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Questions and Answers
- Features of Rheumatoid Arthritis
- How Rheumatoid Arthritis Develops and Progresses
- Occurrence and Impact of Rheumatoid Arthritis
- Searching for the Cause of Rheumatoid Arthritis
- Diagnosing and Treating Rheumatoid Arthritis
- Current Research
- Hope for the Future
- What Are the Treatments?
- For More Information
1. Features of Rheumatoid Arthritis (
top )
Rheumatoid arthritis is an inflammatory disease that causes pain, swelling, stiffness, and loss of function in the joints. It has several special features that make it different from other kinds of arthritis (see information box below). For example, rheumatoid arthritis generally occurs in a symmetrical pattern. This means that if one knee or hand is involved, the other one is also. The disease often affects the wrist joints and the finger joints closest to the hand. It can also affect other parts of the body besides the joints (see illustrations below). In addition, people with the disease may have fatigue, occasional fever, and a general sense of not feeling well (malaise).
Another feature of rheumatoid arthritis is that it varies a lot from person to person. For some people, it lasts only a few months or a year or two and goes away without causing any noticeable damage. Other people have mild or moderate disease, with periods of worsening symptoms, called flares, and periods in which they feel better, called remissions. Still others have severe disease that is active most of the time, lasts for many years, and leads to serious joint damage and disability.
Although rheumatoid arthritis can have serious effects on a person's life and well-being, current treatment strategies--including pain relief and other medications, a balance between rest and exercise, and patient education and support programs--allow most people with the disease to lead active and productive lives. In recent years, research has led to a new understanding of rheumatoid arthritis and has increased the likelihood that, in time, researchers can find ways to greatly reduce the impact of this disease.
Features of Rheumatoid Arthritis
Tender, warm, swollen joints.
Symmetrical pattern. For example, if one knee is affected, the other one is also.
Joint inflammation often affecting the wrist and finger joints closest to the hand; other affected joints can include those of the neck, shoulders, elbows, hips, knees, ankles, and feet.
Fatigue, occasional fever, a general sense of not feeling well (malaise).
Pain and stiffness lasting for more than 30 minutes in the morning or after a long rest.
Symptoms that can last for many years.
Symptoms in other parts of the body besides the joints.
Variability of symptoms among people with the disease.
2. How Rheumatoid Arthritis Develops and Progresses ( top )
The Joints
A normal joint (the place where two bones meet) is surrounded by a joint capsule that protects and supports it (see illustration below). Cartilage covers and cushions the ends of the two bones. The joint capsule is lined with a type of tissue called synovium, which produces synovial fluid. This clear fluid lubricates and nourishes the cartilage and bones inside the joint capsule.
In rheumatoid arthritis, the immune system, for unknown reasons, attacks the person’s own cells inside the joint capsule. White blood cells that are part of the normal immune system travel to the synovium and cause a reaction. This reaction, or inflammation, is called synovitis, and it results in the warmth, redness, swelling, and pain that are typical symptoms of rheumatoid arthritis. During the inflammation process, the cells of the synovium grow and divide abnormally, making the normally thin synovium thick and resulting in a joint that is swollen and puffy to the touch (see illustration).
As rheumatoid arthritis progresses, these abnormal synovial cells begin to invade and destroy the cartilage and bone within the joint. The surrounding muscles, ligaments, and tendons that support and stabilize the joint become weak and unable to work normally. All of these effects lead to the pain and deformities often seen in rheumatoid arthritis. Doctors studying rheumatoid arthritis now believe that damage to bones begins during the first year or two that a person has the disease. This is one reason early diagnosis and treatments are so important in the management of rheumatoid arthritis.
Healthy joint
Rheumatic joint
A joint, (the place where two bones meet), is surrounded by a capsule that protects and supports it. The joint capsule is lined with a type of tissue called synovium, which produces synovial fluid that lubricates and nourishes joint tissues. In rheumatoid arthritis, the synovium becomes inflamed, causing warmth, redness, swelling, and pain. As the disease progresses, abnormal synovial cells invade and erode, or destroy, cartilage and bone within the joint. Surrounding muscles, ligaments, and tendons become weakened. Rheumatoid arthritis can also cause more generalized bone loss that may lead to osteoporosis (fragile bones that are prone to fracture).
Other Parts of the Body
Some people also experience the effects of rheumatoid arthritis in places other than the joints. About one-quarter develop rheumatoid nodules. These are bumps under the skin that often form close to the joints. Many people with rheumatoid arthritis develop anemia, or a decrease in the normal number of red blood cells. Other effects, which occur less often, include neck pain and dry eyes and mouth. Very rarely, people may have inflammation of the blood vessels, the lining of the lungs, or the sac enclosing the heart.
3. Occurrence and Impact of Rheumatoid Arthritis ( top )
Scientists estimate that about 2.5 million people, or 1 percent of the North American adult population, have rheumatoid arthritis. Interestingly, some recent studies have suggested that the overall number of new cases of rheumatoid arthritis may actually be going down. Scientists are now investigating why this may be happening.
Rheumatoid arthritis occurs in all races and ethnic groups. Although the disease often begins in middle age and occurs with increased frequency in older people, children and young adults also develop it. Like some other forms of arthritis, rheumatoid arthritis occurs much more frequently in women than in men. About two to three times as many women as men have the disease.
