Arthritis: Keeping Your Joints Healthy

| April 1, 2008

Arthritis: Keeping Your Joints Healthy

There are more than 100 different types of arthritis, but all have one thing in common: These different diseases affect joints. Many of them also affect the areas and structures surrounding joints. Perhaps more important, arthritis is painful and can interfere with your ability to do the things that you enjoy, from cooking a meal to playing golf.

The number of people with arthritis is staggering. In 2005, 66 million adults in the United States nearly 1 in 3 had either been diagnosed with arthritis or were living with undiagnosed chronic joint pain and other symptoms. Although the risk of some types of arthritis, such as osteoarthritis, increases with age, more than half of those affected by all types of arthritis are younger than 65. In fact, arthritis is the leading cause of disability in Americans older than 15.

It doesn't have to be that way. If you have arthritis, there are steps you can take, starting today, to protect your joints, reduce pain, and improve mobility. The exact strategy depends on the type of arthritis you have, but for most people, there is reason for optimism.

This report describes how arthritis affects the joints and other structures. It explains how the various kinds of arthritis are diagnosed and treated, and tells how to minimize the impact of arthritis in your life.

Obtaining the correct diagnosis is particularly important and sometimes quite difficult. Joint discomfort can result from any one of a number of different conditions, but even blood and imaging tests often provide no definitive answer. Because being able to describe your symptoms is so important, this report discusses the variety of symptoms that may occur, and which are typical of particular kinds of arthritis.

In addition, you will find here detailed information and specific treatment advice for the two most common types of arthritis, osteoarthritis and rheumatoid arthritis, along with a brief look at other types of arthritis, such as gout, pseudogout, ankylosing spondylitis, and infectious arthritis.

Because living with arthritis requires more than finding a drug treatment, this report also provides advice about how to exercise safely, cope with emotions, and evaluate whether complementary therapies, such as glucosamine and chondroitin supplements, are right for you.

well Millions of people live with arthritis, but this report will suggest ways to live .

What is arthritis?

arthron -itis The word arthritis is derived from the Greek word (joint) and suffix (inflammation). For people who have arthritis, the word variously signifies pain, swelling, redness, and heat that may be caused by tissue injury or disease in the joint.

Osteoarthritis is the most common type of arthritis. It is called a degenerative joint disease because it results from the deterioration of the bones and cartilage that make up the joints. The second most common type of arthritis, rheumatoid arthritis, is an inflammatory disease that affects the lining of multiple joints, especially in the hands and feet. Although it affects only one-tenth as many people as osteoarthritis, it can be far more debilitating. The other rheumatic diseases discussed in this report gout, pseudogout, ankylosing spondylitis, reactive arthritis, psoriatic arthritis, enteropathic arthritis, and infectious arthritis are also characterized by inflammation.

The musculoskeletal system

All types of arthritis affect the musculoskeletal system in some way, although the joints involved and the means of damage may vary.

The arrangement of bones and muscles in the body is a marvel of engineering. A model of a skeleton may look rickety and frail, but bones have a compression strength equaling that of cast iron or oak. Although incredibly light the average adult skeleton weighs only 20 pounds or so bones are capable of bearing tremendous weight. Their strength is necessary to withstand the forces of movement. When you walk at a leisurely pace, each foot strikes the ground with a force about three times your weight. At a brisk walk or run, the pressure increases to five to six times your weight. In other words, a 150-pound person's lower extremities are subjected to 450900 pounds of force during normal activity.

The arrangement of muscles helps hold the skeleton together and, at the same time, provides a means of moving individual bones. Tendons and ligaments, the structures that bind bone and muscle, are made of connective tissue. The main proteins that make up connective tissue are collagens and elastins, which imbue it with tensile strength and elasticity.

The immune system

Inflammation is the hallmark of a number of types of arthritis, including rheumatoid arthritis, gout, pseudogout, ankylosing spondylitis, reactive arthritis, psoriatic arthritis, enteropathic arthritis, and infectious arthritis. Such conditions all appear to stem, directly or indirectly, from an inflammatory response instigated by the immune system.

In inflammatory rheumatic diseases, the immune system reacts to elements that the body perceives as foreign be they actual invaders, such as bacteria, or simply cell components wrongly identified as foreign. Research shows that certain people may be more genetically susceptible than others to such inflammatory rheumatic diseases.

Diagnosing arthritis

Diagnosing arthritis poses a significant challenge to any physician because of the sheer number of conditions that can cause joint discomfort and because there are rarely tests available to establish a definitive diagnosis. Consequently, a doctor must rely heavily on your description of symptoms and other relevant information, plus a physical examination. That's why you should prepare for your appointment by making a list of your symptoms and the circumstances under which they occur. Do you notice them during or after a particular activity? Or first thing in the morning?

Primary care doctors can usually determine at the first visit whether the problem is a form of arthritis or some other musculoskeletal problem, such as bursitis or tendonitis. But it may take several visits for your physician to make a more specific diagnosis. While this delay can be frustrating for the patient and family, charting the course of your symptoms is often the only way a doctor can accurately diagnose arthritis.

Your medical history

Your symptoms what they are, when they first began, and how they've changed over time provide potent clues to whether arthritis is inflammatory or noninflammatory. Your doctor will need to know about the following:

type of joint symptoms (such as pain or stiffness)
effect of activity (such as increased pain or relief of stiffness during or after a particular activity)
general pattern of joint symptoms (started gradually or suddenly, worsened over time or stayed about the same, migrated from one joint to another, or fluctuated in intensity)
any other symptoms (fever, fatigue, weight loss, skin problems, bowel problems)
events that occurred near the time the symptoms first appeared (such as viral illness, bacterial infection, injury, vaccination, new medication, or change in activity)
time of day that joint symptoms are worst (prolonged morning stiffness suggests inflammatory arthritis; night pain is more typical of noninflammatory joint disease)
presence or absence of joint swelling, redness, or warmth
previous episodes of similar symptoms
family history of arthritis or rheumatic disease.

When to see a doctor

Because arthritis isn't usually a medical emergency, you can schedule a routine appointment for evaluation. However, certain situations and symptoms demand immediate attention. These include

joint trauma or injury, especially if the joint cannot function or there is a feeling of instability (may require orthopedic treatment)
joint pain accompanied by fever, rash, or other systemic signs, such as fatigue, headache, or weight loss (can indicate other autoimmune diseases, chronic infection, or cancer)
severe pain in one or a few joints (can indicate joint infection or gout)
neurologic symptoms, such as numbness or pain in hands or legs or radiating from neck, or in low back (may indicate nerve compression).

Pain and stiffness

In rheumatic diseases, pain and stiffness go hand in hand. Pain is a subjective experience that's often difficult for people to describe, quantify, or even pinpoint. Chronic arthritis produces aching pain when the affected joints are moved, as opposed to burning or prickling pain unrelated to motion that typifies neurologic disorders. Most people can describe the location of pain in small joints, such as the hands or feet. However, with large joints, the pain is generally more diffuse and may radiate, making it difficult to pinpoint. For example, hip arthritis may cause pain in the groin, thighs, buttocks, or even knees.

People often describe vague muscle aches as stiffness, but rheumatologists use the term more specifically for joint discomfort when a person attempts to move: Stiffness is the tendency of a joint not to move easily and may be prominent even when joint pain is not. The duration of stiffness in the morning or after any period of inactivity can help doctors distinguish osteoarthritis from rheumatoid arthritis and other types of arthritis.

Mild morning stiffness is common in osteoarthritis and resolves after a few minutes of activity. Sometimes people with osteoarthritis notice more stiffness during the day after resting for an hour or so. In rheumatoid arthritis, however, morning stiffness may not begin to improve for an hour or longer. Occasionally, morning stiffness is the first symptom of rheumatoid arthritis.

The nature and duration of your joint symptoms can be helpful. For example, pain and stiffness that develop gradually and intermittently over several months or years suggest osteoarthritis. Rheumatoid arthritis or another inflammatory arthritis may cause pain, stiffness, and fatigue that worsen over several weeks or a few months. In contrast, sudden pain is more likely to be due to an injury or fracture, and pain that intensifies over several hours is typical of bacterial infection or gout.

Helpful hint

A pain record is useful. For two weeks preceding your doctor's appointment, keep a record of your pain, its intensity, duration, characteristics, and any action that makes it worse or better. Your doctor will use this information in diagnosis.

