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RHEUMATOLOGY / ORTHOPAEDICS

RHEUMATOID ARTHRITIS

Tens of millions of Americans experience the nagging pains and physical limitations of arthritis. There are more than 100 forms of arthritis. Rheumatoid arthritis is among the most debilitating of them all, causing joints to ache and throb and eventually become deformed. Sometimes these symptoms make even the simplest things such as opening a jar or taking a walk difficult to manage. Unlike osteoarthritis, which results from wear and tear on the joints, rheumatoid arthritis is an inflammatory condition. The exact cause of it is unknown. But it’s believed to be caused by the body’s immune system attacking the synovium the tissue that lines the joints.

Rheumatoid arthritis affects about 2.1 million Americans. It’s three times more common in women than in men and generally strikes between the ages of 20 and 50. But rheumatoid arthritis also can affect very young children and adults older than age 50. There’s no cure for rheumatoid arthritis. But with proper treatment, a strategy for joint protection and changes in lifestyle, you can live a long, productive life with the condition.

 

SIGNS AND SYMPTOMS

The signs and symptoms of rheumatoid arthritis may come and go over time. They include:

  • Pain and swelling in the smaller joints of your hands and feet
  • Generalized aching or stiffness of the joints and muscles, especially after sleep or after periods of rest
  • Loss of motion of the affected joints
  • Loss of strength in muscles attached to the affected joints
  • Fatigue, which can be severe during a flare-up
  • Low-grade fever
  • Deformity of the joints as time goes on

Rheumatoid arthritis usually causes problems in many joints at the same time. Joints in the wrists, hands, feet and ankles are the ones most often affected. The disease can also involve your elbows, shoulders, hips, knees, neck and jaw. It generally affects both sides of the body at the same time. The knuckles of both hands might be one example.

Small lumps, called rheumatoid nodules, may form under the skin of your elbow, your hands, the back of your scalp, over your knee or on your feet and heels. These nodules can range in size appearing as small as a pea to as large as a walnut. Usually these lumps aren’t painful.

In contrast to osteoarthritis, which affects only your bones and joints, rheumatoid arthritis can cause inflammation of tear glands, salivary glands, the lining of your heart and lungs, the lungs themselves and, in rare cases, your blood vessels.

Although rheumatoid arthritis is often a chronic disease, it tends to vary in severity and may even come and go. Periods of increased disease activity called flare-ups or flares alternate with periods of relative remission, during which the swelling, pain, difficulty in sleeping and weakness fade or disappear.

The flexibility of your joints may be limited by swelling or deformity. But even if you have a severe form of rheumatoid arthritis, you’ll probably retain flexibility in many joints.

CAUSES

As with other forms of arthritis, rheumatoid arthritis involves inflammation of the joints. A membrane called the synovium lines each of your joints. When you have rheumatoid arthritis, white blood cells whose normal job is to attack unwanted invaders such as bacteria and viruses move from your bloodstream into your synovium. There, these blood cells appear to play an important role in causing the synovial membrane to become inflamed.

This inflammation results in the release of proteins that, over months or years, cause thickening of the synovium. These proteins also can damage cartilage, bone, tendons and ligaments. Gradually, the joint loses its shape and alignment. Eventually, it may be destroyed.

Some researchers suspect that rheumatoid arthritis is triggered by an infection possibly a virus or bacterium in people with an inherited susceptibility. Although the disease itself is not inherited, certain genes that create a susceptibility are. People who have inherited these genes will not necessarily develop rheumatoid arthritis. But they may have more of a tendency to do so than others. The severity of their disease may also depend on the genes inherited.

 

WHEN TO SEEK MEDICAL ADVICE

See your doctor if you have persistent discomfort and swelling in multiple joints on both sides of your body. Your physician can work with you to develop a pain management and treatment plan. Also seek medical advice if you experience side effects from your arthritis medications. Side effects may include nausea, abdominal discomfort, black or tarry stools, changes in bowel habits, constipation or drowsiness.

 

SCREENING AND DIAGNOSIS

If you have symptoms of rheumatoid arthritis, your doctor will likely conduct a physical examination and order laboratory tests to determine if you have this form of arthritis. A blood test that measures your erythrocyte sedimentation rate (ESR, or “sed” rate) can indicate the presence of an inflammatory process in your body. People with rheumatoid arthritis tend to have elevated ESRs. The ESRs in those with osteoarthritis tend to be normal.

Another blood test looks for an antibody called rheumatoid factor.

Four out of five people with rheumatoid arthritis eventually have this abnormal antibody, although it may be absent early on in the disease. It’s also possible to have the rheumatoid factor in your blood and not have rheumatoid arthritis.

Doctors may take X-rays of your joints to differentiate between osteoarthritis and rheumatoid arthritis. A sequence of X-rays obtained over time can show the progression of arthritis.

 

COMPLICATIONS

Rheumatoid arthritis causes stiffness and pain and may also cause fatigue. It can lead to difficulty with everyday tasks such as turning a doorknob or holding a pen. Dealing with the pain and unpredictability of rheumatoid arthritis can also cause depression. In the past, people with rheumatoid arthritis may have ended up confined to a wheelchair because damage to joints made it difficult or impossible to walk. That’s not as likely today because of better treatments and self-care methods.

 

TREATMENT

Treatments for arthritis have improved in recent years. Most involve medications. But in some cases, surgical procedures may be necessary.