By all measures, the financial and social impact of all types of arthritis, including rheumatoid arthritis, is substantial, both for the Nation and for individuals. From an economic standpoint, the medical and surgical treatment for rheumatoid arthritis and the wages lost because of disability caused by the disease add up to millions of dollars. Daily joint pain is an inevitable consequence of the disease, and most patients also experience some degree of depression, anxiety, and feelings of helplessness. In some cases, rheumatoid arthritis can interfere with a person's ability to carry out normal daily activities, limit job opportunities, or disrupt the joys and responsibilities of family life. However, there are arthritis self-management programs that help people cope with the pain and other effects of the disease and help them lead independent and productive lives. These programs are described later in the section Diagnosing and Treating Rheumatoid Arthritis.
4. Searching for the Cause of Rheumatoid Arthritis ( top )
Rheumatoid arthritis is one of several "autoimmune" diseases ("auto" means self), so-called because a person's immune system attacks his or her own body tissues. Scientists still do not know exactly what causes this to happen, but research over the last few years has begun to unravel the factors involved.
Genetic (inherited) factors: Scientists have found that certain genes that play a role in the immune system are associated with a tendency to develop rheumatoid arthritis. At the same time, some people with rheumatoid arthritis do not have these particular genes, and other people have these genes but never develop the disease. This suggests that a person's genetic makeup is an important part of the story but not the whole answer. It is clear, however, that more than one gene is involved in determining whether a person develops rheumatoid arthritis and, if so, how severe the disease will become.
Environmental factors: Many scientists think that something must occur to trigger the disease process in people whose genetic makeup makes them susceptible to rheumatoid arthritis. An infectious agent such as a virus or bacterium appears likely, but the exact agent is not yet known. Note, however, that rheumatoid arthritis is not contagious: A person cannot "catch" it from someone else.
Other factors: Some scientists also think that a variety of hormonal factors may be involved. These hormones, or possibly deficiencies or changes in certain hormones, may promote the development of rheumatoid arthritis in a genetically susceptible person who has been exposed to a triggering agent from the environment.
Even though all the answers aren't known, one thing is certain: Rheumatoid arthritis develops as a result of an interaction of many factors. Much research is going on now to understand these factors and how they work together (see the Current Research section).
5. Diagnosing and Treating Rheumatoid Arthritis ( top )
Diagnosing and treating rheumatoid arthritis is a team effort between the patient and several types of health care professionals. A person can go to his or her family doctor or internist or to a rheumatologist. A rheumatologist is a doctor who specializes in arthritis and other diseases of the joints, bones, and muscles. As treatment progresses, other professionals often help. These may include nurses, physical or occupational therapists, orthopedic surgeons, psychologists, and social workers.
Studies have shown that people who are well informed and participate actively in their own care experience less pain and make fewer visits to the doctor than do other people with rheumatoid arthritis.
Patient education and arthritis self-management programs, as well as support groups, help people to become better informed and to participate in their own care. An example of a self-management program is the arthritis self-help course offered by the Arthritis Foundation and developed at one of the NIAMS-supported Multipurpose Arthritis and Musculoskeletal Diseases Centers. Self-management programs teach about rheumatoid arthritis and its treatments, exercise and relaxation approaches, patient/health care provider communication, and problem solving. Research on these programs has shown that they have the following clear and long-lasting benefits:
- They help people understand the disease.
- They help people reduce their pain while remaining active.
- They help people cope physically, emotionally, and mentally.
- They help people feel greater control over their disease and help build a sense of confidence in the ability to function and lead a full, active, and independent life.
Diagnosis
Rheumatoid arthritis can be difficult to diagnose in its early stages for several reasons. First, there is no single test for the disease. In addition, symptoms differ from person to person and can be more severe in some people than in others. Also, symptoms can be similar to those of other types of arthritis and joint conditions, and it may take some time for other conditions to be ruled out as possible diagnoses. Finally, the full range of symptoms develops over time, and only a few symptoms may be present in the early stages. As a result, doctors use a variety of tools to diagnose the disease and to rule out other conditions.
Medical history: This is the patient's description of symptoms and when and how they began. Good communication between patient and doctor is especially important here. For example, the patient's description of pain, stiffness, and joint function and how these change over time is critical to the doctor's initial assessment of the disease and his or her assessment of how the disease changes.
Physical examination: This includes the doctor's examination of the joints, skin, reflexes, and muscle strength.
Laboratory tests: One common test is for rheumatoid factor, an antibody that is eventually present in the blood of most rheumatoid arthritis patients. (An antibody is a special protein made by the immune system that normally helps fight foreign substances in the body.) Not all people with rheumatoid arthritis test positive for rheumatoid factor, however, especially early in the disease. And, some others who do test positive never develop the disease. Other common tests include one that indicates the presence of inflammation in the body (the erythrocyte sedimentation rate), a white blood cell count, and a blood test for anemia.
X rays: X rays are used to determine the degree of joint destruction. They are not useful in the early stages of rheumatoid arthritis before bone damage is evident, but they can be used later to monitor the progression of the disease.
Treatment
Doctors use a variety of approaches to treat rheumatoid arthritis. These are used in different combinations and at different times during the course of the disease and are chosen according to the patient's individual situation. No matter what treatment the doctor and patient choose, however, the goals are the same: relieve pain, reduce inflammation, slow down or stop joint damage, and improve the person's sense of well-being and ability to function.
Treatment is another key area for communication between patient and doctor. Talking to the doctor can help ensure that exercise and pain management programs are provided as needed and that drugs are prescribed appropriately. Talking can also help in making decisions about surgery.