Physical examination

Because many other disorders can masquerade as arthritis, a complete physical examination is a necessary part of the diagnostic process. During your visit, the doctor watches how you move and looks at joints for abnormalities. The doctor moves your joints through their range of motion to detect any pain, resistance, unusual sounds, or instability. The doctor also gains information from a visual assessment of how you use your joints, and so may ask you to take a few steps, move your hands and arms, and so forth.

Swelling. An inflamed synovial membrane often produces mild joint swelling. People may describe a sensation of tightness or fullness inside the joint, or it may feel tender. Doctors describe the joint as feeling "boggy" or soft to the touch. Marked swelling usually indicates excessive joint fluid, a sign of inflammation or perhaps bleeding into the joint.

Enlargement. Enlargement of a joint is not the same as swelling. Bony enlargement without joint swelling feels hard to the touch and is not usually tender. This finding is typical of osteoarthritis, although it may also occur in people who have no joint pain and as a consequence of other joint disease, such as rheumatoid arthritis.

Limited motion. Doctors assess joint mobility in two ways: active range of motion in which the person voluntarily moves the joints, and passive range of motion in which the examiner moves the person's joints. By comparing active and passive movement, doctors can often determine whether the cause is muscle weakness, bursitis, or tendonitis (in which case the joint has wider range of motion during passive movement), or whether the problem is with the joint itself. Doctors listen and feel for crepitus, a crunching or grating sensation that is sometimes audible and is caused by rough surfaces rubbing together inside the joint.

Spine flexibility. To evaluate spine flexibility, the doctor may ask you to stand and, without moving your pelvis, bend forward as if touching your toes, bend backward, lean from one side to the other, and twist your upper body from side to side.

Diagnostic studies

In most types of arthritis, laboratory tests and x-rays or other imaging techniques may be helpful, but by themselves rarely provide enough information for doctors to establish a specific diagnosis. However, there are exceptions. A bacterial infection of the joint, gout, and pseudogout can be diagnosed by removing and testing a sample of joint fluid (see "Arthrocentesis"). X-rays are occasionally diagnostic as well. For example, x-ray abnormalities in the pelvis and spine may reveal ankylosing spondylitis (see "Diagnosing ankylosing spondylitis").

Osteoarthritis

Osteoarthritis is a form of joint disease that develops when cartilage deteriorates. Over time, the space between bones narrows and the surfaces of the bones change shape, leading eventually to friction and joint damage (see Figure 5). Osteoarthritis often affects more than one joint, and while it can affect any joint in the body, some joints are affected much more often than others. For example, osteoarthritis is quite common in the hip, knee, lower back, neck, and certain finger joints, but it is rare in the elbow.

Figure 5: Joint changes in osteoarthritis

Osteoarthritis is the most common of all joint diseases, accounting for about half of arthritis diagnoses in the United States. It affects approximately 21 million Americans. But these numbers only hint at the impact of osteoarthritis, which can send people to pain clinics and doctors' offices, make them reach for medications, keep them home from work, and curtail leisure and everyday activities. Because the risk of developing osteoarthritis increases with age, this form of arthritis is expected to become even more prevalent as the population of the United States grows older.

About equal numbers of men and women have osteoarthritis, but it tends to affect them differently. Men typically develop symptoms before age 45, while women usually don't have symptoms until after age 55. Women more often have osteoarthritis in the hands and knees. Men are more likely to have it in the hips, knees, and spine. Women are 10 times more likely to develop Heberden's nodes, a type of osteoarthritis in which hard, bony growths form on the joint nearest the fingertip.

More than wear and tear

Osteoarthritis is virtually unheard of in children and is rare in young adults. But it's common among older people. Almost everyone over age 65 has some cartilage and bone changes typical of the disorder. For this reason, osteoarthritis was long considered a natural product of aging, reflecting everyday wear and tear on cartilage. Although this attitude still prevails among many physicians, experts now believe the cause is much more complex. External factors, such as injuries, are important initiators, but the rate of progression is probably also affected by genetic and environmental traits.

While it's true that one's risk of developing osteoarthritis symptoms increases with age, many people whose x-ray films indicate joint changes typical of osteoarthritis have no symptoms. The severity of osteoarthritis symptoms depends on many factors, including how people use their joints. That's why taking the time to protect your joints is so important (see "Joint protection strategies").

The first signs of osteoarthritis are microscopic pits and fissures in the surface of the cartilage in your joints (see Figure 5). These fissures indicate that biochemical changes are gradually making the cartilage less resilient. Cartilage cells themselves produce enzymes that damage the molecules making up the structure of the cartilage, and tiny pieces of cartilage may flake off into the joint cavity. This changes the shape of the cartilage lining the bone, causing further damage as the altered surfaces move against each other.

As cartilage degenerates, patches of exposed bone appear. Just as a damaged gasket leads to metal-on-metal contact in a machine, your bones experience mechanical friction and irritation. They try to repair themselves, but the repair is disorderly. As a result, the surface thickens and osteophytes (bone spurs) form.

Once your cartilage is damaged, the resulting abnormalities can irritate surrounding soft tissues and cause inflammation. People with severely damaged joints sometimes have episodes of joint swelling from synovitis (inflammation of the joint's lining); however, this inflammation tends to be much milder than in rheumatoid arthritis or other inflammatory joint diseases. The damaged cartilage, bone rubbing on bone, and the inflammation combine to make movement painful.

Doctors sometimes refer to osteoarthritis as noninflammatory to distinguish it from other rheumatic diseases. But many people with osteoarthritis experience low-grade inflammation. It may arise when the articular cartilage in your joint fails to recover fully from an injury. In addition, inflammation may reflect an attempt by the joint to repair damage, or it may be due to genetic or metabolic factors that predispose you to joint degeneration.

Fast fact

Researchers in a biomechanics laboratory at Wake Forest University reported in 2005 that overweight and obese people with knee osteoarthritis who lost weight could literally reduce the pounding on their knees. For each pound of weight lost during the study, participants experienced a 4-pound reduction in force per step.

Possible causes of osteoarthritis

Doctors may categorize osteoarthritis as primary, meaning the principal cause is unknown. However, excess weight and genetics also contribute to predisposition. Or the disease may be categorized as secondary, originating from trauma, such as a blow or injury, or a recognizable disease process, such as hemophilia. Some scientists believe primary osteoarthritis begins with repeated minor injuries. The cartilage is able to repair itself for a time, but eventually this effort fails.

Symptoms of osteoarthritis

The symptoms of osteoarthritis usually develop over many years. Often, people first experience pain after engaging in strenuous activity or overusing a joint. The joint may be stiff in the morning, but after a few minutes of movement, it loosens up. Gradually, this stiffness becomes a routine part of waking up.

Cartilage is insensitive to pain, but the soft tissue in the joints is not. As more cartilage is worn away, soft tissue becomes increasingly irritated, even by slight movement. Some people have continual joint pain that interferes with sleep. Or the joint may be mildly tender, and movement may produce crepitus, a sensation of crackling or grating. In addition, gradual joint enlargement may interfere with normal mobility. Swelling may also occur as synovial tissues become irritated, or when inflammation develops. Although inflammation is not a cardinal feature of osteoarthritis, it does sometimes occur. Pain usually occurs in the affected joint, although it may extend elsewhere.

When osteoarthritis affects the knee, the result is pain, swelling, and stiffness of that joint. What starts out as some discomfort after a period of disuse can progress to difficulty walking, climbing, bathing, and getting in and out of bed.

Osteoarthritis of the hand often starts with stiffness and soreness of the joint at the base of the thumb, particularly in the morning. You may find it becomes harder to pinch, and your joints crackle when moved. As the condition worsens, the pain at the base of your thumb can become more of a problem, and your ability to pinch decreases even further. The entire area may seem unstable. People with osteoarthritis of the hand may eventually find it impossible to open jars, turn a key, write, or type. Many people with osteoarthritis of the hand find that, with age, their hands thicken and become stiff. Stiffness is gradually followed by pain or instability. In other people, the pain and stiffness of hand osteoarthritis may subside over time, despite marked bony enlargement typical of the disease.

Radiating pain is often the most striking feature of hip and spine osteoarthritis. When osteoarthritis affects your hip, you may feel pain in the groin or down the inside thigh, or pain may radiate to your buttocks or knee. Osteoarthritis of the cervical spine (neck) may cause pain in your shoulders and arms. In the lower spine, osteophytes may impinge on adjacent nerves and send pain radiating to your buttocks or legs.