Medications

Medications for rheumatoid arthritis can relieve its symptoms and slow or halt its progression. They include:

  • Nonsteroidal anti-inflammatory drugs (NSAIDs).

This group of medications, which includes aspirin, helps relieve both pain and inflammation if taken regularly. Prescription NSAIDs can provide higher dosages and more potency than over-the-counter NSAIDs. Yet taking NSAIDs can lead to side effects such as indigestion and stomach bleeding. Other potential side effects may include damage to the liver and kidneys, ringing in your ears (tinnitus), fluid retention, and high blood pressure.

  • COX-2 inhibitors.

This new class of NSAIDs may be less damaging to your stomach. Like other NSAIDs, COX-2 inhibitors celecoxib (Celebrex) and rofecoxib (Vioxx) suppress an enzyme called cyclooxygenase (COX) that’s active in joint inflammation. Researchers believe that NSAIDs work against two versions of COX that are present in your body: COX-1 and COX-2. However, there’s evidence that by suppressing COX-1, NSAIDs may cause stomach and other problems because COX-1 is the enzyme that protects your stomach lining. COX-2 inhibitors suppress only COX-2, the enzyme involved in inflammation. The jury is still out, but some doctors are concerned that COX-2 inhibitors may increase a user’s risk of heart attack. Further review by the Food and Drug Administration (FDA) is needed.

*Corticosteroids.

These medications reduce inflammation and slow joint damage. In the short term, corticosteroids can make you feel dramatically better. But when used for many months or years, they may become less effective and cause serious side effects. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a round face, diabetes and high blood pressure. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication.

*Disease-modifying antirheumatic drugs (DMARDs).

Physicians prescribe DMARDs to limit the amount of joint damage that occurs in rheumatoid arthritis. Taking these drugs at early stages in the development of rheumatoid arthritis is especially important in the effort to slow the disease and save the joints and other tissues from permanent damage.

Because many of them act slowly, it may take weeks to months before you notice any benef. DMARDs typically are used with an NSAID or a corticosteroid. While the NSAID or corticosteroid handles your immediate symptoms and limits inflammation, the DMARD goes to work on the disease itself. Some commonly used DMARDs include hydroxychloroquine (Plaquenil), gold compounds such as auranofin (Ridaura) and aurothioglucose (Solganal), sulfasalazine (Azulfidine) and minocycline (Dynacin, Minocin).

Other forms of DMARDs include immunosuppressants and tumor necrosis factor (TNF) blockers. Immunosuppressant medications act to tame the immune system, which is out of control in rheumatoid arthritis. In addition, some of these drugs attack and eliminate cells that are associated with the disease. Some of the commonly used immunosuppressants include methotrexate (Rheumatrex, Folex), leflunomide (Arava), azathioprine (Imuran), cyclosporine (Sandimmun, Neoral), and cyclophosphamide (Cytoxan, Neosar). These medications can have potentially serious side effects such as increased susceptibility to infection.

 

  • TNF blockers.

These are a relatively new class of DMARD for treatment of rheumatoid arthritis. TNF is a cytokine, or cell protein, that acts as an inflammatory agent in rheumatoid arthritis. TNF blockers, or anti-TNF medications, target or block this cytokine and can help reduce pain, morning stiffness, and tender or swollen joints usually within 1 or 2 weeks after treatment begins. These medications often are taken with the immunosuppressant methotrexate. Two TNF blockers approved for treatment of rheumatoid arthritis are etanercept (Enbrel) and infliximab (Remicade). If you have an active infection, you should not take these medications.

  • Interleukin-1 receptor antagonist (IL-1Ra).

In November 2001, the FDA approved using a recombinant form of the naturally occurring interleukin-1 receptor antagonist (IL-1Ra) in some people with rheumatoid arthritis.

Interleukin-1 (IL-1) is a cell protein that promotes inflammation and occurs in excess amounts in people who have rheumatoid arthritis or other types of inflammatory arthritis. If IL-1 is prevented from binding to its receptor, the inflammatory response decreases.

Several clinical trials have shown favorable response to treatment. The first IL-1Ra that has been FDA approved for use in people with moderate to severe rheumatoid arthritis who haven’t responded adequately to conventional DMARD therapy is anakinra (Kineret). It may be used alone or in combination with methotrexate. Anakinra is given as a daily self-administered injection under the skin.

Some potential side effects include injection site reactions, decreased white blood cell counts, headache, and an increase in upper respiratory infections. There may be a slightly higher rate of respiratory infections in people who have asthma or chronic obstructive pulmonary disease. If you have an active infection, don’t use anakinra.

  • Antidepressant drugs.

Living with arthritis can produce depression in some people. Studies of people with chronic diseases, including arthritis, have

found that about one in five report feelings of depression. If your arthritis has caused feelings of depression, your doctor may prescribe one of the following tricyclic antidepressants: amitriptyline (Elavil, Endep), desipramine (Norpramin), imipramine (Tofranil, Norfranil) or nortriptyline (Pamelor, Aventyl). Many other antidepressants may be prescribed, including trazodone (Desyrel), maprotiline (Ludiomil), fluoxetine (Prozac, Sarafem) and sertraline (Zoloft).

 

Surgical or other Procedures

Although a combination of medication and self-care is the first course of action for rheumatoid arthritis, other methods are available for severe cases.

  • Prosorba column.

This blood-filtering technique removes certain antibodies that contribute to pain and inflammation in your joints and muscles and is usually performed once a week for 12 weeks as an outpatient procedure.