Goals of Treatment
- Relieve pain
- Reduce inflammation
- Slow down or stop joint damage
- Improve a person's sense of well-being and ability to function
Current Treatment Approaches
- Lifestyle
- Medications
- Surgery
- Routine monitoring and ongoing care
Lifestyle
This approach includes several activities that help improve a person's ability to function independently and maintain a positive outlook.
Rest and exercise: Both rest and exercise help in important ways. People with rheumatoid arthritis need a good balance between the two, with more rest when the disease is active and more exercise when it is not. Rest helps to reduce active joint inflammation and pain and to fight fatigue. The length of time needed for rest will vary from person to person, but in general, shorter rest breaks every now and then are more helpful than long times spent in bed.
Exercise is important for maintaining healthy and strong muscles, preserving joint mobility, and maintaining flexibility. Exercise can also help people sleep well, reduce pain, maintain a positive attitude, and lose weight. Exercise programs should be planned and carried out to take into account the person's physical abilities, limitations, and changing needs.
Care of joints: Some people find that using a splint for a short time around a painful joint reduces pain and swelling by supporting the joint and letting it rest. Splints are used mostly on wrists and hands, but also on ankles and feet. A doctor or a physical or occupational therapist can help a patient get a splint and ensure that it fits properly. Other ways to reduce stress on joints include self-help devices (for example, zipper pullers, long-handled shoe horns); devices to help with getting on and off chairs, toilet seats, and beds; and changes in the ways that a person carries out daily activities.
Stress reduction: People with rheumatoid arthritis face emotional challenges as well as physical ones. The emotions they feel because of the disease--fear, anger, frustration--combined with any pain and physical limitations can increase their stress level. Although there is no evidence that stress plays a role in causing rheumatoid arthritis, it can make living with the disease difficult at times. Stress may also affect the amount of pain a person feels. There are a number of successful techniques for coping with stress. Regular rest periods can help, as can relaxation, distraction, or visualization exercises. Exercise programs, participation in support groups, and good communication with the health care team are other ways to reduce stress.
Healthful diet: With the exception of several specific types of oils (mentioned in the Current Research section), there is no scientific evidence that any specific food or nutrient helps or harms most people with rheumatoid arthritis. However, an overall nutritious diet with enough--but not an excess of--calories, protein, and calcium is important. Some people may need to be careful about drinking alcoholic beverages because of the medications they take for rheumatoid arthritis. Those taking methotrexate may need to avoid alcohol altogether. Patients should ask their doctors for guidance on this issue.
Climate: Some people notice that their arthritis gets worse when there is a sudden change in the weather. However, there is no evidence that a specific climate can prevent or reduce the effects of rheumatoid arthritis. Moving to a new place with a different climate usually does not make a long-term difference in a person's rheumatoid arthritis.
Medications
Most people who have rheumatoid arthritis take medications. Some medications are used only for pain relief; others are used to reduce inflammation. Still others--often called disease-modifying antirheumatic drugs, or DMARDs--are used to try to slow the course of the disease. The person's general condition, the current and predicted severity of the illness, the length of time he or she will take the drug, and the drug's effectiveness and potential side effects are important considerations in prescribing drugs for rheumatoid arthritis. The table below about "Medications Commonly Used To Treat Rheumatoid Arthritis" shows currently used rheumatoid arthritis medications, along with their effects, side effects, and monitoring requirements.
Traditionally, rheumatoid arthritis therapy has involved an approach in which doctors prescribed aspirin or similar drugs, rest, and physical therapy first, and prescribed more powerful drugs later only if the disease became much worse. Recently, many doctors have changed their approach, especially for patients with severe, rapidly progressing rheumatoid arthritis. This change is based on the belief that early treatment with more powerful drugs, and the use of drug combinations in place of single drugs, may be more effective ways to halt the progression of the disease and reduce or prevent joint damage.
Medications Commonly used to Treat Rheumatoid Arthritis
Medications |
Uses/Effects |
Side Effects |
Monitoring |
Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)
Examples:
- Plain aspirin
- Buffered aspirin
- Ibuprofen (Advil, Motrin IB)
- Ketoprofen (Orudis)
- Naproxen (Naprosyn)
- Celecoxib (Celebrex)
- Rofecoxib (Vioxx)
|
Used to reduce pain, swelling, and inflammation, allowing patients to move more easily and carry out normal activities. |
Upset Stomach |
Patients should have periodic blood tests. |
* Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.
Surgery
Several types of surgery are available to patients with severe joint damage. The primary purpose of these procedures is to reduce pain, improve the affected joint's function, and improve the patient's ability to perform daily activities. Surgery is not for everyone, however, and the decision should be made only after careful consideration by patient and doctor. Together they should discuss the patient's overall health, the condition of the joint or tendon that will be operated on, and the reason for and the risks and benefits of, the surgical procedure. Cost may be another factor. Commonly performed surgical procedures include joint replacement, tendon reconstruction, and synovectomy.
Joint replacement: This is the most frequently performed surgery for rheumatoid arthritis, and it is done primarily to relieve pain and improve or preserve joint function. Artificial joints are not always permanent and may eventually have to be replaced. This may be an issue for younger people.
Tendon reconstruction: Rheumatoid arthritis can damage and even rupture tendons, the tissues that attach muscle to bone. This surgery, which is used most frequently on the hands, reconstructs the damaged tendon by attaching an intact tendon to it. This procedure can help to restore hand function, especially if the tendon is completely ruptured.