For most people, osteoarthritis develops gradually. Pain and stiffness in affected joints may slowly worsen, but most people are able to lead normal lives.

Symptoms of osteoarthritis

joint pain, bony enlargement and swelling
symptoms worsen after activity
brief duration of joint stiffness in the morning (less than 30 minutes)
grinding sensation when joint is used

Diagnosing osteoarthritis

Diagnosis is usually straightforward and is based on a person's symptoms and medical history (see "Diagnosing arthritis"). When symptoms don't fit the usual pattern for osteoarthritis, further investigation, often by x-ray or other imaging techniques, may be necessary. Such atypical examples may involve arthritis of joints that are usually spared, such as the elbow, shoulder, or ankle, or swelling of the synovium, a condition known as synovitis.

Drug treatment for osteoarthritis

Although no drug exists that will cure or reverse the progression of osteoarthritis, it is usually possible to alleviate pain and inflammation. Medications form the basis of treatment for osteoarthritis, but are best used in conjunction with other pain relief strategies, such as exercising to build your muscles and protecting your joints from injury or overuse (see "Slowing the progression of osteoarthritis").

Surgical treatment for osteoarthritis

Sometimes surgical intervention is necessary to relieve extremely painful or badly misaligned joints. The option your doctor recommends will depend on your age, activity level, and overall health. Surgical options are usually recommended only when drug therapies and other strategies have failed.

Slowing the progression of osteoarthritis

Osteoarthritis is a disease that progresses slowly over many years (see "More than wear or tear"). If you've already been diagnosed with osteoarthritis, you can take steps to slow its progression and reduce your discomfort. These measures are most effective if you begin them in the earlier stages of your condition. But no matter how far your osteoarthritis has progressed, you can benefit from the following.

Rheumatoid arthritis

The treatment of rheumatoid arthritis has changed dramatically since the 1990s, owing to a better understanding of how to slow the progression of joint damage in this disease. Advances in treatment, discussed below, followed decades of research into how the immune system functions.

Until the mid-1960s, physicians lumped together most forms of arthritis that affected four or more joints as rheumatoid arthritis. Then researchers identified rheumatoid factor, an antibody present in the blood of 70%80% of people with rheumatoid arthritis. The presence or absence of rheumatoid factor helped physicians distinguish rheumatoid arthritis from other types of inflammatory arthritis that may occur in people who have psoriasis, inflammatory bowel disease, or infectious diseases. Rheumatoid factor may also help distinguish between rheumatoid arthritis and osteoarthritis, because people with osteoarthritis are no more likely to have rheumatoid factor than the general population.

Rheumatoid arthritis is a chronic autoimmune disease in which the body's immune system attacks healthy tissue lining the joints. It affects about three million Americans, and strikes two to three times more women than men. Although the disease usually first appears during middle age, it may occur in the 20s and 30s. Some children develop a similar disease, called juvenile chronic arthritis, but this is considered a separate disorder.

The chronic inflammation of rheumatoid arthritis begins in the synovium, where an unknown event triggers an inflammatory reaction. As a result, synovial and other cells produce cytokines, other chemical mediators, and proteolytic enzymes, which together can destroy all the components of the joint. The synovial tissue also begins to proliferate, causing the normally smooth synovium to form pannus, a rough, grainy tissue that grows into the joint cavity and erodes cartilage (see Figure 7). If the tendons become inflamed, they may shorten and immobilize the joint, which can cause bone fusion and loss of mobility. If the tendons rupture, the joint may become loose or floppy.

Figure 7: Joint changes in rheumatoid arthritis

Rheumatoid arthritis can affect connective tissue in other parts of the body. Inflammatory skin nodules at pressure points, such as the elbow, can appear gradually or suddenly, and may be tender and sometimes inflamed. Occasionally, surgery is needed if these nodules become infected or are bothersome during activity. At times, they may also disappear spontaneously.

Vasculitis (inflammation of blood vessels) can compromise circulation to the hands, feet, and nerves. People with rheumatoid arthritis often develop eye conditions, including keratoconjunctivitis sicca, or dry eye, which causes redness, burning, itching, reduced tearing, and sensitivity to light. Other complications include respiratory, heart, and neurologic disorders. In rare cases, the ligaments that tether the uppermost vertebrae (which support the skull) are damaged, allowing the vertebrae to slip out of alignment and pinch the spinal cord.

At advanced stages, rheumatoid arthritis can limit a person's ability to carry out normal daily activities such as dressing, bathing, and walking. Those affected often experience feelings of depression and helplessness as the disease progresses. However, medications are now helping to slow the progression of rheumatoid arthritis and make a dramatic difference in the lives of many of those affected.

One of the most important steps you can take if you are diagnosed with the disease is to become an active participant in your own care. This includes working with your doctor so that you can learn to recognize flare-ups and drug side effects, take medication as prescribed, and engage in activities to maintain joint function in order to prevent disability. Balancing rest with activity, dealing with the emotional impact of rheumatoid arthritis, and using splints or assistive devices to protect your joints against overuse are among the most helpful coping strategies (see "Physical and complementary therapies"). The ultimate goals in managing rheumatoid arthritis are to prevent or control joint damage, prevent loss of function, and decrease pain.

Symptoms of rheumatoid arthritis

The following are the most common symptoms of rheumatoid arthritis:

constant or recurring pain or tenderness in joints
stiffness and difficulty using or moving joints normally
swelling in and around multiple joints
warmth and redness in multiple joints
difficulty in performing daily tasks
arthritis in large and small joints in a more or less symmetrical pattern on both sides of the body
weight loss
low-grade fever
fatigue
prolonged morning stiffness (more than 30 minutes).

Possible causes of rheumatoid arthritis

Scientists don't know what causes rheumatoid arthritis, but they are investigating many hypotheses. The disorder runs in families, is more common among women, and may initially resemble some forms of infectious diseases, such as viral arthritis.

Genetic factors. Rheumatologists have long theorized that some insult (perhaps a microbe or an environmental toxin) triggers rheumatoid arthritis in genetically susceptible people. Now geneticists believe that HLA genes may provide the link. HLA-DR genes of which several dozen have now been identified are instrumental in identifying and disposing of foreign antigens. Scientists reported in 1978 that 70% of people with rheumatoid arthritis had molecules of certain DR4 subsets on their lymphocytes, while only 28% of healthy subjects had such molecules. Subsequently, several other genes in the HLA family have been implicated as well.

Infectious agents. Mycoplasma Chlamydia Scientists have searched without success for evidence that individuals with rheumatoid arthritis might harbor certain bacteria known to cause other types of arthritis, such as (which causes pneumonia or genital infections) or (one of several sexually transmitted organisms that can cause Reactive Arthritis). A more likely role for bacteria would be through an immune system error: Lymphocytes might produce antibodies against a bacterial product that also react against a connective tissue protein. Other researchers believe that a virus is the most likely culprit.

This form of arthritis attacks multiple joints and is usually symmetrical it affects joints similarly on both sides of the body, particularly the finger joints, base of the thumbs, wrists, elbows, knees, ankles, or feet. It nearly always involves the wrists and the middle and large knuckles, but seldom the joints nearest the fingertips (see Figure 8). At times, joint pain may be constant, even without movement. Morning stiffness that lasts for an hour or longer is a hallmark of the disease and one of the main ways doctors gauge the severity of inflammation.

The course of rheumatoid arthritis is unpredictable. Early on, the symptoms frequently abate or even disappear, only to flare up weeks or months later. Occasionally complete remission occurs, usually within the first year. But for some people the process is destructive, ending in severe disability within a few years.

Figure 8: Rheumatoid arthritis of the hand

An x-ray revealing rheumatoid arthritis of the right hand.

Diagnosing rheumatoid arthritis

People who have symptoms of arthritis should have a complete medical evaluation (see "Diagnosing arthritis"). The symptoms and physical examination are the most important parts of the diagnostic process. The early joint symptoms of other conditions, such as lupus, are sometimes indistinguishable from those of rheumatoid arthritis, making a definitive diagnosis difficult soon after symptoms start. Blood and imaging tests are often ordered to help with diagnosis.