Some of the side effects include fatigue and a brief increase in joint pain and swelling for the first few days after the treatment.

The Prosorba column treatment isn’t recommended if you are taking angiotensin-converting enzyme (ACE) inhibitors or if you have heart problems, high blood pressure or blood-clotting problems.

  • Joint replacement surgery.

For many people with rheumatoid arthritis, medicines and therapies can’t prevent joint destruction. When joints are severely damaged, joint replacement surgery can often help restore joint function, reduce pain or correct a deformity.

You may need to have an entire joint replaced with a metal or plastic prosthesis. Surgery may also involve tightening tendons that are too loose, loosening tendons that are too tight, fusing bones to reduce pain, or removing part of a diseased bone to improve mobility.

 

SELF-CARE

Treating rheumatoid arthritis typically involves using a combination of medical treatments and self-care strategies. The following self-care procedures are important elements for managing the disease.

  • Exercise regularly.

Different types of exercise achieve different goals. Check with your doctor or physical therapist first and then begin a regular exercise program for your specific needs.

If you can walk, walking is a good starter exercise. If you can’t walk, try a stationary bicycle with little or no resistance or do hand or arm exercise. A chair exercise program may be helpful. Aquatic exercise is another option, and many health clubs with pools offer such classes. It’s good to move each joint in its full range of motion every day. As you move, maintain a slow, steady rhythm. Don’t jerk or bounce. Also, remember to breathe. Holding your breath can temporarily deprive your muscles of oxygen and tire them. It’s also important to maintain good posture while you exercise. Avoid exercising tender, injured or severely inflamed joints. If you feel new joint pain, stop.

New pain that lasts more than 2 hours after you exercise probably means you’ve overdone it. If pain persists for more than a few days, call your doctor.

  • Control your weight.

Excess weight puts added stress on joints in your back, hips, knees and feet are the places where arthritis pain is commonly felt. Excess weight can also make joint surgery more difficult and risky.

  • Eat a healthy diet.

A healthy diet emphasizing fruit, vegetables and whole grains can help you control your weight and maintain your overall health, allowing you to deal better with your arthritis. However, there is no special diet that can be used to treat arthritis.

It hasn’t been proved that eating any particular food will make your joint pain or inflammation better or worse.

  • Apply heat.

Heat will help ease your pain, relax tense, painful muscles and increase the regional flow of blood. One of the easiest and most effective ways to apply heat is to take a hot shower or bath for 15 minutes.

Other options include using a hot pack, an electric heat pad (set on its lowest setting) or a radiant heat lamp with a 250-watt reflector heat bulb to warm specific muscles and joints. If your skin has poor sensation or if you have poor circulation, don’t use heat treatment.

  • Apply cold for occasional flare-ups.

Cold may dull the sensation of pain. Cold also has a numbing effect and decreases muscle spasms. Don’t use cold treatments if

you have poor circulation or numbness.

  • Practice relaxation techniques.

Hypnosis, guided imagery, deep breathing and muscle relaxation can all be used to control pain.

  • Take your medications as recommended.

By taking medications regularly instead of waiting for pain to build, you will lessen the overall intensity of your discomfort.

 

COPING SKILLS

The degree to which rheumatoid arthritis affects your daily activities depends in part on how well you cope with the disease. Physical and occupational therapists can help you devise strategies to cope with specific limitations you may experience as the result of weakness or pain. Here are some general suggestions to help you cope:

  • Keep a positive attitude. With your doctor, make a plan for managing your arthritis. This will help you feel in charge of your dis- ease. Studies show that people who take control of their treatment and actively manage their arthritis experience less pain and have less difficulty functioning.
  • Use assistive devices.

A painful knee may need a brace for support. You also might want to use a cane to take some of the stress off the joint as you walk.

The cane should be used in the hand opposite the affected joint. If your hands are affected, various helpful tools and gadgets are available to help you maintain an active lifestyle. Contact your pharmacy or doctor for information on ordering items that may help you the most.

  • Know your limits.

Rest when you’re tired. Arthritis can make you prone to fatigue and muscle weakness. A rest or short nap that doesn’t interfere with nighttime sleep may help.

  • Avoid grasping actions that strain your finger joints.

Instead of using a clutch purse, for example, select one with a shoulder strap. Use hot water to loosen a jar lid and pressure from your palm to open it, or use a jar opener. Don’t twist or use your joints forcefully.

  • Spread the weight of an object over several joints. For instance, use both hands to lift a heavy pan.
  • Take a break periodically to relax and stretch.
  • Maintain good posture.

Poor posture causes uneven weight distribution and may strain ligaments and muscles. The easiest way to improve your posture is by walking. Some people find that swimming also helps improve their posture.

  • Use your strongest muscles and favor large joints.

Don’t push open a heavy glass door. Lean into it. To pick up an object, bend your knees and squat while keeping your back straight.

 

COMPLEMENTARY AND ALTERNATIVE MEDICINE

Many complementary medicine approaches haven’t been studied extensively by researchers using scientific methods.

As a result it’s difficult for the scientific community to evaluate the effectiveness or safety of these alternative approaches. And with much of today’s research funding coming from the pharmaceutical industry, some low-tech, nontraditional approaches to managing diseases such as arthritis may not get as much attention from the research community as they deserve. For these reasons, many Western physicians just don’t know enough about these methods to endorse them. Nonetheless, a growing body of evidence indicates that complementary medicine practices could have a role in treating and managing some diseases.