Synovectomy: In this surgery, the doctor actually removes the inflamed synovial tissue. Synovectomy by itself is seldom performed now because not all of the tissue can be removed, and it eventually grows back. Synovectomy is done as part of reconstructive surgery, especially tendon reconstruction.
Routine Monitoring and Ongoing Care
Regular medical care is important to monitor the course of the disease, determine the effectiveness and any negative effects of medications, and change therapies as needed. Monitoring typically includes regular visits to the doctor. It may also include blood, urine, and other laboratory tests and x rays.
Osteoporosis prevention is one issue that patients may want to discuss with their doctors as part of their long-term, ongoing care. Osteoporosis is a condition in which bones lose calcium and become weakened and fragile. Many older women are at increased risk for osteoporosis, and their rheumatoid arthritis increases the risk further, particularly if they are taking corticosteroids such as prednisone. These patients may want to discuss with their doctors the potential benefits of calcium and vitamin D supplements, hormone replacement therapy, or other treatments for osteoporosis.
Alternative and Complementary Therapies
Special diets, vitamin supplements, and other alternative approaches have been suggested for the treatment of rheumatoid arthritis. Although many of these approaches may not be harmful in and of themselves, controlled scientific studies either have not been conducted or have found no definite benefit to these therapies. Some alternative or complementary approaches may help the patient cope or reduce some of the stress associated with living with a chronic illness. As with any therapy, patients should discuss the benefits and drawbacks with their doctors before beginning an alternative or new type of therapy. If the doctor feels the approach has value and will not be harmful, it can be incorporated into a patient's treatment plan. However, it is important not to neglect regular health care. The Arthritis Foundation publishes material on alternative therapies as well as established therapies, and patients may want to contact this organization for information. (See the For More Information section.)
6. Current Research ( top )
Over the last several decades, research has greatly increased our understanding of immunology, genetics, and cellular and molecular biology. This foundation in basic science is now showing results in several areas important to rheumatoid arthritis. Scientists are thinking about rheumatoid arthritis in exciting ways that were not possible even 10 years ago.
The National Institutes of Health funds a wide variety of medical research at its headquarters in Bethesda, Maryland, and at universities and medical centers across the United States. One of the NIH institutes, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, is a major supporter of research and research training in rheumatoid arthritis through grants to individual scientists, Specialized Centers of Research, and Multipurpose Arthritis and Musculoskeletal Diseases Centers.
Following are examples of current research directions in rheumatoid arthritis supported by the Federal Government through the NIAMS and other parts of the NIH.
Scientists are looking at basic abnormalities in the immune systems of people with rheumatoid arthritis and in some animal models of the disease to understand why and how the disease develops. Findings from these studies may lead to precise, targeted therapies that could stop the inflammatory process in its earliest stages. They may even lead to a vaccine that could prevent rheumatoid arthritis.
Researchers are studying genetic factors that predispose some people to developing rheumatoid arthritis, as well as factors connected with disease severity. Findings from these studies should increase our understanding of the disease and will help develop new therapies as well as guide treatment decisions. In a major effort aimed at identifying genes involved in rheumatoid arthritis, the NIH and the Arthritis Foundation have joined together to support the North American Rheumatoid Arthritis Consortium. This group of 12 research centers around the United States is collecting medical information and genetic material from 1,000 families in which two or more siblings have rheumatoid arthritis. It will serve as a national resource for genetic studies of this disease.
Scientists are also gaining insights into the genetic basis of rheumatoid arthritis by studying rats with autoimmune inflammatory arthritis that resembles human disease. NIAMS researchers have identified several genetic regions that affect arthritis susceptibility and severity in these animal models of the disease, and found some striking similarities between rats and humans. Identifying disease genes in rats should provide important new information that may yield clues to the causes of rheumatoid arthritis in humans.
Scientists are studying the complex relationships among the hormonal, nervous, and immune systems in rheumatoid arthritis. For example, they are exploring whether and how the normal changes in the levels of steroid hormones (such as estrogen and testosterone) during a person's lifetime may be related to the development, improvement, or flares of the disease. Scientists are also looking at how these systems interact with environmental and genetic factors. Results from these studies may suggest new treatment strategies.
Researchers are exploring why so many more women than men develop rheumatoid arthritis. In hopes of finding clues, they are studying female and male hormones and other elements that differ between women and men, such as possible differences in their immune responses.
To find clues to new treatments, researchers are examining why rheumatoid arthritis often improves during pregnancy. Results of one study suggest that the explanation may be related to differences in certain special proteins between a mother and her unborn child. These proteins help the immune system distinguish between the body's own cells and foreign cells. Such differences, the scientists speculate, may change the activity of the mother's immune system during pregnancy.
A growing body of evidence indicates that infectious agents, such as viruses and bacteria, may trigger rheumatoid arthritis in people who have an inherited predisposition to the disease. Investigators are trying to discover which infectious agents may be responsible. More broadly, they are also working to understand the basic mechanisms by which these agents might trigger the development of rheumatoid arthritis. Identifying the agents and understanding how they work could lead to new therapies.
Scientists are searching for new drugs or combinations of drugs that can reduce inflammation, can slow or stop the progression of rheumatoid arthritis, and also have few side effects. Studies in humans have shown that a number of compounds have such potential. For example, some studies are breaking new ground in the area of "biopharmaceuticals", or "biologics". These new drugs are based on compounds occurring naturally in the body, and are designed to target specific aspects of the inflammatory process.
