Rheumatoid arthritis seldom goes away. Eighty percent or more of patients will continue to live with it. When its initial
symptoms appear,it's almost impossible to tell who will do well and who will do badly. But we do know that joint damage occurs
early on,and we have only a short period of time--a year or less-to prevent this damage with an effective treatment program
In practise,this means that treatment is divided into two phases: 1) An initial phase (preferably short) where RA is
suppressed as completely as possible. 2) A long-term surveillance phase where local complications of RA are spotted and dealt
with before damage can be caused,and where major flare-ups are anticipated and prevented if possible.
Treatment involves a long-term contract between physician and patient. Each must understand the other as fully as possible.
Communication must be open. there will be times when contact is broken off because the disease is stable,but it must be re-established
when necessary. And the patient be able to judge that when that time is.
It is important for the patient to learn as much as possible about the disease,its complications and its treatment. Know
when treatment is working and when it is not. Be aware of possible side effects and inform the physician when it occurs.
It's also essential to be open and be honest with the physician, If you don't understand something,or you're worrying
over something,ask. Physicians often assume that patients know more then they do,while patients are often afraid to appear
"stupid". And if you are hesitant to take a medication,or in fact not taking it-for whatever reason-say so.
Your right to refuse treatment is (or should be) recognized by the physician. The fact that you are refusing should't
be taken as a challenge to the physician's authority,and shouldn't cause him/her to treat you. There is almost always another
way to approach a problem. If the treatment being recommended is truly necessary,more information or changing circumstances
will probably enable you to accep it in time.
Five basic rules for treating Ra: 1) Treat as soon as the diagnosis is made. 2) Treat to suppress all evidence
of inflammation. 3) Fear rhe disease more than the treatment. 4) Treat the specific problem in the individual patient. 5)
Use all available resources such as social work,surgery,hospitalization and monitoring the disease
NSAIDs-nonsteriodal anti-inflammatory drugs are invariably the first class of medication given ( there's a host of them
),and one of the last stopped. Whether it's naproxen or a relative new one like celecoxib,no single drug has ever been shown
to be significantly better than another. But different people react differently,with regard to both good and bad effects.
this means that a patient may have to try two or three different NSAIDs before deciding which one is best. "Best" may
mean "most effective" or "best tolerated". If two drugs are equally good,the choice may boil down to "most convient" or "cheapest."
No NSAID can completely suppress RA inflamation. At best 25 percent of this problem will be dealt with-just enough to
take the edge off. Because NSAIDs have both anti-inflammatory and analgesic (pain-killing) properties,it's sometimes hard
to tell which of the two effects is helping the most.
NSAIDs are "base-line" therapy-the first treatment. Once it's determined which one seems to work best,it usually takes
a few weeks,it's time to add a "second-line" agent. The second-line drug is taken in addition to the NSAID.
Disease modifying drugs (DMARDs) can significantly suppress the rheumatoid disease process. As with NSAIDs,the discovery
of the best one for the individual patient is a trial-and error process,sometimes. This doesn't rule out intelligent guesses,because
the odds are better for some than for others. At best,a given drug will work in about two-thirds of all patients,and have
no effect on the other third.
These agents are also called "slow-acting" drugs,because it may take up to six months for their full benifit to develop;even
the fastest usually takes about a month. Even though a drug works well initially,as time goes by the benifit may weaken or
lose it. This happens with most drugs in this class.
Combination drugs are being used more-and-more in rheumatology. (such as hydroxychloroquine,sulfasazine and methotrexate)
Results seem to be better,especially in aggressive disease.
In choosing a DMARD,the patient's disease severity is considered. Relatively mild RA may require hydroxychloroquine;
very painful and extensive RA,particularily in an elderly person with a positive test for rheumatoid factor (RF),calls for
one of the stronger agents like methotrexate or gold
For the very severe patient,one who has not responded to any of the conventional approaches ,alone or in combination,biologic
drugs are available.
Corticosteriods is used when the situation calls for it. This is usually when starting a patient on DMARD therapy. Steriods
can be used as a "bridge" until the DMARDs take full effect or later, as a supplement if the effect isn't quite good enough.
If you have inflammatory arthritis or you're going through a periodic inflammatory phase of osteoarthritis,you're probably
experiencing pain. Since it usually takes al least two to four weeks before any NSAID begins to reduce inflammation-the source
of the pain-patients will want something that will help in the interim.
That's where straighforward analgesics-pain relieving medications,come in. For minimal to moderate pain,there are a number
of over-the-counter formulations; for more severe pain,you may require prescription medication.
