears behind the knee. It can burst and leak fluid into the calf.
• Feet and ankles: RA commonly affects the joints in the middle of the toes and the ankle joints. The deformities and pain in the toes can cause problems with walking. The sole of the foot can feel tingly or numb.

The progression of RA is hard to predict. The swelling of RA flares up and dies down, and milder forms of the disease often don’t require much treatment. Mild RA may even go undiagnosed.

Diagnosis

How do doctors identify RA?

No single test can confirm a diagnosis of RA. Many findings over a period of time lead to the diagnosis. In fact, your doctor can’t even positively diagnose RA until you’ve had symptoms for at least several weeks. Early on, many characteristics of RA haven’t developed yet, such as the pattern of joints that are affected, X-ray findings, and blood test changes. And RA in its early stages can look a lot like other forms of arthritis, such as lupus, psoriatic arthritis, and diseases of the spine. Your doctor will need to consider each of these diagnoses and perhaps do tests to rule them out.

Your doctor will start with a detailed health history. You will need to describe your pain and be very specific about where your pain is located and when it came on. You will also need to tell your doctor about any other medical conditions you have had and drugs you are taking. Even if these other conditions are not related to your joint pain, your doctor will need to know these things to help you find effective treatment. Your doctor will also examine your joints closely. Your doctor will be looking for bone-on-bone crepitus, a high-pitched screech that you can feel or hear in the joint. It is the sound of bone rubbing on bone, and nothing else makes this sound.

Every patient with RA has inflammation of the synovial membranes. Your doctor can confirm this by checking the count of white blood cells (WBC) in your synovial fluid. This involves inserting a thin needle into your joint and drawing out a small amount of the fluid for testing. The fluid can also be tested for other things. The WBC alone doesn’t prove that you have RA. Your doctor will need to rule out other causes of synovitis.

Your doctor will also ask you to undergo a blood test. RF, or rheumatoid factor, is found in the blood of about 85 percent of RA patients. But this test alone can’t confirm RA either. Some patients with RA do not have RF, and people with RF can have other forms of arthritis.

Another blood test is the erythrocyte sedimentation rate (ESR, or sed rate), which measures how fast red blood cells settle in the test tube. Red blood cells that settle faster than normal indicate inflammation in the body. But the ESR varies greatly between people. It is even possible for a patient with RA to have a normal ESR. The ESR may be more useful in monitoring the progress of your disease than in diagnosing it. A higher ESR usually means that the inflammation is more severe.

The C-reactive protein test can also monitor inflammation. It is a newer test that may be more accurate than the ESR. This test measures the amount of a certain protein that is produced by the body due to inflammation. When inflammation is very active the amount of C-reactive protein is high, and when inflammation is brought under control the level of protein decreases.

At some point your doctor will probably ask you to get X-rays of your affected joints and organs. X-rays and other imaging techniques can show damage to the cartilage and bone and the swelling in the soft tissues of the joint.

In some cases your doctor may want to biopsy the rheumatoid nodules. A small amount of the nodule is removed and examined in a laboratory.

Treatment

What can be done for the condition?

Doctors have learned much about RA in recent years, but they still don’t know much more about how to truly cure the disease. They do have many strategies for treating the symptoms of RA. If you start treatment within a few months after your symptoms appear, the better you will probably do in the long-term. Early detection and treatment can help avoid the worst joint damage. Sudden remission does occur, but it’s unclear how often, and it appears to be more likely within the first two years of the disease. Patients who develop RA at a young age, are RF positive, have close relatives with RA, and have RA nodules tend to have a more difficult time managing the disease.

Your doctor will prescribe one or more medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, can help decrease the pain and swelling. Corticosteroids taken by mouth can also help with inflammation. Because steroid use can cause other problems in your body, they are usually not be used over long periods of time, if at all possible. Corticosteroid injections into the affected joints can ease the swelling and give you immediate, short-term relief. And your doctor may prescribe eye medications, even if you have no eye symptoms. Because eye inflammation is so common with RA and is hard to diagnose, the eye drops can help prevent it from developing or becoming severe.

Disease-modifying antirheumatic drugs (DMARDs) are important in treating RA. No one is sure exactly how well DMARDs actually slow or prevent the structural damage from RA. However, tests have shown all DMARDs to be effective for at least one year of treatment.

DMARDs can be very hard on your body and can interact with other drugs, so it is not always easy to find the best medication for you. Often more than one drug is taken at the same time. Several DMARDs are frequently prescribed:

• Hydroxychloroquine is a relatively nontoxic drug that was made to treat malaria. It can be safely used with other DMARDs. It is most useful in early, mild RA. You should get regular eye check-ups while taking this drug.
• Sulfasalazine is much like hydroxychloroquine. This drug requires regular blood monitoring.
• Gold salts can cause short-term remissions. Over the long-term, however, the RA does progress. Blood and urine monitoring is required.
• Methotrexate can help manage RA, but it is unclear how much it actually changes the course of the disease. Methotrexate can be very useful over the long-term, but there are problems with flare-ups when patients stop taking it.
• Azathioprine is used with moderate and severe RA.
• Penicillamine is only used in patients who have systemic disease that doesn’t respond well to other medications.
• Cyclosporine is expensive and hard on the kidneys, so it is most often used in severe RA.
• Cyclophosphamide is very effective but very toxic, so it is only used in specific cases.
• Certain antibiotics are somewhat effective in mild cases.

Combining methotrexate with another drug to get the desired results (decreased joint pain, swelling, and stiffness) is a popular and effective strategy for many patients. One group of disease modifying medications used along with methotrexate is called anti-tumor necrosis factor (TNF) agents.

Another term for the anti-TNF agents is TNF inhibitors. These are a special type of antibody also 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.

Anyone taking tumor necrosis inhibitors must be careful to report any signs of infection to the physician right away. There have been reports of deaths possibly associated with unrecognized or untreated infections in patients taking these immune suppressing drugs.

Symptoms of infection anywhere but commonly affecting skin, lungs, or urinary tract include fever, chills, fatigue, enlarged lymph nodes, skin rash or red streaks, cough, and/or sore throat. Upset stomach, painful urination or blood in the urine or stools are additional important symptoms that could be a signal of infection and should be reported to the physician as well.

In general, your doctor may recommend some of the following treatments that will require some effort and lifestyle changes from you:

• Patient education. RA is a frustrating and complex disease. The more you understand it, the better you can help treat your own symptoms and prevent flare-ups.
• Range-of-motion and strengthening exercises. These will most often be designed and monitored by a physical or occupational therapist.
• Equipment and gadgets, such as canes and jar openers that can help you go about your daily business without putting too much stress on affected joints.
• Gentle aerobic exercise.
• Support groups.

At least half of RA patients don’t find much relief from treatment and eventually need surgery on the affected joints. Surgery, including total joint replacement, can be a very effective way to help you overcome the pain and loss of movement of RA.

For most patients, RA is a disease that comes and goes throughout their lives. But it doesn’t have to be crippling. With your doctor’s help, you should be able to find treatment that works for you.

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.