Investigators have also shown that treatment of rheumatoid arthritis with minocycline, a drug in the tetracycline family, has a modest benefit. The effects of a related tetracycline called doxycycline are under investigation. Other studies have shown that the omega-3 fatty acids in certain fish or plant seed oils also may reduce rheumatoid arthritis inflammation. However, many people are not able to tolerate the large amounts of oil necessary for any benefit.
Investigators are examining many issues related to quality of life for rheumatoid arthritis patients and quality, cost, and effectiveness of health care services for these patients. Scientists have found that even a small improvement in a patient's sense of physical and mental well-being can have an impact on his or her quality of life and use of health care services. Results from studies like these will help health care providers design integrated treatment strategies that cover all of a patient's needs--emotional as well as physical.
7. Hope for the Future ( top )
Scientists are making rapid progress in understanding the complexities of rheumatoid arthritis--how and why it develops, why some people get it and others do not, why some people get it more severely than others. Results from research are having an impact today, enabling people with rheumatoid arthritis to remain active in life, family, and work far longer than was possible 20 years ago. There is also hope for tomorrow, as researchers continue to explore ways of stopping the disease process early, before it becomes destructive, or even preventing rheumatoid arthritis altogether.
8. What Are the Treatments? ( top )
Treatments for rheumatic diseases include rest and relaxation, exercise, proper diet, medication, and instruction about the proper use of joints and ways to conserve energy. Other treatments include the use of pain relief methods and assistive devices, such as splints or braces. In severe cases, surgery may be necessary. The doctor and the patient work together to develop a treatment plan that helps the patient maintain or improve his or her lifestyle. Treatment plans usually combine several types of treatment and vary depending on the rheumatic condition and the patient.
Rest, Exercise, and Diet
People who have a rheumatic disease should develop a comfortable balance between rest and activity. One sign of many rheumatic conditions is fatigue. Patients must pay attention to signals from their bodies. For example, when experiencing pain or fatigue, it is important to take a break and rest. Too much rest, however, may cause muscles and joints to become stiff.
People with a rheumatic disease such as arthritis can participate in a variety of sports and exercise programs. Physical exercise can reduce joint pain and stiffness and increase flexibility, muscle strength, and endurance. It also helps with weight reduction and contributes to an improved sense of well-being. Before starting any exercise program, people with arthritis should talk with their doctor. Exercises that doctors often recommend include:
- Range-of-motion exercises (e.g., stretching, dance) to help maintain normal joint movement, maintain or increase flexibility, and relieve stiffness.
- Strengthening exercises (e.g., weight lifting) to maintain or increase muscle strength. Strong muscles help support and protect joints affected by arthritis.
- Aerobic or endurance exercises (e.g., walking, bicycle riding) to improve cardiovascular fitness, help control weight, and improve overall well-being. Studies show that aerobic exercise can also reduce inflammation in some joints.
Another important part of a treatment program is a well-balanced diet. Along with exercise, a well-balanced diet helps people manage their body weight and stay healthy. Weight control is important to people who have arthritis because extra weight puts extra pressure on some joints and can aggravate many types of arthritis. Diet is especially important for people who have gout. People with gout should avoid alcohol and foods that are high in purines, such as organ meats (liver, kidney), sardines, anchovies, and gravy.
Medications
A variety of medications are used to treat rheumatic diseases. The type of medication depends on the rheumatic disease and on the individual patient. The medications used to treat most rheumatic diseases do not provide a cure, but rather limit the symptoms of the disease. Infectious arthritis and gout are exceptions if medications are used properly. Another example is Lyme disease, caused by the bite of certain ticks, where symptoms of arthritis may be prevented or may disappear if the infection is caught early and treated with antibiotics.
Medications commonly used to treat rheumatic diseases provide relief from pain and inflammation. In some cases, the medication may slow the course of the disease and prevent further damage to joints or other parts of the body.
The doctor may delay using medications until a definite diagnosis is made because medications can hide important symptoms (such as fever and swelling) and thereby interfere with diagnosis. Patients taking any medication, either prescription or over-the-counter, should always follow the doctor's instructions. The doctor should be notified immediately if the medicine is making the symptoms worse or causing other problems, such as an upset stomach, nausea, or headache. The doctor may be able to change the dosage or medicine to reduce these side effects.
Analgesics (pain relievers) such as acetaminophen (Tylenol)* and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are used to reduce the pain caused by many rheumatic conditions. NSAIDs have the added benefit of decreasing the inflammation associated with arthritis. A common side effect of NSAIDs is stomach irritation, which can often be reduced by changing the dosage or medication. New NSAIDs, including celecoxib (Celebrex) and rofecoxib (Vioxx), were introduced to reduce gastrointestinal side effects and offer additional options for treatment. However, even new medications are occasionally associated with reactions ranging from mild to severe, and their long-term effects are still being studied. The dosage will vary depending on the particular illness and the overall health of the patient. The doctor and patient must work together to determine which analgesic to use and the appropriate amount. If analgesics do not ease the pain, the doctor may use other medications.
* Brand names included in this fact sheet are provided as examples only, and their inclusion does not mean that these products are endorsed by the KyoCare Arthritis Clinic.