In the meantime,chart exactly how much pain you're experiencing. On a sheet of paper,draw a scale from 0 to 10,where
10 is the worst pain you've ever felt or can imagine.,then mark where you feel your present pain is. this allows you to measure
whether you're getting better or worse by giving you a baseline reference point,and it provides your doctor with valuable
information when prescribing your pain medication. If you're in a lot of pain,don't be bashful about asking your physician
for strong medicine.
Once you've established your pain reference point,you can determine whether nonprescription medication will provide enough
relief or whether you need stronger,prescription medication from your doctor. If,for example,your pain level is at 3 or below,try
a nonprescription analgesic,or even a nonmedical approach (such as a ice bag). If the pain persists for more than seventyotwo
hours or worsens,consult your doctor. But you be the judge;everybody experiences pain differently.
There are many nonprescription pain relievers for arthritis-acetaminophen (Tylenol,Panadol,Exdol etc.) ASA (Aspirin,Entrophe,Anacin
etc.) and ibuprofen (Advil,Motrin etc.). They're more or less equally effective and well tolerated,provided you're not already
taking prescription NSAID: ASA and ibuprofen are also anti-inflammatory medications and should't be taken in addition to a
prescription NSAID,because of a slightly higher risk of side effects. If you are taking aan NSAID,acetaminophen is the preferred
choice,because it can be safely combined with a prescrition NSAID for increased pain relief or for headaches and fever.
Acetaminophen is safe and effective,but it does have limits. You can take regular-strength tablets (325mg.) every four
hours to a maximum of 12 in a 24-hour period,or extra-strength tablets (500 mg.) every six hours,to a maximum of 8 tablets
in a 24 hour period. Be careful about exceeding those limits,a serious overdose can cause permanent liver damage If you find
yourself repeatedly taking acetaminphen repeatedly than recommended,consult your doctor about a stronger pain medication.
One option is an acetaminophen formulation with codeine,which affects the central nervous system,reducing pain sensivity.
It's most often available in combination with 325 mg. of acetaminophen and 32 mg of caffeine (the caffeine's to combat any
drowsiness the codeine causes). Regardless of the brand,the amount of codiene ranges from 8 mg. per tablet in nonprescription
formulations,such as Tylenol 1,Exdol-8,or Atasol-8,to 15 mg. of codiene in Tylenol 2,Tylenol 3 has 30 mg per tablet (which
requires a prescription.
A common fear about pain relievers is addiction (codiene is a narcotic) even some doctors are wary about prescribing
what some of their patients believe to be essential levels of pain-relieving medication. The important point is that pain
medications only make pain more bearable-they don't treat the underlying cause. Make sure you treat the underlying cause.
Make sure you also seek treatment for the real source of the pain. Certainly analgesics shouldn't be used to mask pain. If
you feel no pain at all from an arthritic joint,you might bbe tempted to overuse it,causing irrepairable damage. Again,the
best approach to controlling pain involves medication with complementary therapies and coping strategies (though if you're
in extreme pain,your doctor can prescribe a limited course of a stronger pain reliever).
Clinical research shows that people who take a narcotic at a appropriate dose for their level of pain are at a very low
risk of becoming addicted. Drug dependency is fuelled by a psychological cravings for the euphoric effects of certain narcotics,such
as the opiates.
Although codeine is a narcotic,when its used solely for pain relief it rarely produces the "highs" that drug users seek-if
anything,it tends to make life seem a little dull and colourless. Furthermore codiene is the weakest of all the narcotic agents
and can be taken for relatively long periods of time without fear of addiction-particularily if you decrease your daily dose
as your pain decreases over time.
Still concerned ? Then ask yourself these questions: If you're not in pain and you don't take the codiene,do you feel
a need for it ? Do you require rapidly increasing doses to control the same level of pain ? Do you get "high" when you take
codiene ? Chances are, you answered "no" to all of these questions. If so,relax. You're not addicted to codiene.
The biggest problem with codiene is constipation (because it slows down the digestive tract). The best response is to
increase your fibre and liquid intake You can try Metamucil,a nonabsorbed fibre,which may take a few days or a week to work
but is an effective preventive (not a treatment) for most people. Psyllium,the active ingredient,is also available as Prodiem
Plain,in chocolate mint,some people find it easier to tolerate. N.B. Don't take Metamucil WITH your medications,because they
may pass right through your system with it,losing their effectiveness.
For the most part,stimulant laxatives aren't avisable,because the bowel can become "addicted" to them-i.e., it doesn't
evacuate easily without them Glycerin suppositories are an alternative. They dehydrate the bowel,helping to soften stools.