Common forms of complementary and alternative medicine for treatment of arthritis include:

  • Acupuncture
  • Copper jewelry
  • Nutritional supplements, including glucosamine and chondroitin sulfate
  • Homeopathy
  • Magnets

Be careful when considering alternative therapies. Many are expensive and some may be harmful. Before taking any complementary medications or dietary supplements, talk with your doctor to learn about potential dangers, particularly if you’re taking other medications.

Additional Resources

Arthritis Foundation

National Institutes of Health: National Institute of Arthritis and Musculoskeletal and Skin Diseases

DS00020

March 04, 2002

© 1998-2005 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. “Mayo,” “Mayo Clinic,” “MayoClinic.com,” “Mayo Clinic Health Information,” “Sharing our Tradition of Trusted Answers” and the triple-shield Mayo logo are trademarks of Mayo Foundation for Medical Education and Research.

 

OSTEOARTHRITIS

OVERVIEW

Arthritis is one of the most common medical problems and the No. 1 cause of disability in America. The word arthritis is a blend of the Greek words arthron, for joint, and itis, for inflammation. In other words, arthritis literally means “joint inflammation.” Although

arthritis is often referred to as one disease, it’s not. Arthritis has more than 100 forms.

Osteoarthritis, sometimes called degenerative joint disease or osteoarthrosis, is the most common form of arthritis. Osteoarthritis affects nearly 21 million people in the United States. It’s characterized by the breakdown of joint cartilage and may affect any joint in your body, including those in your fingers, hips, knees, lower back and feet. Initially it may strike only one joint. But if your fingers are affected, multiple hand joints may become arthritic.

There’s no cure for osteoarthritis, but treatments today are far ahead of what was available just a few years ago. In addition, how well you live with arthritis often depends on your actions and attitude. If you actively manage your arthritis, you may be able to gain control over your pain.

 

SIGNS AND SYMPTOMS

Osteoarthritis often develops slowly, and some people may not experience any signs or symptoms. However, osteoarthritis can cause the following signs and symptoms:

  • Pain in a joint during or after use, or after a period of inactivity
  • Discomfort in a joint before or during a change in the weather
  • Swelling and stiffness in a joint, particularly after using it
  • Bony lumps on the middle or end joints of your fingers or the base of your thumb
  • Loss of joint flexibility

The acute pain of early osteoarthritis often tends to fade within a year of its appearance, but it may return if you overuse the

affected joint and this is especially true of fingers affected by osteoarthritis.

Areas osteoarthritis typically affects include:

Fingers. Bony knobs called nodes can enlarge your finger joints, creating a gnarled appearance. Early in the course of the disease, your joints may feel painful or stiff and numb. Eventually, the pain often subsides, leaving just bony nodes that affect the mobility of the joints at the end of your fingers. These nodes tend to run in families and affect more women than men.

  • Spine. Slow deterioration of disks between the bones along your spine can lead to back and neck pain and stiffness.

Weight-bearing joints. The parts of your body that bear the majority of your weight as your hips, knees and feet are more susceptible to osteoarthritis. As cartilage slowly deteriorates over the years, you can develop chronic pain or varying amounts of discomfort when you stand and walk. Swelling also may occur, especially in your knees.

Unless you’ve been injured or placed unusual stress on a joint, it’s uncommon for osteoarthritis to affect your jaw, shoulder, elbows, wrists or ankles.

 

CAUSES

With osteoarthritis the problem lies in the cartilage that cushions the ends of bones in your joints. Over time, the cartilage deteriorates, and its smooth surface roughens. Eventually, if the cartilage wears down completely, you may be left with bone rubbing on bone causing the ends of your bones to become damaged and your joints to become painful.

The exact cause of osteoarthritis isn’t known. Researchers suspect that it’s a combination of factors, including being overweight, the aging process, joint injury or stress, heredity and muscle weakness.

Some scientists believe the cartilage damage may be due to a mechanical stress that results in an imbalance of enzymes released from the cartilage cells or from the lining of the joint. When balanced, these enzymes allow for the natural breakdown and regeneration of cartilage. But too much of the enzymes can cause the joint cartilage to break down faster than it’s rebuilt. The exact cause of this enzyme imbalance is unclear.

Your body goes to work repairing the damage, but the repairs may be inadequate, resulting instead in growth of new bone along the sides of the existing bone, which produces prominent lumps, most noticeable on hands and feet. Each of the steps in this repair process produces pain. The pain and tenderness over the bony lumps may be most marked early in the course of the dis- ease and less evident later on.

Osteoarthritis commonly occurs in the neck or lower back. Hips and knees also are frequently affected because they bear most of your weight. You can have chronic pain or varying amounts of discomfort when you stand and walk. Swelling also may occur, especially in your knees.

 

RISK FACTORS

The exact causes of osteoarthritis are unclear, but these factors increase your risk:

  • Being 45 years old or older
  • Being female
  • Having certain hereditary conditions, including defective cartilage and malformed joints
  • Having joint injuries caused by physical activity or sports
  • Being obese
  • Having diseases that change the normal structure and function of cartilage, such as rheumatoid arthritis, hemochromatosis, gout

or pseudogout

  • Having weak thigh (quadriceps) muscles, which may lead you to develop osteoarthritis in your knees

 

WHEN TO SEEK MEDICAL ADVICE

If you have swelling or stiffness in your joints that lasts for more than two weeks, seek medical advice. If your doctor determines that you have osteoarthritis, he or she can work with you to develop a pain management and treatment plan. Also seek medical advice if you experience side effects from arthritis medications, such as nausea, abdominal discomfort, black or tarry stools, con- stipation and drowsiness.

