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Treating Rheumatoid Arthritis

Doctors use a variety of approaches to treat rheumatoid arthritis. These are used in different combination 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, the goals are the same: to relieve pain, reduce inflammation, slow down or stop joint damage, and improve the person’s sense of well-being and ability to function.

People with rheumatoid arthritis need a good balance between rest and exercise, 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 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.

Some people find 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. 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 change in the ways that a person carries out daily activities.

People with rheumatoid arthritis face emotional challenges as well as physical ones. The emotions they feel because of the disease-fear, anger, and frustration-combined with any pain and physical limitation 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 including regular rest periods, relaxation, or visualization exercises.

There is no scientific evidence that any specific food or nutrient helps or harms 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.

Most people who have rheumatoid arthritis take medications. Some are used only for pain relief; others are used to reduce inflammation. Still others, often called disease-modifying antirheumatic drugs, 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.

In patients with severe joint damage, several types of surgery are available. 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 and patient and doctor should make careful consideration.

The most frequently performed surgery for rheumatoid arthritis is joint replacement 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, an important consideration for young people.

Rheumatoid arthritis can damage and even rupture tendons, the tissues that attach muscle to bone. Tendon reconstruction, 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 is a surgery where 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.

Regular medical care is important to monitor the course of the disease, determine the effectiveness and any negative effect of medication, and change therapies as needed. Monitoring typically includes regular visits to the doctor.

What is Fibromyalgia?

Fybromyalgia syndrome is a common and chronic disorder characterized by widespread pain, diffuse tenderness, and a number of other symptoms. The word “fibromyalgia” comes from the Latin term for fibrous tissue (fibro) and the Greek terms for muscle (myo) and pain (algia).

Although fibromyalgia is often considered an arthritis-related condition, it is not truly a form of arthritis (a disease of the joints) because it does not cause inflammation or damage to the joints, muscles, or other tissues. Like arthritis, however, fibromyalgia can cause significant pain and fatigue, and it can interfere with a person’s ability to carry on daily activities. Also like arthritis, fibromyalgia is considered a rheumatic condition, a medical condition that impairs the joints and/or soft tissues and causes chronic pain.

In addition to pain and fatigue, people who have fibromyalgia may experience a variety of other symptoms including:

  • Cognitive and memory problems (sometimes referred to as “fibro fog”)
  • Sleep disturbances
  • Morning stiffness
  • Headaches
  • Irritable bowel syndrome
  • Painful menstrual periods
  • Numbness or tingling of the extremities
  • Restless legs syndrome
  • Temperature sensitivity
  • Sensitivity to loud noises or bright lights


Fibromyalgia is a syndrome rather than a disease. A syndrome is a collection of signs, symptoms, and medical problems that tend to occur together but are not related to a specific, identifiable cause. A disease, on the other hand, has a specific cause or causes and recognizable signs and symptoms.

Young Women With Fibromyalgia

In a study funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and led by Carol S. Burckhardt, Ph.D., investigators look to develop a model to plan early intervention strategies that minimize fibromyalgia-related disabilities and maximize health status in young women with the syndrome.

The project focused on describing how fibromyalgia affects the lives of young women during the first year after diagnosis. The investigators recruited 98 women (48 in the United States, 50 from Sweden) between the ages of 18 and 39. Participants were interviewed within 6 months of diagnosis and again 6 months and 12 months later. They were asked questions about their employment, medications, diet, health provider visits, other illnesses, social support, strategies for dealing with symptoms, and their physical, psychological, and social difficulties. They were also asked their marital status, how many children they had, and their education level. The women answered self-report questionnaires that measured depression, anxiety, pain-coping strategies, and self-efficacy. (A person's self-efficacy is the degree to which he or she believes one can controls the effects of one's health problem.)

Participants in both countries agreed that difficulties maintaining personal, work, and social roles arose from sources such as pain, severe fatigue, high stress, an inability to concentrate, standing or sitting for long periods of time, heavy lifting, and a lack of understanding by employers, colleagues, and family members. At the time of diagnosis, 71 percent of women interviewed were employed. By the time of the first study interview, that percentage had dropped to 60 percent. Twelve months after that first interview, 41 percent were employed. Predictors of unemployment included age (younger people were more likely to be unemployed), low physical functioning, pain severity that interferes with the ability to work, and a lack of belief in one's ability to control pain.