It's important to understand that it may take several weeks (and several visits) before you receive a definite diagnosis. People often find it frustrating to wait, and they worry that they are not receiving prompt treatment. But you may find it reassuring to know that a few weeks' delay will not jeopardize your health, whereas undergoing the wrong therapy could.

Medications for rheumatoid arthritis

In the 1990s, the treatment of rheumatoid arthritis changed significantly, as researchers developed new medications to treat this disease. Prior to this, doctors treated rheumatoid arthritis conservatively. But evidence that joint damage starts early in the course of the disease has prompted physicians to treat it more aggressively from the beginning.

Given the complex nature of rheumatoid arthritis, and the fact that its progression varies from person to person, there are no easy answers when it comes to deciding on a treatment plan. In general, it is best to wait six to eight weeks to allow for a definitive diagnosis and to see how you respond to initial treatment before committing to long-term aggressive medical therapy. It is also important to remember that treatment should be tailored to the individual: Although some people with rheumatoid arthritis begin aggressive therapy within weeks of diagnosis, others may not need it right away.

Drugs for rheumatoid arthritis fall into several classes (see Appendix), and may be given in combination or sequentially. Although newly approved drugs tend to generate a lot of excitement, it's best to be cautious when using any new drug. The withdrawal of two COX-2 inhibitors from the market because of safety concerns shows dramatically that the true benefits and risks of any medication may not be known for years. Studies conducted to gain FDA approval for a drug may enroll no more than a few hundred or a few thousand people, who may be healthier than those who take the drug after it is approved. What's more, pre-approval studies are often limited in duration, while people taking the drugs for a disease like rheumatoid arthritis may take them for years. Uncommon side effects, interactions with other drugs, and long-term side effects only emerge in the general population in the years following approval. Unfortunately, there is no system in place to reliably identify these problems sooner. For all these reasons, make sure you understand and carefully weigh the risks and benefits before deciding to try a novel therapy.

Surgery for rheumatoid arthritis

Some people with rheumatoid arthritis require surgery to reconstruct or replace a damaged joint. Surgery is usually recommended when drug treatment alone can no longer improve the situation, although the timing of such surgery and whether to go ahead with it is up to you and your physician. Surgery is usually viewed as a last resort to reduce pain and improve function. One possible exception is hand surgery, as many hand surgeons advocate early surgical intervention to remove inflamed tissue and to help protect the joints and nearby tendons.

Many of the surgical procedures used to repair joints damaged by osteoarthritis are also used in rheumatoid arthritis. The most common surgical procedures for rheumatoid arthritis are arthroscopy, synovectomy (removal of the inflamed tissue that lines the joint), and arthroplasty (joint repair, including joint replacement). The choice depends, in part, on which joints are involved and whether you have any other medical problems. Total joint replacement, most commonly for severe hip or knee arthritis, is a major operation and carries the associated risks (see "Joint reconstruction or replacement").

Slowing the progression of rheumatoid arthritis

Rheumatoid arthritis is a chronic condition, without a cure. For that reason, most people find that it's necessary to combine the drug therapies and surgical options already described with lifestyle changes and supportive services. It's also a good idea to periodically review your balance of drug, surgery, and other management strategies to make sure they still meet your individual needs.

Physical and occupational therapy. When you have rheumatoid arthritis, it's important to pay special attention to the way you move and the way you function in general. Joint pain and generalized symptoms such as fatigue and stiffness can make ordinary activities known as activities of daily living more challenging, especially during flares. An occupational therapist or physical therapist can offer many suggestions about how to optimize your capacity to manage everyday tasks at home and at work.

These therapists can also provide you with special devices to help conserve your energy and protect your joints. For example, during times when your joints are particularly tender, you can use a splint, brace, sling, elastic bandage, or cane to reduce the pressure on your joints and protect them from further injury. A podiatrist may provide shoe inserts (orthotics), recommend special shoes, or suggest other treatments to reduce pain in your feet and improve your ability to function.

Exercise. To prevent disability and preserve joint function, it's important to develop an exercise routine. It may help to have your health care provider or a physical therapist evaluate the motion of your joints and suggest specific exercises to help maintain your present level of functioning. If you don't actively use a diseased joint because of pain, you may develop muscle atrophy, which can result in loss of muscle strength and endurance.

Isometric exercises, which do not require joint motion, can be especially effective during flares. It is crucial to work with your health care provider to arrive at the right balance between exercise and rest. Never exercise to the point of increased or severe pain.

Diet. Although unscrupulous vendors may claim otherwise, there is no diet known to improve the symptoms of rheumatoid arthritis, and there are no proven dietary supplements that are clearly effective over a long period of time.

Complementary and alternative therapies. A number of alternative therapies have been advocated for rheumatoid arthritis, although most have not been rigorously studied. Researchers are sorting out which complementary approaches work best for people with rheumatoid arthritis (see "Physical and complementary therapies").

Other types of arthritis

Many other types of arthritis exist. The most common ones are discussed below.

Gout

Gout, a painful and potentially debilitating form of arthritis, has afflicted such famed figures as Benjamin Franklin and Henry VIII. Today it affects roughly two million Americans. This disorder develops after tiny, needle-like crystals of uric acid (a biological waste product) accumulate in joints, causing swelling and extreme sensitivity, sometimes to the point where even the slight touch of a sheet is unbearable. The same crystals may cause kidney stones if they accumulate in the kidneys.

Gout usually affects one joint at a time, most often the big toe, but sometimes a knee, ankle, wrist, foot, or finger. If gout persists for many years, uric acid crystals may collect in the joints or tendons and under the skin, forming whitish deposits known as tophi. About 90 percent of people with gout are men older than 40, and African American men are twice as likely as Caucasian men to be affected. Gout tends not to occur in women until at least 10 years after menopause.

Pseudogout

Pseudogout is a form of arthritis that occurs when a particular type of calcium crystal accumulates in the joints. As more of these crystals are deposited in the affected joint, they can cause a reaction that leads to severe pain and swelling. The swelling can be either short-term or long-term and occurs most frequently in the knee, although it can also affect the wrist, shoulder, ankle, elbow, or hand. The pain caused by pseudogout is sometimes so excruciating that it can incapacitate someone for days.

As its name suggests, the symptoms of pseudogout are similar to those of gout (see "Gout"). Pseudogout can also resemble osteoarthritis or rheumatoid arthritis. A correct diagnosis is vital, as untreated pseudogout can lead to joint degeneration and osteoarthritis. Pseudogout is most common in the elderly, occurring in about 3% of people in their 60s and as many as half of people in their 90s.

Ankylosing spondylitis

Ankylosing spondylitis is a chronic, systemic inflammatory disease that may strike in the prime of life, often between the ages of 20 and 40. It's more common in men than in women. The disease develops as tendons attaching muscles to the spine become inflamed, causing pain and limiting movement. As ankylosing spondylitis progresses, vertebrae in the spinal column may fuse (see Figure 10). In its most advanced stages, the disease may affect joints in the lower back and upper buttocks and also cause inflammation or damage to the eyes, heart, and lungs.

Figure 10: X-ray of the spine

This x-ray shows a fused bamboo-like spine characteristic of ankylosing spondylitis.

Reactive arthritis

Reactive arthritis is the more appropriate term for what doctors in the past called Reiter's syndrome.

Reactive arthritis gets its name from the fact that symptoms are triggered by some type of infection elsewhere in the body. The infection is most commonly in the intestinal tract (such as salmonella) or a sexually transmitted disease (such as Chlamydia). The arthritis may develop weeks or months after the original infection, well after the infection has been treated and is cured. When it does appear, symptoms may flare suddenly, causing pain and stiffness in joints, most typically in the wrists, knees, ankles, and feet.

About 40% of people with reactive arthritis develop conjunctivitis (eye inflammation), which is usually mild and transient. Some people have uveitis, a more serious eye inflammation that may also occur in ankylosing spondylitis. In addition, many people with reactive arthritis develop urinary symptoms due to inflammation of the urethra (the tube that carries urine from the bladder out of the body). Many people with reactive arthritis have the "classic" combination of all three problems arthritis, eye inflammation, and urinary symptoms.