Depending on the type of arthritis, a person may be asked to take a disease-modifying antirheumatic drug (DMARD). This category includes several unrelated medications that are intended to slow or prevent damage to the joint and thereby prevent disability and discomfort. DMARDs include methotrexate, sulfasalazine, and leflunomide (Arava).
Biological response modifiers are new drugs used for the treatment of rheumatoid arthritis. They can help reduce inflammation and structural damage of the joints by blocking the reaction of a substance called tumor necrosis factor, a protein involved in immune system response. These drugs include etanercept (Enbrel), infliximab (Remicade), and anakinra (Kineret).
Corticosteroids, such as prednisone, cortisone, solumedrol, and hydrocortisone, are used to treat many rheumatic conditions because they decrease inflammation and suppress the immune system. The dosage of these medications will vary depending on the diagnosis and the patient. Again, the patient and doctor must work together to determine the right amount of medication.
Corticosteroids can be given by mouth, in creams applied to the skin, or by injection. Short-term side effects of corticosteroids include swelling, increased appetite, weight gain, and emotional ups and downs. These side effects generally stop when the drug is stopped. It can be dangerous to stop taking corticosteroids suddenly, so it is very important that the doctor and patient work together when changing the corticosteroid dose. Side effects that may occur after long-term use of corticosteroids include stretch marks, excessive hair growth, osteoporosis, high blood pressure, damage to the arteries, high blood sugar, infections, and cataracts.
Hyaluronic acid products like Hyalgan and Synvisc mimic a naturally occurring body substance that lubricates the knee joint. They are usually injected directly into the joint to help provide temporary relief of pain and flexible joint movement.
Devices Used in Treatment
Transcutaneous electrical nerve stimulation (TENS) has been found effective in modifying pain perception. TENS blocks pain messages to the brain with a small device that directs mild electric pulses to nerve endings that lie beneath the painful area of the skin.
A blood-filtering device called the Prosorba Column is used in some health care facilities for filtering out harmful antibodies in people with severe rheumatoid arthritis.
Heat and Cold Therapies
Heat and cold can both be used to reduce the pain and inflammation of arthritis. The patient and doctor can determine which one works best.
Heat therapy increases blood flow, tolerance for pain, and flexibility. Heat therapy can involve treatment with paraffin wax, microwaves, ultrasound, or moist heat. Physical therapists are needed for some of these therapies, such as microwave or ultrasound therapy, but patients can apply moist heat themselves. Some ways to apply moist heat include placing warm towels or hot packs on the inflamed joint or taking a warm bath or shower.
Cold therapy numbs the nerves around the joint (which reduces pain) and may relieve inflammation and muscle spasms. Cold therapy can involve cold packs, ice massage, soaking in cold water, or over-the-counter sprays and ointments that cool the skin and joints.
Capsaicin cream is a preparation put on the skin to relieve joint or muscle pain when only one or two joints are involved.
Hydrotherapy, Mobilization Therapy, and Relaxation Therapy
Hydrotherapy involves exercising or relaxing in warm water. The water takes some weight off painful joints, making it easier to exercise. It helps relax tense muscles and relieve pain.
Mobilization therapies include traction (gentle, steady pulling), massage, and manipulation. (Someone other than the patient moves stiff joints through their normal range of motion.) When done by a trained professional, these methods can help control pain, increase joint motion, and improve muscle and tendon flexibility.
Relaxation therapy helps reduce pain by teaching people various ways to release muscle tension throughout the body. In one method of relaxation therapy, known as progressive relaxation, the patient tightens a muscle group and then slowly releases the tension. Doctors and physical therapists can teach patients a variety of relaxation techniques.
Assistive Devices
The most common assistive devices for treating arthritis pain are splints and braces, which are used to support weakened joints or allow them to rest. Some of these devices prevent the joint from moving; others allow some movement. A splint or brace should be used only when recommended by a doctor or therapist, who will show the patient the correct way to put the device on, ensure that it fits properly, and explain when and for how long it should be worn. The incorrect use of a splint or brace can cause joint damage, stiffness, and pain.
A person with arthritis can use other kinds of devices to ease the pain. For example, the use of a cane when walking can reduce some of the weight placed on a knee or hip affected by arthritis. A shoe insert (orthotic) can ease the pain of walking caused by arthritis of the foot or knee. Other devices can help with activities such as opening jars, closing zippers, and holding pencils.
Surgery
Surgery may be required to repair damage to a joint after injury or to restore function or relieve pain in a joint damaged by arthritis. The doctor may recommend arthroscopic surgery, bone fusion (surgery in which bones in the joint are fused or joined together), or arthroplasty (also known as total joint replacement, in which the damaged joint is removed and replaced with an artificial one).
Nutritional Supplements
Nutritional supplements are often reported as helpful in treating rheumatic diseases. These include products such as S-adenosylmethionine (SAM-e) for osteoarthritis and fibromyalgia, dehydroepiandrosterone (DHEA) for lupus, and glucosamine and chondroitin sulfate for osteoarthritis. Reports on the safety and effectiveness of these products should be viewed with caution since very few claims have been carefully evaluated.
Myths About Treating Arthritis
At this time, the only type of arthritis that can be cured is that caused by infections. Although symptoms of other types of arthritis can be effectively managed with rest, exercise, and medication, there are no cures. Some people claim to have been cured by treatment with herbs, oils, chemicals, special diets, radiation, or other products. However, there is no scientific evidence that such treatments cure arthritis. Moreover, some may lead to serious side effects. Patients should talk to their doctor before using any therapy that has not been prescribed or recommended by the health care team caring for the patient.