Preliminary findings suggest that early intervention to assist newly diagnosed young women might lead to better outcomes in health status and quality of life. Useful interventions would be those that help women maintain paid employment, learn ways to manage their pain and fatigue, engage in physical exercise, maintain leisure activity, and encourage support from their social system.

The Who and What of Fibromyalgia

Scientists estimate that fibromyalgia affects 5 million Americans age 18 or older. For unknown reasons, between 80 and 90 percent of those diagnosed with fibromyalgia are women; however, men and children also can be affected. Most people are diagnosed during middle age, although the symptoms often become present earlier in life.

People with certain rheumatic diseases, such as rheumatoid arthritis, systemic lupus erythematosus (commonly called lupus), or ankylosing spondylitis (spinal arthritis) may be more likely to have fibromyalgia, too.

Several studies indicate that women who have a family member with fibromyalgia are more likely to have it themselves; but the exact reason for this: whether it is heredity, shared environmental factors, or both‚ is unknown. One current study supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is trying to determine whether variations in certain genes cause some people to be more sensitive to stimuli, which lead to pain syndromes.

The causes of fibromyalgia are unknown, but there are probably a number of factors involved. Many people associate the development of fibromyalgia with a physically or emotionally stressful or traumatic event, such as an automobile accident. Some connect it to repetitive injuries. Others link it to an illness. While for others, fibromyalgia seems to occur spontaneously.

Many researchers are examining other causes, including problems with how the central nervous system (the brain and spinal cord) processes pain.

Some scientists speculate that a person’s genes may regulate the way his or her body processes painful stimuli. According to this theory, people with fibromyalgia may have a gene or genes that cause them to react strongly to stimuli that most people would not perceive as painful. There have already been several genes identified that occur more commonly in fibromyalgia patients, and NIAMS-supported researchers are currently looking at other possibilities.

Symptoms of Fibromyalgia

The overwhelming characteristic of fibromyalgia is long-standing, body-wide pain with defined tender points. Tender points are distinct from trigger points seen in other pain syndromes. Unlike tender points, trigger points can occur in isolation and represent a source of radiating pain, even in the absence of direct pressure.

Fibromyalgia pain can mimic the pain that occurs with various types of arthritis. However, the significant swelling, destruction, and deformity of joints seen in diseases such as rheumatoid arthritis do not occur with fibromyalgia syndrome alone.

The soft-tissue pain of fibromyalgia is described as deep aching, radiating, gnawing, shooting or burning, and ranges from mild to severe. Fibromyalgia sufferers tend to wake up with body aches and stiffness.

For some patients, pain improves during the day and increases again during the evening, though many patients with fibromyalgia have daylong, unrelenting pain. Pain can increase with activity, cold or damp weather, anxiety, and stress.

Specific symptoms of fibromylagia include:

  • Body aches
  • Chronic facial muscle pain or aching
  • Fatigue
  • Irritable bowel syndrome
  • Memory difficulties and cognitive difficulties
  • Multiple tender areas (muscle and joint pain) on the back of the neck, shoulders, sternum, lower back, hips, shins, elbows, and knees
  • Numbness and tingling
  • Palpitations
  • Reduced exercise tolerance
  • Sleep disturbances
  • Tension or migraine headaches


Diagnosis of fibromyalgia requires a history of a least 3 months of widespread pain, and pain and tenderness in at least 11 of 18 tender-point sites. These tender-point sites include fibrous tissue or muscles of the:
Arms (elbows)
Buttocks
Chest
Knees
Lower back
Neck
Rib cage
Shoulders
Thighs

Sometimes, laboratory and x-ray tests are done to help confirm the diagnosis by ruling out other conditions that may have similar symptoms.

Fibromyalgia is a common and chronic problem. The symptoms sometimes improve. At other times, the symptoms may worsen and continue for months or years. The key is seeking professional help, which includes a multi-faceted approach to the management and treatment of the disease.

Treating Lower-Back with Spinal Manipulation

Evidence indicates that spinal manipulation, the application of controlled force to a joint, can provide mild-to-moderate relief from lower-back pain. It appears to be as effective as conventional treatments, and recent guidelines for health care practitioners include it as a treatment option for pain that does not improve with self-care.