Symptoms of reactive arthritis

fatigue and fever
generalized muscle aching and joint pain
low back pain radiating to buttocks or thighs
discomfort aggravated by inactivity, eased by exercise
arthritis that develops suddenly
eye redness and discomfort in some people
symptoms following an infection of the intestinal tract or a sexually transmitted disease

Psoriatic arthritis

Psoriatic arthritis is a complication of psoriasis, a chronic skin disease that is characterized by bright pink or salmon-colored scales covering the knees, elbows, chest, back, or scalp. While most people with psoriasis do not develop arthritis, around 15% do. About 75% of people develop psoriatic arthritis only after the skin condition appears, although in some people the arthritis occurs before the skin condition.

Psoriatic arthritis usually develops between ages 20 and 50 and can affect any joint of the body. At least five variations of psoriatic arthritis exist, differentiated according to which joints are involved and whether both sides of the body are uniformly affected (such as one elbow or both elbows). When fingernails are affected by psoriasis, becoming pitted and ridged, the joints at the tips of the affected fingers are especially likely to develop arthritis. Psoriatic arthritis affects everyone differently, as symptoms and their intensity may vary and can also change within individuals as time passes. Psoriatic arthritis, like psoriasis, is lifelong and cannot be prevented.

Enteropathic arthritis

Enteropathic arthritis develops in approximately 9%20% of people with ulcerative colitis or Crohn's disease, which are types of inflammatory bowel disease. These disorders cause episodes of abdominal pain, diarrhea, and weight loss. When arthritis develops in people with ulcerative colitis or Crohn's disease, it usually affects multiple joints in the arms and legs. About 20% of people with enteropathic arthritis have sacroiliitis, an inflammation of the sacroiliac joints in the lowest region of the back.

Lyme disease and other infectious arthritis

Infectious arthritis, as indicated by its name, is caused by an infection with bacteria, viruses, or fungi. Infections usually spread to the joints from the site of origin by way of the bloodstream, so it may be difficult to determine where the infection started. Once the infection reaches the joint, it can cause warmth, pain, and swelling, sometimes accompanied by fever and chills. Occasionally, infection is introduced directly, as with a puncture wound or major injury.

Infectious arthritis due to bacteria most often affects the knee, although infections that are caused by viruses are most likely to affect small joints such as fingers or toes. People with other joint diseases, such as rheumatoid arthritis, are slightly more likely to develop infectious arthritis, although the overall frequency of infectious arthritis, even among people with existing joint problems, is relatively low.

Physical and complementary therapies

Despite the variety of medications available for arthritis, physical therapy remains a cornerstone of traditional treatment. In addition, many people with arthritis try various complementary therapies to alleviate pain and other symptoms. Options abound in both these areas and, when carefully chosen, such nonmedical therapies can help you maintain and improve joint function.

Physical therapists focus on restoring or maintaining physical function by designing an individualized treatment program for you. The physical therapist first will thoroughly evaluate your pain, functional ability, strength, and endurance levels, then will provide advice about ways to ease pressure on your joints while building muscles to support them. Physical therapy can take place at a hospital or outpatient clinic, in the therapist's office, or in your home. Some activities can be done alone; others require the therapist's assistance.

You are likely to have much less guidance when it comes to deciding on whether to use complementary therapies, and which ones. Such therapies literally run the gamut from A to Z from acupuncture to zinc supplements. And they're popular: One widely cited 1997 paper estimated that one in four people with arthritis used some type of complementary therapy. Although hundreds of such therapies exist, only a few have actually proved to be effective when evaluated in rigorous studies.

To become a wise consumer of complementary therapies, become a skeptical one. Don't buy into any treatment that promises a quick cure. And be sure to ask questions about complementary therapies: Do the claims rely only on testimonials from people who have tried the treatment, rather than on scientific studies? Are the promises extravagant? Do proponents advise not telling your doctor about the treatment? Do they suggest stopping medical treatment? Are the ingredients unidentified or "secret"? If you answer any of these questions "yes," your best response to trying a therapy is an emphatic "no."

Finally, if you are contemplating any physical or complementary treatment, you should first discuss it with your doctor to make sure it will support, rather than hinder, your arthritis management plan.

Heat and cold therapy

In the 19th and early 20th centuries, wealthy Europeans embraced hydrotherapy (warm baths) and sought cures at exotic spas for real and imagined ailments. Most resorts claimed that the health benefits were from minerals in the water. The therapeutic value actually lay mostly in the water's temperature. Heat raises the pain threshold and relaxes muscles.

Hydrotherapy remains a standard part of the physical therapist's practice, and its techniques can be used at home. A bathtub equipped with water jets or a hot tub can closely duplicate the warm-water massage of whirlpool baths used by professionals. Of course, oversized tubs are expensive luxuries. For most people, the bathtub works nearly as well. A 1520 minute soak in a warm bath exposes the body to warmth and allows the weight-bearing muscles to relax.

A warm shower can relieve the morning stiffness of ankylosing spondylitis and may help lessen the stiffness caused by other kinds of arthritis. People can upgrade their showers with an adjustable shower-head massager that's inexpensive and easy to install. It should deliver a steady fine spray or a pulsing stream, usually with a few options in between. Therapists also recommend taking a warm shower or bath before exercising to relax joints and muscles. Dress warmly after a shower or bath to prolong the benefit.

A heating pad is another good idea, but keep in mind that moist heat penetrates more deeply. Although you can purchase hot packs and moist/dry heating pads, a homemade hot pack works just as well. Heat a damp folded towel in a microwave oven (usually for about 1060 seconds, depending on the oven and the towel's thickness) or in an oven set at 300 degrees (for 510 minutes again, this depends on the oven and towel thickness). To prevent burns, always test the heated towel on the inside of your arm before applying to a joint: It should feel comfortably warm, not hot. To be extra safe, wrap the heated, moist towel in a thin, dry one before placing it on the skin.

Sometimes therapists recommend a paraffin bath. You dip your hands or feet into wax melted in an electric appliance that maintains a safe temperature. After the wax hardens, the therapist wraps the treated area in a plastic sheet and blanket to retain the heat. Treatments generally take about 20 minutes, after which the wax is peeled off. Paraffin bath kits are also available for home use, but it's important to talk with your physical therapist for recommendations and cautions before purchasing one, to avoid burning yourself.

Cold has analgesic effects similar to those of heat: An ice pack on the joint relieves pain, especially after an injury. Gel-filled cold packs are inexpensive and available in different sizes and shapes. Keep two or more in the freezer so you'll have cold therapy available instantly. Ice chips in a plastic bag also work well. Cold packs should be applied for 1520 minutes and can be reapplied hourly or as needed. Coolant sprays, available from pharmacies, may also be used. Cooling is a temporary measure to relieve pain; too much may induce muscle stiffness and painful circulatory disturbances.

Exercise

Even the healthiest people find it difficult to maintain an exercise regimen. But those with arthritis commonly discover that if they don't exercise regularly, they'll pay the price in pain, stiffness, and fatigue. Regular exercise not only helps maintain joint function, but also relieves stiffness and decreases pain and fatigue. Feeling tired may be partly the result of inflammation and medications, but it's also caused by muscle weakness and poor stamina. If a muscle isn't used, it can lose 3% of its function every day and 30% of its bulk in just a week.

Work with your physician or physical therapist to develop your own exercise program. Most likely this will involve exercises with three goals.

Increase range of motion. These exercises aim to increase the mobility and flexibility of your joints. To increase your range of motion, move a joint as far as it can go and then try to push a little farther. These exercises can be done any time, even when your joints are painful or swollen, as long as you do them gently. For several examples of range-of-motion exercises you can do at home, see Figure 11.

Figure 11: Range-of-motion exercises for arthritis

Hand

Open your hand, holding fingers straight. Bend the middle finger joints. Next, touch your finger-tips to the tops of your palm. Open your hand. Repeat 10 times with each hand. Next, reach your thumb across your hand to touch the base of your little finger. Stretch your thumb back out. Repeat 10 times.

Knee

Sit in a chair that is high enough for you to swing your legs. Keep your thighs on the seat and straighten out one leg. Hold for a few seconds. Then bend your knee and bring your foot as far back as possible. Repeat with the other leg. Repeat 10 times.

Shoulder

Lie on your back with your hands at your sides. Raise one arm slowly over your head, keeping your arm close to your ear and your elbow straight. Return your arm to your side. Repeat with the other arm. Repeat 10 times.

Hip

Lie on your back, legs straight and about 6 inches apart. Point your toes toward the ceiling. Slide one leg out to the side and then back to its original position. Try to keep your toes pointed up the whole time. Repeat 10 times with each leg.