 

SCREENING AND DIAGNOSIS

Your doctor may use a variety of methods to diagnose osteoarthritis, including a physical examination, blood tests and certain imaging techniques. Doctors use blood tests to diagnose or rule out specific types of arthritis. Fluid may be withdrawn from a joint for analysis (joint aspiration).

Imaging techniques may include X-rays, bone scans, computerized tomography (CT scan), magnetic resonance imaging (MRI) and

arthrography an image taken after dye has been injected into your joint. Imaging techniques can reveal bone spurs, worn-down cartilage and loss of joint space, indicating the presence of osteoarthritis.

 

COMPLICATIONS

The major complication of osteoarthritis is pain. The degree of pain can vary greatly, from being a mild inconvenience to being debilitating. Although arthritis doesn’t go away, for many people the acute pain of early osteoarthritis often diminishes within a year. However, it can return if you overuse affected joints. Your doctor can help you determine how to adjust your activities to reduce stress on those joints. People with very painful osteoarthritic joints may require joint replacement surgery for pain relief.

 

TREATMENT

There’s no known cure for osteoarthritis, but treatments can help to reduce pain and maintain joint movement. Your doctor may recommend a combination of treatments that may include medication, self-care, physical therapy and occupational therapy. In some cases, surgical procedures may be necessary.

Medications

Medications are used to treat the pain and mild inflammation of osteoarthritis and to improve your joints’ functioning. They include both topical medications and oral medications. Over-the-counter (OTC) medications may be sufficient to treat milder osteoarthritis, but stronger prescription medications also are available.

Topical pain relievers. Various OTC products are available as creams, gels, ointments and sprays to temporarily relieve arthritis pain. Products containing the pain reliever trolamine salicylate include Aspercreme and Sportscreme. Products containing one or more of the counterirritant medications methyl salicylate, menthol and camphor include Eucalyptamint, Icy Hot and Ben-Gay. Capsaicin (Zostrix, Capzasin-P), a cream made from the seeds of hot chili peppers, may relieve pain in joints close to your skin surface, such as your fingers, knees and elbows.

Acetaminophen. Acetaminophen (Tylenol, others) can relieve pain, but doesn’t reduce inflammation. It has been shown to be effective for people with osteoarthritis who have mild-to-moderate pain. Taking more than the recommended dosage of acetaminophen can cause liver damage, especially if you consume three or more alcoholic drinks a day. It might be best to limit or abstain from alcohol if you take acetaminophen regularly. Acetaminophen can also affect other medications you may be taking, so be sure to inform your doctor if you’re taking it.

NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) work in two ways. They relieve pain (such as from osteoarthritis and sore muscles), and they fight inflammation (such as from rheumatoid arthritis). NSAIDs range from OTC aspirin, ibuprofen (Advil, Motrin, others), and naproxen sodium (Aleve) which are also available at higher dosages by prescription to others that are only available by prescription, such as ketoprofen (Oruvail), diclofenac (Cataflam, Voltaren) and nabumetone (Relafen). NSAIDs have risks of side effects that increase when used at high dosages for long-term treatment. Side effects may include ringing in your ears, gastric ulcers, gastrointestinal bleeding and liver and kidney damage. Consuming alcohol or taking corticosteroids while using NSAIDs also increase your risk of gastrointestinal bleeding.

COX-2 inhibitors. Considered as effective for managing pain and inflammation as other NSAIDs, COX-2 inhibitors such as celecoxib (Celebrex) may not have the same stomach-damaging effects. But side effects may include fluid retention and causing or exacerbating high blood pressure. Furthermore, this class of drugs has been linked to an increased risk of heart attack and stroke.

  • Tramadol. Tramadol (Ultram) is a centrally acting analgesic that’s available by prescription. It has no anti-inflammatory effect, but can provide effective pain relief with fewer side effects such as stomach ulcers and bleeding than NSAIDs. However, Tramadol may cause nausea and constipation. It’s generally used for short-term treatment of acute flare-ups.

Antidepressants. Independent of their antidepressant properties, antidepressants, especially tricyclics, can help reduce chronic pain. Some people with arthritis also experience symptoms of depression. Antidepressant medications can treat the sleep disturbance that can accompany arthritis. The most common antidepressants used for arthritis pain and nonrestorative sleep are amitriptyline (Elavil), nortriptyline (Pamelor, Aventyl) and trazodone (Desyrel).

Intra-articular injections. Occasionally, your doctor may suggest injecting a joint space with a corticosteroid, which can offer some pain relief and reduce inflammation. Injecting hyaluronic acid derivatives into knee joints (viscosupplementation) can relieve pain from osteoarthritis. Hyaluronic acid is a component of joint fluid, and Hylan G-F20 (Synvisc) and hyaluronate (Hyalgan, Supartz) are derivatives made from cockscomb.

Surgical or other procedures

Surgical procedures can help relieve disability and pain caused by osteoarthritis.

Joint replacement. In joint replacement surgery (arthroplasty), your surgeon removes your damaged joint and replaces it with a plastic or metal device called a prosthesis. The hip and knee joints are the most commonly replaced joints. But today implants can replace your shoulder, elbow, finger or ankle joints. Joint replacement is most successful in large joints, such as hips and knees. It can help you resume an active, pain-free lifestyle. In smaller hand joints, it also can improve appearance and comfort and may improve your joint’s mobility.