Spinal manipulation is generally a safe treatment for lower-back pain. Again, it is the application of controlled force to a joint, moving it beyond the normal range of motion in an effort to aid in restoring health. The most common side effects (e.g., discomfort in the treated area) are minor and go away within 1-2 days.

In the United States, spinal manipulation is often performed as part of chiropractic care. Chiropractic care is a whole medical system that focuses on the relationship between the body’s structure, mainly the spine, and function. Practitioners perform adjustments (also called manipulation) with the goal of correcting structural alignment problems to assist the body in healing. Back problems are the most common reason people seek chiropractic care.

In 2007 guidelines, the American College of Physicians and the American Pain Society include spinal manipulation as one of several treatment options for practitioners to consider using when pain does not improve with self-care. Recent studies have found that spinal manipulation provides relief from lower-back pain at least over the short term and that pain-relieving effects may continue for up to 1 year. In one study funded by the National Center for Complementary and Alternative Medicine (NCCAM) that examines long-term effect in more than 600 people with lower-back pain, results to date suggest that chiropractic care involving spinal manipulation is at least as effective as conventional medical care for up to 18 months. However, less than 20 percent of participants in this study were pain free at 18 months, regardless of the type of treatment used.

Reviews have concluded that spinal manipulation is relatively safe when performed by a trained and licensed practitioner. The most common side effects, discomfort in the area treated, headache, and tiredness, are generally minor and temporary. The rate of serious complications from spinal manipulation, although not definitely known, appears to be very low overall.

Osteoarthritis

People with osteoarthritis, the most common type of arthritis, often have joint pain and reduced motion. Unlike some other forms of arthritis, osteoarthritis affects only joints and not internal organs.

Osteoarthritis is a joint disease that mostly affects cartilage, the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over each other, helping to absorb shock of movement. In osteoarthritis, the top layer of cartilage breaks down and wears away. This allows bones under the cartilage to rub together causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Also, bone spurs may grow on the edges of the joint. Bits of bone or cartilage can break off and float inside the joint space, which cause more pain and damage.

Although the exact causes of osteoarthritis are unknown, there are factors that might cause it including: being overweight, getting older, joint injury, joints that are not properly formed, a genetic defect in joint cartilage, or stresses on the joints from certain jobs and playing sports.

Often times there are warning signs of osteoarthritis. It can occur in any joint, but most often occurs in the hands, knees, and spine. Stiffness in a joint after getting out of bed or sitting for a long period of time is one such warning sign. Others include, swelling or tenderness in one or more joints and a crunching feeling or sound of bone rubbing bone.

While no single test can diagnose osteoarthritis, most doctors use several standard methods to diagnose and rule out other problems. Along with a complete medical history and a physical exam, x-rays or blood tests may be taken to examine the fluid in the joints. Treatment plans involve exercise, weight control, rest and joint care, non-drug pain relief techniques to control pain, medicines, complementary and alternative therapies and in more extreme cases surgery may be an option.

Low Bone Mass Versus Osteoporosis

If you have low bone mass that is not low enough to be diagnosed as osteoporosis, this is sometimes referred to as osteopenia. Low bone mass can be caused by many factors such as:

  • Heredity
  • The development of less-than-optimal peak bone mass in your youth
  • A medical condition or medication to treat such a condition that negatively affects bone
  • Abnormally accelerated bone loss.

Although not everyone who has low bone mass will develop osteoporosis, everyone with low bone mass is at higher risk for the disease and the resulting fractures.

As a person with low bone mass, you can take steps to help slow down your bone loss and prevent osteoporosis in your future. Your doctor will want you to develop—or keep—healthy habits such as eating foods rich in calcium and vitamin D and doing weight-bearing exercise such as walking, jogging, or dancing. In some cases, your doctor may recommend medication to prevent osteoporosis.

If you are diagnosed with osteoporosis, these healthy habits will help, but your doctor will probably also recommend that you take medication. Several effective medications are available to slow—or even reverse—bone loss. If you do take medication to treat osteoporosis, your doctor can advise you concerning the need for future BMD tests to check your progress.

The U.S. Preventive Services Task Force recommends that women age 65 and older be screened routinely for osteoporosis. The task force also recommends that routine screening begin at age 60 for women who are at increased risk for osteoporotic fractures.

In addition, a panel convened by the National Institutes of Health in 2000 recommended that bone density testing be considered in people taking glucocorticoid medications for 2 months or more and in those with conditions that place them at high risk for an osteoporosis-related fracture.