Strengthen your muscles. An excellent way to provide aching joints with more support is to strengthen the muscles surrounding them. Strengthening exercises use resistance to build muscles. You can use your own body weight as resistance. One example: Sit in a chair. Now lean forward and stand by pushing up with your thigh muscles (try to use your arms only for balance). Stand a moment, then sit back down, using your thigh muscles. This simple exercise will help ease the strain on your knees by building up your thigh muscles. Avoid these exercises during arthritis flare-ups.

Build endurance. Aerobic activities such as walking, swimming, and bicycling can all build your heart and lung function, which in turn increases endurance and overall health. Just be careful to pick activities with low impact on your joints. If you have arthritis, you should avoid high-impact activities such as jogging. If you're having a flare-up of symptoms, wait until it subsides before doing endurance exercises.

Joint protection strategies

When you have arthritis, it's important to pay attention to your body's signals. Overuse of arthritic joints can lead to pain, swelling, and additional joint damage. A physical or occupational therapist can teach you how to conserve energy, protect your joints, accomplish daily tasks more easily, and adapt to lifestyle disruptions. Many of these strategies are simple common sense.

Keep moving. Avoid holding one position for too long. When working at a desk, for example, get up and stretch every 15 minutes. Do the same while sitting at home reading or watching television.

Avoid stress. Avoid positions or movements that put extra stress on joints. For example, opening a tight lid can be difficult if you have hand arthritis. One solution is to set the jar on a cloth, lean on the jar with your palm, and turn the lid using a shoulder motion. Better yet, purchase a jar opener that grips the lid, leaving both hands free to turn the jar.

Discover your strength. Use your strongest joints and muscles. To protect finger and wrist joints, push open heavy doors with the side of the arm or shoulder. To reduce hip or knee stress on stairs, lead with the stronger leg going up and the weaker leg going down.

Plan ahead. Simplify life as much as possible. Eliminate unnecessary activities (for example, buy clothing that doesn't need ironing). Organize work and storage areas; store frequently used items within easy reach. Keep duplicate household items in several places; for example, stock the kitchen and all bathrooms with cleaning supplies.

Use labor-saving items. In the kitchen, use electric can openers and mixers. In the bathroom, cut down on scrubbing by using automatic toilet bowl cleaners and spray-on mildew remover in showers or tubs.

Use adaptive aids. Numerous devices on the market can help you avoid unnecessary bending, stooping, or reaching. Long-handled grippers, for example, are designed to grasp and retrieve out-of-reach objects. People with limited movement might have an easier time getting dressed by using long-handled hooks to put on socks and long-handled shoe horns. Also helpful are shoes that slip on or fasten with Velcro, pre-tied neckties, and garments with Velcro fasteners, zippers, or hooks and eyes instead of buttons. Rubber grips are available to help you get a better handle on faucets, pens, toothbrushes, and silverware. Pharmacies, medical supply stores, and online vendors stock a variety of aids for people with arthritis.

Make home modifications. Using casters on furniture can make housecleaning easier. A grab bar mounted over the tub is a necessity for many people, as is a suction mat in the tub to prevent falls. Putting a bathing stool in the tub or shower is a good idea for people who have arthritis in the lower extremities.

Ask for help. Maintaining independence is essential to self-esteem, but independence at all costs is a recipe for disaster. Achieve a balance by educating family members and friends about the disease and the limitations it imposes and enlisting their support. Ask for help with specific tasks.

Other physical therapies

A variety of other physical therapies have been suggested for the pain of arthritis, but the scientific evidence for their effectiveness is scant. If you choose to explore such therapies and find them useful, be sure to continue your conventional therapy and visit your physician regularly.

For example, a technique called diathermy (deep heat) uses electromagnetic waves of different frequencies to deliver heat deep to the tissues. Microwave and ultrasound are the most common wave frequencies used in physical therapy, chiefly to relieve muscle spasm. Microwaves relax muscles, while ultrasound penetrates deeper to reach other soft tissues as well. Diathermy should not be used on actively inflamed joints, and people with pacemakers cannot be treated with microwaves (although ultrasound is safe for such people). Whether diathermy is useful for people with inflammatory arthritis is controversial.

Doctors sometimes recommend transcutaneous electrical nerve stimulation (TENS) for people with chronic pain. TENS works by stimulating large nerve fibers, which theoretically blocks transmission of pain signals from small fibers. Some people with chronic pain from rheumatoid arthritis or osteoarthritis find TENS quite effective. The TENS device consists of a battery pack and electrodes that attach near the painful joint. The battery generates a very low electrical current to the electrodes, producing a pleasant tingling, vibrating, or massaging sensation.

Diet

The idea that a diet, supplement, or vitamin pill could prevent or cure arthritis is very appealing, but as yet there's no scientific evidence of an effective dietary solution for most types of arthritis. Gout, which can be triggered by certain foods, is the notable exception (see "Treating gout").

However, it is important to keep two issues in mind when it comes to diet. The first is that it's important to eat in a way that helps you to maintain a healthy weight, because excess pounds only increase the stress on your joints. To maintain a healthy weight, exercise regularly and eat a diet low in saturated and trans fats and high in vegetables and lean proteins.

Second, there is some evidence that omega-3 fats, found in cold-water fish such as salmon, herring, sardines, and mackerel, may help reduce inflammation. And some early studies have found that consuming such fats on a regular basis can reduce morning stiffness and joint tenderness in people with rheumatoid arthritis. But it's too soon to know whether these results will hold up over time, or whether people can continue the diet without gaining weight which would just create other problems. Even so, it may be wise to increase your consumption of omega-3 fats, if only because this type of diet is a good way to reduce your risk of heart disease.

Acupuncture

Many Americans undergo acupuncture treatments to help relieve pain, including the pain of arthritis. Acupuncture, which involves the application of tiny sterile needles to the skin, has been a staple of Chinese medicine for 2,000 years. Acupuncture is based on the belief that qi, or life force, flows along 14 meridians (channels) within the body. A blockage of qi is said to cause illness, while stimulating certain areas along the meridians with fine needles releases qi and restores health. Acupuncture seems to work by releasing endorphins, a natural morphine-like chemical in the nervous system.

Annals of Internal Medicine Although some people with arthritis find acupuncture treatments relieve their symptoms, results from studies have been inconsistent. However, a randomized controlled study of 570 people with osteoarthritis, published in the in 2004, found improvement in both joint function and pain relief with acupuncture therapy compared with sham therapy ("fake" acupuncture that participants believed was real). There is no proof that acupuncture reduces inflammation in joints. If you do choose to try acupuncture, talk with your doctor first and find a licensed acupuncturist.

Glucosamine and chondroitin

Glucosamine and chondroitin are both chemical components of cartilage, which has raised the hope that supplements containing synthetic versions of these substances might help stop joint destruction and ease arthritis pain. And over the years, some people who have osteoarthritis have claimed to have less pain and stiffness when regularly taking such products.

New England Journal of Medicine A major study designed to answer a key question whether these supplements relieve pain concluded that the answer may depend on the severity of pain you experience. The Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), reported in the in 2006, involved more than 1,500 people with osteoarthritis of the knee. Participants were randomly assigned to take glucosamine hydrochloride alone, chondroitin alone, a glucosamine-chondroitin combination, or the COX-2 inhibitor celecoxib (Celebrex). The study found that, on the whole, glucosamine and chondroitin supplements either taken alone or in combination provided no more pain relief than a placebo, but that celecoxib did. But the study also revealed that a certain subgroup of people those with moderate to severe pain did experience greater pain relief by taking the glucosamine-chondroitin combination than those taking a placebo.

To complicate matters further, the GAIT study used glucosamine hydrochloride, which is a different formulation from the glucosamine sulfite that other studies have found effective in relieving osteoarthritis pain. Meanwhile, the answer to a second key question whether taking glucosamine and chondroitin supplements will slow the process of cartilage destruction in the joints (as earlier studies have suggested) won't be known until the GAIT researchers complete that portion of the study.

At this point, if you're wondering whether you should take glucosamine and chondroitin supplements, the answer is: It depends. If you are experiencing moderate to severe osteoarthritis pain, try the glucosamine-chondroitin combination for two to three months. If you find it eases your pain, keep using it. If not, you might as well save your money. As always, if you choose to take these or any other alternative preparations, be sure to inform your physician.