Fragment removal. Other surgical techniques are designed to remove loose fragments of bone or cartilage that may cause pain or cause mechanical problems such as “locking.” The procedure is usually done with an arthroscope, a small tube inserted into the joint, through which the surgeon works. A study reported in July 2002 in the New England Journal of Medicine evaluated some types of arthroscopic procedures in people with osteoarthritis of the knees. The study showed no significant difference in pain relief or improved function two years after the surgery among those who underwent arthroscopic surgery and those who underwent a sham placebo procedure. The majority of the people in the study were men. Additional studies, including women, are necessary to better evaluate the results of this study.

  • Repositioning bones. Surgeons can also reposition your bones to help correct deformities (osteotomy).

Surgeons also can permanently fuse bones in a joint (arthrodesis) to increase stability and reduce pain. The fused joint, such as an ankle, can then bear weight without pain, but has no flexibility.

 

SELF-CARE

Fortunately, you can relieve much of the discomfort associated with osteoarthritis through healthy living strategies and simple self- care techniques, such as the following:

  • Exercise regularly. Different types of exercise achieve different goals. Check with your doctor first and then begin a regular exercise program for your specific needs. Muscle strengthening exercises may be recommended to help support an arthritic joint. If you can walk, walking is a good starter exercise. If you can’t walk, try a stationary bicycle using no resistance or do hand or arm exercises. Aquatic exercise is another option, and many health clubs with pools offer classes. If you don’t have access to a pool, tai chi may be a good alternative. It teaches strengthening, range of motion exercises and relaxation techniques, and can improve balance. It’s good to move each joint in its full range of motion every day. As you move, maintain a slow, steady rhythm. Don’t jerk or bounce. Also don’t hold your breath, as this can temporarily deprive your muscles of oxygen and tire them. Maintain good posture while you exercise. Avoid exercising tender, injured or severely inflamed joints. If you feel new joint pain, stop. New pain that lasts more than two hours after you exercise probably means you’ve overdone it. If pain persists for more than a few days, call your doctor.
  • Control your weight. Excess weight puts added stress on joints in your back, hips, knees and feet places where arthritis pain is commonly felt. Excess weight can also make joint surgery more difficult and risky.
  • A healthy diet emphasizing fruit, vegetables and whole grains can help you control your weight and maintain your overall health, allowing you to deal better with your arthritis. However, there’s no special diet effective for treating arthritis. It hasn’t been proved that eating any particular food will make your joint pain or inflammation better or worse.
  • Apply heat. Heat will ease your pain, relax tense, painful muscles and increase the regional flow of blood. You may find it especially helpful to apply heat before exercising. One of the easiest and most effective ways to apply heat is to take a 15-minute hot shower or bath. Other options are a hot pack, an electric heating pad on its lowest setting or a radiant heat lamp with a 250-watt reflector heat bulb. If your skin has poor sensation or if you have poor circulation, don’t use heat treatment.
  • Choose appropriate footwear. Wearing comfortable cushioned shoes that properly support your weight is especially important if you have arthritis in your weight-bearing joints or back.
  • Apply cold for occasional flare-ups. Cold may dull the sensation of pain during the first day or two. Cold also has a numbing effect and decreases muscle spasms. Don’t use cold treatments if you have poor circulation or numbness.
  • Practice relaxation techniques. Hypnosis, guided imagery, deep breathing and muscle relaxation can all be used to control pain.
  • Take your medications as recommended. By taking medications regularly instead of waiting for pain to build, you will lessen the overall intensity of your discomfort.

 

COPING SKILLS

Osteoarthritis can affect your everyday activities and overall quality of life. As a result, it’s important to adopt coping strategies for dealing with the disease. You might consider the following:

  • Keep a positive attitude. Make a plan with your doctor for managing your arthritis. This will help you feel that you’re in charge of your disease, rather than vice versa. Studies show that people who take control of their treatment and actively manage their arthritis experience less pain and function better.
  • Use assistive devices. Your painful knee may need a brace for support. You might also opt for a cane to take weight off the joint as you walk. The cane should be used in the hand opposite the affected joint. If your hands are affected, various helpful tools and gadgets are available to help you maintain an active lifestyle. Contact your pharmacy or doctor’s office for information on ordering the items that may help you the most.
  • Know your limits. Rest when you’re tired. Arthritis can make you prone to fatigue and muscle weakness a deep exhaustion that makes everything you do a great effort. A rest or short nap that doesn’t interfere with nighttime sleep may help.
  • Avoid grasping actions that strain your finger joints. For example, instead of a clutch-style purse, select one with a shoulder strap. Use hot water to loosen a jar lid and pressure from your palm to open it, or use a jar opener. Don’t twist or use your joints forcefully.
  • Spread the weight of an object over several joints. Use both hands, for example, to lift a heavy pan. Try using a walking stick or cane.
  • Take a break. Periodically relax and stretch.
  • Maintain good posture. Poor posture causes uneven weight distribution and may strain ligaments and muscles. The easiest way to improve your posture is by walking. The faster you walk, the harder your muscles must work to keep you upright. Some people find that swimming also helps improve their posture.
  • Use your strongest muscles and favor large joints. Don’t push open a heavy glass door. Lean into it. To pick up an object, bend your knees and squat while keeping your back straight.