Mineral oils aren't a good idea. They deplete the body of vitamin A,D,E,and K.
Range-of-motion (ROM) exercises are the key to maintaining maximum range of motion and flexibility (not strength) in
arthritic joints. They involve gentle movements that exercises each joint as fully as possible. Many ROM exercises can be
done before you get out of bed in the morning,and some may alleviate the morning stiffness associated with certain forms of
arthritis.
Hands are most easily exercised on a tabletop,with your forearms and hands face down. Keeping your palms flat on the
table lift each finger and thumb (of both hands) one after another as high as you can without causing pain. Once all your
fingers are up,raise your whole hand,bending it gently back,with your forearm still resting on the table.
Exercise your wrists simply by slackening the tension in your fingers and bending your hand back and forth in all the
normal range of motion,several times. Then relax.
With your hands flat on the table and your fingers together,slowly slide your first finger toward your thumb and hold.
Repeat the motion with your second finger,then the third and fourth,until all your fingers are together. Repeat three times.
Hold your hand straight up,with the fingers extended. Now slowly bend the fingers down to your palm without bending the
large knucles. Open and repeat three times. For the thumb,hold your hand open,with the fingers straight. Reach your thumb
across your palm and try to touch the base of your little finger. Hold,relax,and repeat.
You can do your elbows lying down,with your arms lying close to your body. Keeping your upper arms flat on the bed (or
floor),raise your forearms so that the're perpendicular to your body. Now rotate them slowly,so that you're looking alternately
at your palms and the back of your hands. Repeat several times.
Still lying on your back,with your arms flat at the sides,move them out,as though you're making "an angel" in the snow,then
return them to their original position and repeat. This exercises one plane of motion for your shoulders.
For another plane,stay flat,with your arms at your sides. Now raise one arm at a time through an arc directly in
front of you until it's flat on the bed or floor over your head (as if,standing,you tried to touch the ceiling). Return it
to the original position,then repeat with the other arm.
You can exercise your neck standing or sitting. Turn your head slowly so that you're looking over your right shoulder,then
turn it back to face forward. Stop. Then turn it to look over your left shoulder. Repeat. Now try tilting your head to the
side,so that it comes as close as you can bring it to your shoulder without pin. Repeat on the other side,and repeat both
motions twice more.
To work the back of the neck,tuck your chin down onto your chest and hold,keeping your neck straight ( you should be
able to feel the muscles on the back of the neck pulling slightly).
For your back,stand with your hands on your hips and your feet shoulder-width apart. Swivel your head and shoulders to
the right and hold. Return to face forward. Swivel to the left and hold. Repeat.
You can exercise the muscles of the lower back in a vertical direction by lying on your back and trying to press your
back into the floor. Hold and repeat
.
Sit up for the hips. Stretch your legs out in front of you,then roll them in,so the toes of one foot are pointing to
the toes of the other foot. Then roll your legs in the opposite direction,so your toes are pointing away from each other
.
Also for the hips,lie flat on your back with your legs about six inches apart. Slide one leg out to the side as far as
you can,keeping the toes pointed up. Slide it back,and repeat with the other leg.
A variation that exercises both the hip and the knee is done from the same position,toes pointing up. Instead of sliding
the leg out to the side,hold the knee straight and rotate your legs,so that your toes arepointing out. Hold and repeat with
the other leg.
You can work your knees while you're sitting in a chair. Make sure the chair is high enough so that you can swing your
legs. With your thigh on the seat of the chair,raise one leg from the knee and hold it out straight in front of you,bending
your knee back as far as possible (without pain,of course)
Another knee exercise can be done while lying on your back with your legs extendd. Bring one knee up to your chest and
hold,then lower it slowly to the floor. Repeat fouur times,then follow the same pattern with the other leg.
The "towel grab" is one of the best ROM exercises for the arch of the foot and the toes. Standing up or sitting,with
a towel under your foot,try to pull the towel toward you,in bunches,with your toes. (You can get the same effect by trying
to pick up marbles with your toes)
Sitting on the floor with your legs extended in front of you,rotate each foot in turn,describing circles in the air,first
in one direction,then the other.
These are just a few of the many exercises that can be done to increase the joints'range of motion. Do exercises you
enjoy doing. for more exercises and the proper way of doing them consult a physiotherapist or occupational therapist. there
are also modified strengthening exercises you can learn to do that will strengthen muscles around a joint,again consult the
P.T and O.T, for the proper exercise and the proper way to do it.
Light weights are good strengthening exercisess for most people.
Dancing is good exercise for everyone who can.