Work With Your Doctor To Limit Your Pain
The role you play in planning your treatment is very important. It is vital for you to have a good relationship with your doctor in order to work together. You should not be afraid to ask questions about your condition or treatment. You must understand the treatment plan and tell the doctor whether or not it is helping you. Research has shown that patients who are well informed and participate actively in their own care experience less pain and make fewer visits to the doctor.
What Can Be Done To Help?
Studies show that an estimated 18 percent of Americans who have arthritis or other rheumatic conditions believe that their condition limits their activities. People with arthritis may find that they can no longer participate in some of their favorite activities, which can affect their overall well-being. Even when arthritis impairs only one joint, a person may have to change many daily activities to protect that joint from further damage and reduce pain. When arthritis affects the entire body, as it does in people with rheumatoid arthritis or fibromyalgia, many daily activities have to be changed to deal with pain, fatigue, and other symptoms.
Changes in the home may help a person with chronic arthritis continue to live safely, productively, and with less pain. People with arthritis may become weak, lose their balance, or fall. In the bathroom, installing grab bars in the tub or shower and by the toilet, placing a secure seat in the tub, and raising the height of the toilet seat can help. Special kitchen utensils can accommodate hands affected by arthritis to make meal preparation easier. An occupational therapist can help people who have rheumatic conditions identify and make adjustments in their homes to create a safer, more comfortable, and more efficient environment.
Friends and family members can help a patient with a rheumatic condition by learning about that condition and understanding how it affects the patient's life. Friends and family can provide emotional and physical assistance. Their support, as well as support from other people who have the same disease, can make it easier to cope. The Arthritis Foundation and the Arthritis Society has a wealth of information to help people with arthritis.
What Research Is Being Done on Arthritis?
The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the National Institutes of Health (NIH), leads the Federal medical research effort in arthritis and rheumatic diseases. The NIAMS sponsors research and research training on the NIH campus in Bethesda, Maryland, and at universities and medical centers throughout the United States. Research activities include both basic (laboratory) and clinical (involving patients) research studies to better understand what causes these conditions and how best to treat and prevent them.
The NIAMS currently supports three types of research centers that study arthritis, rheumatic diseases, and other musculoskeletal conditions: Multidisciplinary Clinical Research Centers (MCRCs), Specialized Centers of Research (SCORs), and Core Centers. A list of these centers and their locations can be obtained from the Institute (listed at the end of this fact sheet).
The MCRCs are programs that focus on clinical research designed to assess and improve outcomes for patients affected by arthritis and other rheumatic diseases, musculoskeletal disorders (including bone and muscle diseases), and skin diseases. Each center studies one or more of the diseases within the NIAMS mission and provides resources for developing clinical projects using more than one approach.
Each SCOR focuses on a single disease. Currently, rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, osteoporosis, and scleroderma are being studied. Combining laboratory and clinical studies under one roof speeds up research on the causes of these diseases and hastens transfer of advances from the laboratory to the bedside to improve patient care.
Core Centers promote interdisciplinary collaborative efforts among scientists doing high-quality research related to a common theme. By providing funding for facilities, pilot and feasibility studies, and program enrichment activities at the Core Center, the Institute reinforces investigations already underway in NIAMS program areas. Current centers include Rheumatic Diseases Research Core Centers, Skin Disease Research Core Centers, and Core Centers for Musculoskeletal Disorders.
Research registries provide a means for collecting clinical, demographic, and laboratory information from patients and, sometimes, their relatives. These registries facilitate studies that could ultimately lead to improved diagnosis, treatment, and prevention. NIAMS currently supports research registries for rheumatoid arthritis, antiphospholipid syndrome (an autoimmune disorder), ankylosing spondylitis, lupus and neonatal lupus, scleroderma, juvenile rheumatoid arthritis, and juvenile dermatomyositis.
Some current NIAMS research efforts in rheumatic diseases are outlined below.
Biomarkers
Recent scientific breakthroughs in basic research have provided new information about what happens to the body's cells and other structures as rheumatic diseases progress. Biomarkers (laboratory and imaging signposts that detect disease) help researchers determine the likelihood that a person will develop a specific disease and its possible severity and outcome. Biomarkers have the potential to lead to novel and more effective ways to predict and monitor disease activity and responses to treatment. The NIAMS supports research on biomarkers for rheumatic and skin diseases, including a new initiative on osteoarthritis. Additional studies on specific rheumatic diseases follow.
Rheumatoid Arthritis
Researchers are trying to identify the cause of rheumatoid arthritis in order to develop better and more specific treatments. They are examining the role that the endocrine (hormonal), nervous, and immune systems play, and the ways in which these systems interact with environmental and genetic factors in the development of rheumatoid arthritis. Some scientists are trying to determine whether an infectious agent triggers rheumatoid arthritis. Others are studying the role of certain enzymes (specialized proteins in the body that spark biochemical reactions) in breaking down cartilage. Researchers are also trying to identify the genetic factors that place some people at higher risk than others for developing rheumatoid arthritis.
Moreover, scientists are looking at new ways to treat rheumatoid arthritis. They are experimenting with new drugs and "biologic agents" that selectively block certain immune system activities associated with inflammation. Newly developed drugs include etanercept (Enbrel) and infliximab (Remicade). Followup studies show promise for their effectiveness in slowing disease progression. Studies for additional new drugs continue. Other investigators have shown that minocycline and doxycycline, two antibiotic medications in the tetracycline family, have a modest benefit for people with rheumatoid arthritis. Research continues in this area.