COMPLEMENTARY AND ALTERNATIVE MEDICINE

Because many complementary medicine methods haven’t been studied extensively by researchers using mainstream scientific methods, it’s difficult for the scientific community to evaluate their effectiveness and safety. And with much of today’s research funding coming from the pharmaceutical industry, some “low-tech,” nontraditional approaches to manage diseases such as arthritis may not get as much attention from the research community as they deserve. For these reasons, many Western physicians just don’t know enough about these methods to endorse them. Nonetheless a growing body of evidence indicates that complementary medicine practices could have a role in treating and managing some diseases.

Common forms of complementary and alternative medicine for treatment of osteoarthritis include:

*Acupuncture

*Copper jewelry

*Homeopathy

*Magnets

Some studies have shown positive effects of nutritional supplements such as glucosamine and chondroitin sulfate preparations on

 

osteoarthritis. Studies are ongoing in people who have osteoarthritis to compare results of using glucosamine with those of using chondroitin sulfate and of using a mixture of the two. Don’t use glucosamine if you’re allergic to shellfish. Glucosamine may raise your blood insulin level if you have diabetes. Chondroitin sulfate may affect blood levels of warfarin (Coumadin) if you’re taking that medication.

Be careful when considering alternative therapies. Many are expensive, and some may be harmful. Before taking any complementary medications or dietary supplements, talk with your doctor to learn about potential dangers, particularly if you’re taking other medications.

By Mayo Clinic staff

© 1998-2005 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. “Mayo,” “Mayo Clinic,” “MayoClinic.com,” “Mayo Clinic Health Information,” “Reliable information for a healthier life” and the triple-shield Mayo logo are trademarks of Mayo Foundation for Medical Education and Research.

 

ANKYLOSING SPONDYLITIS

OVERVIEW

Ankylosing spondylitis is one of many forms of inflammatory arthritis, the most common of which is rheumatoid arthritis. Ankylosing spondylitis primarily causes inflammation of the joints between the vertebrae of your spine and the joints between your spine and pelvis (sacroiliac joints). However, ankylosing spondylitis may also cause inflammation and pain in other parts of your body:

  • Where your tendons and ligaments attach to bones
  • Joints between your ribs and spine
  • Your hips, shoulders, knees and feet joints
  • Your eyes

As the condition worsens and the inflammation persists, new bone forms as a part of the healing process. Your vertebrae begin to grow together, forming vertical bony outgrowths (syndesmophytes) and becoming stiff and inflexible. Fusion can also stiffen your rib cage, restricting lung capacity and function.

Ankylosing spondylitis is a chronic condition. Also called spondylitis or rheumatoid spondylitis, ankylosing spondylitis affects about 129 of every 100,000 people in the United States. Treatments can decrease your pain and lessen your symptoms. Effective treatment may also help prevent complications and physical deformities.

 

SIGNS AND SYMPTOMS

Your condition may change over time, with symptoms getting worse, improving or completely stopping at any point. Early signs and symptoms may include pain and stiffness in your lower back and hips which is often worse in the morning, at night and after periods of inactivity. Over time, the pain and stiffness may progress up your spine and to other joints, such as those in your hips, shoulders, knees and feet.

In advanced stages, the following signs and symptoms may develop:

  • Restricted expansion of your chest
  • Chronic stooping
  • Stiff, inflexible spine
  • Fatigue
  • Loss of appetite
  • Weight loss
  • Eye inflammation (iritis)
  • Bowel inflammation

 

CAUSES

Ankylosing spondylitis has no known specific cause, though genetic factors seem to be involved. The majority of people with ankylosing spondylitis have a gene called HLA-B27. This gene may make people more susceptible to developing ankylosing spondylitis.

RISK FACTORS

Genetics may play a role in the development of ankylosing spondylitis. In fact, the majority of people with this condition have the HLA-B27 gene. Having this gene doesn’t mean that you’ll acquire ankylosing spondylitis only about two percent of people with this gene develop the condition but it may make you more susceptible to the disease.

 

If you test positive for the HLA-B27 gene, are younger than 40 and have a family member with ankylosing spondylitis, you have about a one in five chance of developing the condition. However, if you’re older than 40, your chances of acquiring ankylosing spondylitis are low. If you have ankylosing spondylitis, you have about a 50 percent chance of passing the HLA-B27 gene on to your children if you have the gene.

Ankylosing spondylitis affects males more often than it affects females, and its onset generally occurs between the ages of 16 and

40. In the United States, ankylosing spondylitis is most common among some American Indian tribes.

 

WHEN TO SEEK MEDICAL ADVICE

See your doctor if you have symptoms of ankylosing spondylitis. Also contact your doctor if you’re being treated for the disease, and new signs and symptoms develop.

 

SCREENING AND DIAGNOSIS

Diagnosis of ankylosing spondylitis may be delayed if your symptoms are very mild or if you mistakenly attribute some of your symptoms to more common back problems.

To determine the cause of your discomfort, your doctor will conduct a medical history and complete a physical examination. Then, your doctor may use the following diagnostic procedures:

  • X-rays or other imaging. X-rays allow your doctor to check for changes in your joints and bones, though the characteristic effects of ankylosing spondylitis may not be evident early in the disease. Your doctor may also use other imaging tests, such as compuerized tomography (CT) or magnetic resonance imaging (MRI) scans, to detect inflammation and other changes in your joints.
  • Blood tests. Your doctor may check to see if you have an elevated sedimentation rat a measurement of the speed at which your red blood cells settle to the bottom of a tube of blood in one hour which is an indication of inflammation. Another blood test can determine if you have anemia, a condition in which there aren’t enough healthy red blood cells to carry adequate oxygen to your tissues. Anemia is a complication that can result from the chronic inflammation of ankylosing spondylitis. Finally, you may need a blood test to see if you have the HLA-B27 gene. The presence of this gene doesn’t determine whether you have ankylos- ing spondylitis. But its absence makes it less likely that you do.