Living with arthritis

People with arthritis often worry about the possibility of losing mobility, being unable to work, or growing dependent on others. But only a very small percentage of people with arthritis ever become severely disabled. Still, the emotional burdens of arthritis are considerable and may result in stress, anxiety, and depression.

Because living with chronic arthritis can be difficult, many physicians use questionnaires to assess your psychological function. Depression and anxiety are of particular concern.

Your doctor may also ask questions about what type of family and social supports you have available, to determine whether you need additional help. For example, if you live alone and have trouble walking, your doctor may refer you to a social worker who can help arrange for someone to handle shopping and other chores. If you are depressed or have anxiety, you may be referred to a psychiatrist.

Depression. Depression is common in people with chronic diseases. Arthritis specialists have assumed that depression is directly related to the amount of pain and the number of swollen joints a person has, but this isn't always the case. While some people equate a large number of swollen joints with severe disability, those whose favorite pastime is reading or spending time with family might not consider themselves disabled. However, a relatively slight impairment in hand mobility could be devastating for a pianist or artist, and could have a profound emotional impact. Diagnosing and treating depression can be challenging because its symptoms differ from person to person. But effective medications are available, and they often work best in combination with counseling or psychotherapy.

Stress. People with rheumatoid arthritis often report that the disease seems to flare up following stressful events. Because these anecdotes aren't easy to prove scientifically, some doctors have dismissed them. But within the past decade, immunologists have discovered that stress does, in fact, affect immune function. You can help yourself by finding ways to reduce stress.

Sexual intimacy. Arthritis may interfere with sexual intimacy, especially when the hips, knees, or spine are involved. However, even people with severe arthritis can enjoy an active sex life. A flexible attitude often compensates quite well for having a less-than-flexible body. For example, one might experiment with different positions to find the one most comfortable for intercourse; people with hip, knee, or spine arthritis often find it most comfortable when both parties lie on their sides. There are also other mutually gratifying sexual activities besides intercourse.

Many people find that taking an analgesic an hour before sex or having a warm shower lessens muscle and joint stiffness. Rescheduling sexual activity may also help; afternoons may be better if pain and fatigue are worse in the morning, for example.

Appendix: Drugs used to treat arthritis

Mild pain relievers (analgesics)
Generic name		Brand name				Use		Side effects		Comments
acetaminophen		Panadol, Tylenol, others				Relieves pain		Nausea, vomiting, diarrhea, jaundice, rash, tiredness, weakness; less likely to cause gastric bleeding than other pain relievers		Drinking large amounts of alcohol during long-term therapy with acetaminophen may cause liver damage. Kidney damage also possible with long-term use.
aspirin		Bayer, Bufferin, others				Reduces inflammation and relieves pain		Stomach pain, bleeding, ulcers		High doses may cause ringing in the ears. Before using, let your doctor know if you are on blood thinners or have liver or kidney problems.
Oral nonsteroidal anti-inflammatory drugs (NSAIDs)
Generic name		Brand name					Use		Side effects	Comments
diclofenac		Cataflam, Voltaren					Reduce inflammation and relieve pain		Stomach pain or bleeding, ulcers, weight loss, nausea, vomiting, drowsiness, dizziness, fluid retention, heartburn, diarrhea, constipation, blurred vision, tinnitus	Allergic reactions are rare but can occur. High doses can cause ringing in the ears. People who are allergic to aspirin should not take NSAIDs. People who take high doses for a long time should have periodic blood tests to check for bleeding and liver or kidney damage. May cause kidney damage in people who are dehydrated, or who already have a kidney problem or heart failure.
diflunisal		Dolobid
etodolac		Lodine
fenoprofen		Nalfon
flurbiprofen		Ansaid
ibuprofen		Advil, Motrin, others
indomethacin		Indocin
ketoprofen		Actron, Orudis, others
meclofenamate		Meclomen
mefenamic acid		Ponstel
meloxicam		Mobic
nabumetone		Relafen
naproxen		Aleve, Naprosyn, others
oxaprozin		Daypro
phenylbutazone		Cotylbutazone
piroxicam		Feldene
sulindac		Clinoril
tolmetin		Tolectin
COX-2 inhibitor
Generic name	Brand name					Use		Side effects		Comments
celecoxib	Celebrex					Reduces inflammation and relieves pain		Stomach upset, fluid retention; fewer gastrointestinal side effects than traditional NSAIDs; possible increased risk of heart attack or stroke		Same as for NSAIDs. Does not have the beneficial cardiovascular effects of aspirin. Should not be taken by those allergic to sulfonamides (common antibiotics). Talk with your doctor if you have heart disease.
Narcotic/analgesics
Generic name	Brand name					Use		Side effects		Comments
propoxyphene	Darvon (contains aspirin), Darvocet (contains acetaminophen), others					Relieves pain		Dizziness, sedation, nausea, vomiting, constipation, abdominal pain, rash, lightheadedness, headache		May be habit-forming when taken long-term or in large doses. Should be used cautiously by people with peptic ulcers, blood-clotting disorders, and liver disease.
tramadol	Ultram					Relieves pain		Convulsions		Those with a history of seizures, psychotropic drug use, or dependence on narcotics should not take tramadol. Drug interactions are common.
Corticosteroids*
Generic name	Brand name					Use		Side effects		Comments
methylpredni-solone	Medrol					Suppresses inflammation in severe organ disease or life-threatening disease		Fluid retention, weight gain, facial hair growth, easy bruising, ulcer, loss of calcium from bones (increases risk of fractures), cataracts, acne, bacterial infection, adrenal suppression (at doses above 5 mg per day), sleeplessness, muscle wasting and weakness, headache, glucose intolerance		Side effects are related to dosage and length of therapy. If a low dose is taken for a week or less, side effects are rare. Therapy for several months or years causes more noticeable and serious side effects, even at low doses.
prednisone	Deltasone, Orasone, others					Suppresses inflammation
injectable corticosteroids	varies					Relieve pain and suppress inflammation of synovitis, bursitis, tendonitis, or carpal tunnel syndrome		Same as above; also tenderness, burning, or tingling at injection site, thinning of skin at injection site, joint infections, cartilage damage		Injected into joints, tendon sheaths, or bursae. Undesirable systemic side effects seldom occur.
*Corticosteroids suppress the adrenal glands, which produce natural steroids. Abruptly stopping oral steroids can cause a life-threatening condition called Addisonian crisis. For this reason, corticosteroids must be taken exactly as prescribed. Before stopping corticosteroids, the dosage is lowered gradually, often over a period of several weeks or months.
Disease-modifying antirheumatic drugs (DMARDs)*
Generic name			Brand name		Use			Side effects		Comments
auranofin (oral gold)			Ridaura		Reduces inflammation in rheumatoid arthritis			Diarrhea, rash, kidney problems, blood abnormalities		Less toxic, but also less effective, than injectable gold. Rarely used for rheumatoid arthritis.
azathioprine			Imuran		Suppresses immune system in lupus, rheumatoid arthritis, and psoriatic arthritis			Nausea, vomiting, diarrhea, liver damage, blood abnormalities, risk of cancer with long-term therapy, infertility		Equal to other DMARDs in effectiveness, but slightly more likely to cause side effects. Generally reserved for people who do not respond to therapy with other DMARDs. Rarely used for rheumatoid arthritis.
cyclophospha-mide			Cytoxan		Suppresses immune system in severe lupus, rheumatoid arthritis, and other rheumatic diseases			Urinary tract bleeding, risk of infection including shingles, infertility in men and women, risk of cancers (including bladder cancer and leukemia)		Generally used to treat people who are unresponsive to other therapy, or who have dangerous inflammatory conditions. This drug was originally used to treat cancer. Rarely used for rheumatoid arthritis; more commonly used to treat lupus-related kidney disease or vasculitis.
cyclosporine			Neoral		Reduces inflammation in rheumatoid arthritis			Impaired kidney function, high blood pressure, hair growth, gum swelling, tremor, convulsions, headache		This drug was originally used to prevent organ rejection in transplant patients. Its effectiveness is equal to penicillamine and azathioprine. Generally used in combination with other DMARDs.
gold salts (injectable)			Myochrysine		Reduce inflammation in rheumatoid arthritis and psoriatic arthritis			Rash, mouth ulcers; in rare cases, blood abnormalities, kidney damage, inflammation of the upper respiratory tract		Effectiveness similar to many other DMARDs. Few people stay on this therapy for longer than five years because effect wears off or side effects occur. Rarely used for rheumatoid arthritis now.
hydroxychloro-quine			Plaquenil		Suppresses inflammation in rheumatoid arthritis; reduces disease activity in lupus			Nausea, vomiting, diarrhea, irritability, nervousness, rash, visual problems		This antimalarial drug is less likely to cause side effects than chloroquine; most commonly used to treat mild rheumatoid arthritis or lupus.
leflunomide			Arava		Reduces inflammation in rheumatoid arthritis			Birth defects, liver damage		Should not be used by people with liver disease or by women who are or plan to become pregnant. Women of childbearing age should use contraception while taking leflunomide.
methotrexate			Folex, Rheumatrex, Trexall		Suppresses inflammation in rheumatoid arthritis			Nausea, abdominal pain, ulcers, appetite loss, rash, liver damage, lung damage, headaches, blurred vision, drowsiness; long-term use results in immunosuppression		Folic acid supplements reduce gastrointestinal symptoms. This drug is as effective as or slightly better than other DMARDs and works more rapidly (in one to two months) than most DMARDs.
penicillamine			Cuprimine, Depen		Suppresses inflammation in rheumatoid arthritis			Nausea, vomiting, diarrhea, rash, kidney damage, blood abnormalities, and several unusual autoimmune problems such as drug-induced lupus		Side effects are common: 25% of people stop taking the drug within the first year. Rarely used for rheumatoid arthritis or other rheumatic disease.
sulfasalazine			Azulfidine		Suppresses inflammation in rheumatoid arthritis, ankylosing spondylitis, and other spondyloarth-ropathies			Nausea, vomiting, loss of appetite, severe rash, abdominal pain, blood abnormalities, headache, low sperm count		Should not be taken by people allergic to sulfonamide antibiotics.
*While taking a DMARD, you will undergo frequent monitoring tests to avoid complications. Depending on the DMARD prescribed, such monitoring may include eye tests, blood pressure monitoring, regular urinalysis, and/or one or more blood tests (such as a complete blood count or those used to measure kidney or liver function).
Anti-TNF compounds
Generic name	Brand name				Use			Side effects		Comments
adalimumab	Humira				Suppress inflammation in rheumatoid arthritis and other rheumatic diseases such as ankylosing spondylitis			Redness and irritation at injection site, increased risk of infection; may reactivate tuberculosis; may be associated with multiple sclerosislike reactions and, possibly, increased risk of lymphoma		Taken by self-injection. Taken every 2 weeks, with methotrexate, or on its own
etanercept	Enbrel				Same as above		Taken by self-injection once or twice weekly, often with methotrexate.
infliximab	Remicade				Same as above; may worsen heart failure		Given intravenously every 4 to 8 weeks, in conjunction with weekly oral methotrexate. Should not be used in people with heart failure.
Interleukin-1 inhibitor
Generic name	Brand name			Use				Side effects		Comments
anakinra	Kineret			Treats moderate to severe rheumatoid arthritis in people who do not respond to DMARD drugs				Mild redness and swelling at site of injection, headache, nausea, diarrhea		Taken by injection. Should not be used in combination with TNF-blocking agents.
Immune cell inhibitors
Abatacept	Orencia			Suppresses inflammation, for moderate to severe rheumatoid arthritis in people who do not respond to DMARD drugs				Headache, sore throat, nausea; rare but serious allergic reactions, increased risk of infection and possibly cancer. May worsen symptoms of chronic obstructive pulmonary disease (COPD)		Taken by monthly intravenous injection. Should not be used in combination with TNF-blocking agents
Rituximab	Rituxan			In combination with methotrexate, suppresses inflammation, for moderate to severe rheumatoid arthritis in people who do not respond to anti-TNF compounds				Infusion reactions; fever, chills, shakes, itching, hives, sneezing, swelling, throat irritation or tightness, and cough within 1-2 days after injection; increased risk of infection		Taken by intravenous injection twice over 2 weeks, often repeated every 6 to 12 months. Should not be used in combination with TNF-blocking agents.