However, the panel did not find enough scientific evidence upon which to base universal recommendations about when all women and men should obtain a BMD test. Instead, an individualized approach is recommended.

Juvenile Fibromyalgia

New research supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and published in Arthritis and Rheumatism, suggests that adolescents with fibromyalgia are more likely than their peers to experience social problems like isolation and peer rejection. This may result in increased anxiety, social withdrawal and mood difficulties. Susmita Kashikar-Zuck, Ph.D., of the Cincinnati Children's Hospital Medical Center, and her colleagues at the center and several other institutions, recruited 55 adolescents with juvenile primary fibromyalgia syndrome (JPFS) and matched them with classroom peers who didn't have a chronic illness. Each adolescent was matched according to his or her age, gender, race or ethnicity, and classroom. The researchers collected data from teachers, peers and the participants in a classroom setting without acknowledging JPFS involvement. The research indicated that adolescents with JPFS were consistently rated by teachers, peers and themselves as more sensitive and isolated. These adolescents were rated by their classmates as having fewer popularity and leadership qualities. They also had significantly fewer reciprocated friendships than peers without chronic illness. Fibromyalgia is a syndrome that causes significant pain and fatigue, which interfere with a person's ability to carry on daily activities. When diagnosed in adolescents, it is called JPFS. It typically begins in girls at ages 13-15.

Gabapentin Shown Effective for Fibromyalgia Pain

In new research supported by the National Institutes of Health’s National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) shows that the anticonvulsant medication gabapentin, which is used for certain types of seizures, can be an effective treatment for the pain and other symptoms associated with the common, often hard-to-treat chronic pain disorder, fibromyalgia.

In the NIAMS-sponsored, randomized, double-blind clinical trial of 150 women (90 percent) and men with the condition, Lesley M. Arnold, M.D., director of the Women’s Health Research Program at the University of Cincinnati College of Medicine, and her colleagues found that those taking gabapentin at dosages of 1,200 to 2,400 mg daily for 12 weeks displayed significantly less pain than those taking placebo. Patients taking gabapentin also reported significantly better sleep and less fatigue. For the majority of participants, the drug was well tolerated. The most common side effects included dizziness and sedation, which were mild to moderate in severity in most cases.

NIAMS Director Stephen I. Katz. M.D., Ph.D., remarked “While gabapentin does not have Food and Drug Administration approval for fibromyalgia1, I believe this study offers additional insight to physicians considering the drug for their fibromyalgia patients. Fibromyalgia is a debilitating condition for which current treatments are only modestly effective, so a study such as this is potentially good news for people with this common, painful condition.”

Fibromyalgia is a chronic disorder characterized by chronic, widespread muscle pain and tenderness, and is frequently accompanied by fatigue, insomnia, depression, and anxiety. It affects three million to six million Americans, mostly women, and can be disabling.

The precise cause of fibromyalgia in not known, but research suggests it is related to a problem with the central nervous system’s processing of pain. As with some other chronic pain conditions, people with fibromyalgia often develop a heightened response to stimuli, experiencing pain that would not cause problems in other people. Yet, unlike many other pain syndromes, there is no physical evidence of inflammation or central nervous system damage.

Although gabapentin has little, if any, effect on acute pain, it has shown a robust effect on pain caused by a heightened response to stimuli related to inflammation or nerve injury in animal models of chronic pain syndromes. Researchers have suspected that it might have the same effect in people with fibromyalgia. The new research, published in the April 2007 edition of Arthritis & Rheumatism, indicates the suspicions were correct.

Although the researchers cannot say with certainty how gabapentin helps reduce pain, Dr. Arnold says one possible explanation involves the binding of gabapentin to a specific subunit of voltage-gated calcium channels on neurons. “This binding reduces calcium flow into the nerve cell, which reduces the release of some signaling molecules involved in pain processing,” she says.

How gabapentin improves sleep and other symptoms is less clear, and there are probably different mechanisms involved in fibromyalgia symptoms. “Gabapentin improved sleep, which is an added benefit to patients with fibromyalgia who often report unrefreshing or disrupted sleep,” Dr. Arnold says.

What is important is that people with fibromyalgia now have a potential new treatment option for a condition with few effective treatments. “Studies like this give clinicians evidence-based information to guide their treatment of patients,” says Dr. Arnold.