 

COMPLICATIONS

Ankylosing spondylitis doesn’t follow a set course. The severity of symptoms and development of complications vary widely among individuals. Complications may include:

  • Difficulty walking or standing. Typically, ankylosing spondylitis begins with soreness in your lower back. As the disease progresses, the affected bones may fuse together, rendering your joints immobile and causing a stiff, inflexible spine (bamboo spine). This can make walking or standing difficult. Your joints may fuse even if you undergo proper treatment and once joints fuse, additional treatment won’t help restore mobility. However, if fusion occurs with your spine in an upright position, you can remain more able to perform activities of daily living.
  • Difficulty breathing. Inflammation can also spread up your spine and cause the bones in your rib cage to fuse. This results in breathing problems. When your ribs can’t move when you breathe, it’s difficult to fully inflate your lungs. However, if you don’t have an unrelated lung condition, you may be able to continue your everyday activities without experiencing shortness of breath.
  • Heart problems. If the inflammation reaches your heart, you can develop valve problems, such as inflammation of the body’s largest artery (aorta), also known as aortitis. Another possible complication is aortic valve regurgitation, which occurs when the aortic ring and aortic valve are distorted.
  • Lung infections. In some people with ankylosing spondylitis, cavitary lesions develop in the upper portion of the lungs. These cavities can slowly enlarge over many years and develop infections, most commonly fungal infections.

Inflammation can also involve other parts of your body, resulting in conditions such as:

  • Inflammatory bowel disease
  • Anemia
  • Painful and inflamed eyes (iritis)

 

TREATMENT

The goal of treatment is to relieve pain and stiffness, and prevent or delay complications and spinal deformity. Treatment of ankylosing spondylitis is most successful early, before it causes irreversible damage to your joints, such as fusion, especially in positions that limit your function.

 

Medications

Your doctor may recommend that you take one or more of the following medications:

Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs such as naproxen (Naprosyn) and indomethacin (Indocin) are the medications doctors most commonly use to treat ankylosing spondylitis. They can relieve your inflammation, pain and stiffness.

  • Disease-modifying antirheumatic drugs (DMARDs). Your doctor may prescribe a DMARD, such as sulfasalazine (Azulfidine) or methotrexate (Rheumatrex), to treat inflamed joints and other tissues.
  • Corticosteroids. These medications, such as prednisone, may suppress inflammation and slow joint damage in severe cases of ankylosing spondylitis. You usually take them orally, ideally for a limited period of time because of their side effects. Occasionally,

corticosteroids are injected directly into a painful joint.

  • Tumor necrosis factor (TNF) blockers. Doctors originally used TNF blockers to treat rheumatoid arthritis. TNF is a cytokine, or cell protein, that acts as an inflammatory agent in rheumatoid arthritis. TNF blockers target or block this protein and can help reduce pain, stiffness, and tender or swollen joints. These medications, such as etanercept (Enbrel) and infliximab (Remicade), may decrease inflammation and improve pain and stiffness for people with ankylosing spondylitis.

 

Physical therapy

Physical therapy can provide a number of benefits, from pain relief to improved physical strength and flexibility. Your doctor may recommend that you meet with a physical therapist to provide you with specific exercises designed for your needs.

Range-of-motion and stretching exercises can help maintain flexibility in your joints and preserve good posture. In addition, specific breathing exercises can help to sustain and enhance your lung capacity.

As your condition worsens, your upper body may begin to stoop forward. Proper sleep and walking positions and abdominal and back exercises can help maintain your upright posture. Though you may develop spine stiffness despite your treatment, proper posture can help to ensure that your spine is fused in a fixed upright position.

 

Surgery

Most people with ankylosing spondylitis don’t need surgery. Surgery may help if you have severe pain or joint damage. You may need surgery if a nonspinal joint needs to be replaced. However, doctors don’t usually recommend back surgery.

 

PREVENTION

Because genetic factors appear to play a part in ankylosing spondylitis, it’s not possible to prevent the disease. However, being aware of any personal risk factors for the disease can help in early detection and treatment. Proper and early treatment can relieve joint pain and help to prevent or delay the onset of physical deformities.

 

SELF-CARE

If you smoke, try to quit. Smoking is bad for your health, but creates additional problems for people with ankylosing spondylitis. Depending on the severity of your condition, ankylosing spondylitis can affect the mobility of your rib cage. Damaging your lungs by smoking can further compromise your ability to breathe.

 

COPING SKILLS

The course of your condition may change over time, and you may experience relapses and remissions throughout your life. But despite the potential complications, most people are able to live productive lives despite a diagnosis of ankylosing spondylitis. You may want to join a support group of other people with this condition, in order to share experiences and support. Contact your local office of the Arthritis Foundation to see if there are any groups in your area or if you can start your own.

By Mayo Clinic staff

© 1998-2005 Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. A single copy of these materials may be reprinted for noncommercial personal use only. “Mayo,” “Mayo Clinic,” “MayoClinic.com,” “Mayo Clinic Health Information,” “Sharing our Tradition of Trusted Answers” and the triple-shield Mayo logo are trademarks of Mayo Foundation for Medical Education and Research.

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