Novel studies using imaging technologies are underway as well. These techniques help identify targets for new drugs by allowing researchers to see changes in cells during the disease process.
Osteoarthritis
The NIAMS has embarked on several innovative approaches to understand the causes and identify effective treatment and prevention methods for osteoarthritis. Through a public/ private partnership, researchers are identifying biomarkers for osteoarthritis to help develop and test new drugs. Imaging studies designed to better identify joint disorders and assess their progression are taking place as well.
The National Center for Complementary and Alternative Medicine and the NIAMS at the National Institutes of Health are currently funding a study on the usefulness of the dietary supplements glucosamine and chondroitin sulfate for osteoarthritis. Previous studies suggest these substances may be effective for reducing pain in knee osteoarthritis. Researchers are also investigating whether they prevent the loss of cartilage.
Some genetic and behavioral studies are focusing on factors that may lead to osteoarthritis. Researchers recently found that daughters of women who have knee osteoarthritis have a significant increase in cartilage breakdown, thus making them more susceptible to disease. This finding has important implications for identifying people who are susceptible to osteoarthritis. Other studies of risk factors for osteoarthritis have identified excessive weight and lack of exercise as contributing factors to knee and hip disability.
Researchers are working to understand what role certain enzymes play in the breakdown of joint cartilage in osteoarthritis and are testing drugs that block the action of these enzymes.
Studies of injuries in young adults show that those who have had a previous joint injury are more likely to develop osteoarthritis. These studies underscore the need for increased education about joint injury prevention and use of proper sports equipment.
Systemic Lupus Erythematosus
Researchers are looking at how genetic, environmental, and hormonal factors influence the development of systemic lupus erythematosus. They are trying to find out why lupus is more common in certain populations, and they have made progress in identifying the genes that may be responsible for lupus. Researchers also continue to study the cellular and molecular basis of autoimmune disorders such as lupus. Promising areas of research on treatment include biologic agents; newer, more selective drugs that suppress the immune system; and bone transplants to correct immune abnormalities. Contrary to the widely held belief that estrogens can make the disease worse, clinical studies are revealing that it may be safe to use estrogens for hormone replacement therapy and birth control in women with lupus.
Scleroderma
Current studies on scleroderma are focusing on overproduction of collagen, blood vessel injury, and abnormal immune system activity. Researchers hope to discover how these three elements interact to cause and promote scleroderma. In one study, researchers found evidence of fetal cells within the blood and skin lesions of women who had been pregnant years before developing scleroderma. The study suggests that fetal cells may play a role in scleroderma by fostering the maturation of immune cells that promote the overproduction of collagen. Scientists are continuing to study the implications of this finding.
Treatment studies are underway as well. One study in particular is looking at the effectiveness of oral collagen in treating scleroderma.
Fibromyalgia
Scientists are looking at the basic causes of chronic pain and the health status of young women affected by fibromyalgia. The effectiveness of behavior therapy, acupuncture, and some alternative medical approaches for dealing with pain and loss of sleep are being tested. Researchers are also studying whether certain genes contribute to this disease.
Spondyloarthropathies
Researchers are working to understand the genetic and environmental causes of spondyloarthropathies, which include ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, and reactive arthritis (Reiter's syndrome), as well as related conditions of the eye. They are also looking at new imaging methods that will help with early and accurate diagnosis, guide treatment, and detect responses to treatment. Research on new treatments is also underway.
9. For More Information ( top )
National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484 or 877-22-NIAMS (226-4267) (free of charge)
TTY: 301-565-2966
Fax: 301-718-6366
http://www.niams.nih.gov/
The clearinghouse provides information about various forms of arthritis and rheumatic disease and bone, muscle, and skin diseases. It distributes patient and professional education materials and refers people to other sources of information. Additional information and updates can also be found on the NIAMS Web site.
American Academy of Orthopaedic Surgeons
P.O. Box 2058
Des Plaines, IL 60017
Phone: 800-824-BONE (2663) (free of charge)
www.aaos.org
The academy provides education and practice management services for orthopaedic surgeons and allied health professionals. It also serves as an advocate for improved patient care and informs the public about the science of orthopaedics. The orthopaedist's scope of practice includes disorders of the body's bones, joints, ligaments, muscles, and tendons. For a single copy of an AAOS brochure, send a self-addressed stamped envelope to the address above or visit the AAOS Web site.
American College of Rheumatology
1800 Century Place, Suite 250
Atlanta, GA 30345
Phone: 404-633-3777
Fax: 404-633-1870
www.rheumatology.org
This association provides referrals to doctors and health professionals who work on arthritis, rheumatic diseases, and related conditions. It also provides educational materials and guidelines.
Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
Phone: 404-872-7100 or 800-283-7800 (free of charge)
or call your local chapter (listed in the telephone directory)
www.arthritis.org
This is the major voluntary organization devoted to arthritis. The foundation publishes a free brochure, Coping With Pain, and a monthly magazine for members that provides up-to-date information on all forms of arthritis. The foundation also can provide addresses and phone numbers for local chapters and physician and clinic referrals.
The Arthritis Society (National Office)
393 University Avenue, Suite 1700
Toronto, Ontario M5G 1E6
CANADA
Phone: 416-979-7228
Fax: 416-979-8366
Email:info@arthritis.ca
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