Joint Injections for Arthritis

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.

Systemic Lupus Erythematosus

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

Systemic Lupus Erythematosus

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.

Lyme Disease

A Patient’s Guide to Lyme Disease

Introduction

Lyme Disease Lyme disease is an inflammatory disease caused by tick bites. It is the most common tick-borne disease in North America, Europe, and Asia. Connecticut has the highest annual rate of new cases of Lyme disease each year. The name Lyme disease was used because of the number of children in Lyme, Connecticut who first developed this problem back in the late 1970s.

More than 90 percent of the Lyme disease cases in the United States continue to occur in Connecticut and nine other states including New York, New Jersey, Rhode Island, Massachusetts, Pennsylvania, Wisconsin, Delaware, Maryland, and Minnesota.

It is possible to visit these areas and have the infection show up later, when you are back home. And although children between the ages of five and nine seem to be affected most often, adults between the ages of 55 and 59 seem to have a peak incidence as well. The summer months are the peak time when infection may occur, but cases have been reported in all 50 states year-round.

This guide will help you understand

  • how Lyme disease develops
  • how doctors diagnose the condition
  • what treatments are available

Anatomy

What parts of the body are affected?

Lyme disease can cause inflammation in many systems of the body if left untreated. It mostly affects the skin, joints, the heart, and the nervous system. When the joints are affected, the knee is involved most often. Lyme-associated arthritis has also been reported in the shoulder, elbow, hip, and ankle.

Causes

Why do I have this problem?

Lyme disease is caused by Borrelia burgdorferi, a spiral-shaped organism transmitted through the bite of an infected tick. The human body mounts a reaction to the infecting organism that triggers production of inflammatory agents throughout the body. These inflammatory agents are the chemicals produced by the body’s immune system that normally fight off infection.

Symptoms

What does Lyme disease feel like?

Doctors divide the symptoms of Lyme disease into three phases: early localized, early disseminated, and late disease. The three phases of symptoms can overlap. Many patients never show early symptoms at all.

Early localized disease refers to a red rash in the area of the tick bite. This rash shows up two to 30 days after the tick bite. The bite itself is usually found near the waist or belt line, or in other warm, moist areas of the body. In children, the rash is seen first on the head and neck, arms and legs, or back and less often on the abdomen, groin, or chest. The bite may burn, itch, or hurt. The rash usually grows over a period of days. The rash may be in a bulls-eye pattern, red with a white spot in the middle, or completely red.

Most patients with early localized Lyme disease also complain of flu-like symptoms, such as headaches, fatigue, and muscle and joint pain.

Early disseminated disease shows up days to months after the tick bite. Patients may not remember any rashes or bites. The most common symptoms of early disseminated disease are cardiac and nervous system problems. About eight percent of patients who have the rash and are not treated with antibiotics develop heart problems referred to as Lyme carditis. Heart effects include heart blockage and weakening of the heart muscle. The patient may experience dizziness, fainting, fatigue, shortness of breath, and/or heart palpitations. Most of the time, the heart symptoms clear up on their own or after treatment.

About ten percent of patients who don’t receive antibiotics develop damage to the nervous system. Neurologic symptoms also tend to go away on their own, but very slowly. These neurologic symptoms can include meningitis and headaches. Individual nerves can be affected causing numbness, weakness, and pain in the areas the damaged nerve travels.

Late disease symptoms develop months or even years after the tick bite. Some patients who have late disease symptoms have never had any other symptoms of Lyme disease. Late disease causes arthritis pain that comes and goes in many joints. About ten percent of people with late Lyme disease develop chronic (long-lasting) arthritis of one knee. Other joints can be affected (e.g., hip, shoulder, elbow, ankle) but the number of patients with other joint involvement is considerably less.

Many patients who have had Lyme disease describe headaches, fatigue, and joint pain that can last for months after treatment. These problems generally go away without any extra treatment, but very slowly.

Diagnosis

How do doctors identify the condition?

Doctors diagnose Lyme disease based on your health history and a physical exam. Your doctor may order blood tests, but they are only used to confirm the diagnosis. The techniques used to test your blood are called ELISA and Western blot. Both tests can sometimes give false positive or unclear results. If you have had the infection for less than six weeks, your body may not even be making enough antibodies to be detected in the tests.

Lyme disease affecting the knee must be differentiated from septic (infectious) arthritis, which has both a different cause and a different treatment. The two distinguishing features of septic knee arthritis that set it apart from Lyme knee arthritis are refusal to put weight on the knee and fever (more then 101.5 degrees Fahrenheit). Patients with Lyme disease may have a low-grade fever and pain on weight-bearing but do not exhibit the high fever and refusal to put weight on the affected leg observed more often with septic knee arthritis.

When trying to rule out septic arthritis, the synovial fluid (the lubricating fluid of a joint) or spinal fluid may need to be analyzed. Studies show that patients with septic (infectious) knee arthritis are 3.6 times more likely to have a high synovial fluid cell count compared with patients with Lyme disease. But some patients with Lyme disease have elevated synovial fluid cell count, too so this test is just one of many tools used to diagnose the problem. The fluid can also be cultured to identify the presence of bacteria such as staphylococcus aureus (staph infection), streptococcus pneumonia (strep infection), or other less common types of bacterial infections. Bacteria associated with septic arthritis help rule out a diagnosis of Lyme disease.

Treatment Options

What can be done for Lyme disease?

Two to four weeks of antibiotics almost always cures Lyme disease. Early treatment usually prevents later heart, nerve, and joint symptoms. If you have symptoms of early disseminated or late disease, your doctor will probably start you on intravenous (IV) antibiotics.

In a small number of cases, it may be necessary to surgically drain the joint of fluid. This is especially true if there is a suspicion of septic arthritis that cannot be confirmed or differentiated from Lyme disease. In cases of true Lyme joint disease that does not respond to medical treatment, the surgeon may have to remove some of the damaged joint synovium. The procedure is called a synovectomy.

Headaches, fatigue, and muscle and joint pain may continue for months after finishing the antibiotics. Neurologic damage may take even longer to go away, as the nervous system regenerates only one or two millimeters each day. This does not mean that you need more antibiotics. Your body just needs more time to heal. If the antibiotics do not help your symptoms at all, you and your doctor should consider that Lyme disease may not be the cause of your symptoms and look for other possible causes.

The risk of getting Lyme disease is very small, even if a tick has bitten you. Doctors do not treat you just in case. You must show symptoms.

The best treatment for Lyme disease is prevention. Check for ticks at the end of a day outdoors. Wear light clothes so you can see ticks. Wear long clothing, and tuck your pants into your socks. And finally, use a bug spray that contains DEET (a chemical used in some types of insect repellents) to keep the ticks away.

Osteoarthritis

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?

Osteoarthritis

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

Osteoarthritis

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.