Glossary

antibodies: Proteins produced by white blood cells to fight viruses, bacteria, and other foreign invaders.

antigen: A foreign protein or carbohydrate complex that causes an immune response.

articular cartilage: Tough, rubbery tissue that forms the surface of bones within joints.

autoimmune disease: A condition caused when an individual's immune system reacts against his or her own organs and tissues.

bursitis: Inflammation of the bursae, fluid-filled sacs that ease friction between tendons and bones (and tendons and ligaments), causing swelling and pain.

cartilaginous joint: A joint that contains a tough cartilage plate that permits slight movement.

collagen: The main structural protein in connective tissue.

connective tissue: The material that holds various body structures together; cartilage, tendons, ligaments, and blood vessels are composed entirely of connective tissue.

cytokines: Messenger molecules that allow cells to communicate and alter one another's function.

diathermy: Physical therapy using high-frequency electric current, ultrasound, or microwaves to deliver heat to muscles and ligaments.

elastin: Stretchable protein found in connective tissue.

enthesis: A site where ligaments or tendons attach to bone; plural is entheses.

enzyme: A protein that regulates chemical changes in other substances.

fixed joint: Fibrous tissue connecting the plates of the skull.

gout: Arthritis caused by uric acid crystals.

Heberden's node: A bony growth on the joint nearest the fingertip, caused by osteoarthritis.

human leukocyte antigen (HLA) complex: A type of receptor on cells involved in recognizing foreign antigens; these receptors are genetically determined, and some are associated with different types of arthritis.

inflammation: A response to injury or foreign invasion designed to protect the body; the symptoms are heat, redness, swelling, and pain.

ligament: Fibrous tissue connecting bones and cartilage.

Lyme disease: An infectious disease transmitted by a tick bite; characterized by rash, flulike symptoms, and inflammation of the heart, nerves, and joints.

lymphocyte: A type of white blood cell. B lymphocytes produce antibodies. T lymphocytes destroy abnormal cells and interact with B lymphocytes.

psoriasis: A common skin disease characterized by thickened patches of inflamed red skin; sometimes accompanied by painful joint swelling and stiffness.

reactive arthritis: Joint problems triggered by bacterial or viral infection elsewhere in the body.

rheumatic disease: Any one of over 100 disorders that cause inflammation in connective tissues.

rheumatoid factor: An antibody found in about 85% of people with rheumatoid arthritis; also appears in other diseases and sometimes in healthy people.

rheumatology: The branch of medicine devoted to the study and treatment of connective tissue diseases.

scleroderma: An autoimmune disease in which the skin thickens and hardens; sometimes other parts of the body are affected, and joint pain may result.

synovial joint: The most mobile type of joint; found in the shoulders, wrists, fingers, hips, etc.

synovitis: Inflammation of the synovium.

synovium: A thin membrane lining joint capsules that produces synovial fluid.

tendon: A tough, fibrous band of tissue that attaches muscle to bone.

tendonitis: Inflammation of a tendon, usually caused by injury, which may restrict movement of the muscle attached to the tendon.

urethritis: Inflammation of the urethra.

vasculitis: Inflammation of blood vessels.

Resources

Organizations

American Academy of Orthopaedic Surgeons 6300 N. River Road Rosemont, IL 60018 800-346-2267 (toll free) or 847-823-7186 www.aaos.org

This nonprofit organization provides education and services for orthopaedic surgeons and other health professionals. The Web site includes patient information and a doctor referral service.

American College of Rheumatology 1800 Century Place, Suite 250 Atlanta, GA 30345 404-633-3777 www.rheumatology.org

This professional organization of physicians, health professionals, and scientists engages in education, research, and advocacy in order to improve the care of people with arthritis and other rheumatic and musculoskeletal diseases. It also offers practice support to health care providers. The Web site includes patient fact sheets.

Arthritis Foundation P.O. Box 7669 Atlanta, GA 30357 800-568-4045 (toll free) www.arthritis.org

This nonprofit foundation sponsors public education programs and continuing education for professionals, raises money for research, and publishes patient information materials. Local chapters can advise about doctors and sponsor activities such as swimming and self-help classes.

National Institute of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse National Institutes of Health 1 AMS Circle Bethesda, MD 20892 877-226-4267 (toll free) www.niams.nih.gov

This federal agency distributes patient and professional education materials about arthritis and rheumatic diseases. Also refers people to other sources of information.

Review Date: 2008-04-01

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