Sock's Rheumatoid Arthritis Page 1:
Living With RA
Home | Therapy | Diet And RA | General | Medications | Summary | Arthritis I | Arthritis II | Osteoarthritis | Guidelines | Extra-articular Features | Alternates | Drugs Used | Coping | Complementary | Living With RA | Disease Process | Treatment | Management | Features | Rheumatoid Arthritis | RA Links-BRMs | Research | Communication | Updates | Chronic Pain

There are periods of time when the patient "feels good" and times when the patient "feels worse. There will likely be times that a patient with RA "feels cured" It is important to understand that there are very few patients that have complete remission of the disease and it is essential that the RA patient do not stop the treatment program established by knowledgable health care practisioners. Rarely does the disease "go away",although at times the symptoms might temporarily remit.
 
Many patients with the more severe type of RA feel ill,much as if they have a chronic bad flu. Patients may feel tired,have no energy,feel nauseated,may lose their appetite and sometimes,even lose weight. These symptoms are typical in many RA patients and are called constitutional features.
 
Many patients will feel unwell,but persons with moderate-severe disease will feel it more.  Like extra-articular features,differences in medication,effects and therapy.the severity of the symptoms and patient differences helps to separate RA from other forms of arthritis.
 
The pain of arthritis varies greatly from person to person,for reasons that doctors do not yet understand, completely. Factors that contribute to the pain include swelling within the joint the amount of  heat or redness present or damage that has occured within the joint.
 
The number of joints involved is a important consideration in therapy.Most RA patients have < 20 painful joints affected.In addition activities affect pain differently so that some patients note pain in their joints after getting out of bed in the morning  whereas others develop pain after prolonged use of the joint.
 
Each individual has a different threshold and tolerance for pain often affected by both emotional and physical factors. These can include depression,anxiety and even hypersensivity at the affected site due to inflammation and tissue injury. This increased sensivity appears to affect the amount of pain perceived by the individual.
 
Pain is a private, unique experience that cannot be seen. The most common way to measure pain is for the doctor to ask the patient, e.g., The doctor may ask you to describe-"the level of pain you feel on a scale of 1 to10".
 
You may use words like aching,burning,stinging,or throbbing  .These words will give the doctor a cleaner picture of the pain you are experiencing.  The patient must relay the pain experience to your  doctor since he or she will use it as a guide for their treatment plan.
 
During physical activity your body releases certain chemicals (endorphins) that block  signals from reaching your brain. "Endorphins are the body's natural pain relieving chemicals that are in many cases more powerful than morphine," says a pain specialist.
 
The more endorphins that you produce on your own,the less you will have to rely on external forms of pain management such as medications. These chemicals also help alleviate anxiety and depression, conditions  that can make your pain more difficult to control.
 
Heat and cold can both be used to reduce the pain of inflmmation. Both therapies come in different forms,and the patient and doctor can determine which works best for the individual. Studies have shown heat and cold therapies usually work equally (depends on patient) in reducing pain,although they are usually avoided in acute gout.
 
Heat therapy increases blood flow,tolerance for pain,and flexibility. Heat therapy,can involve treatment with paraffin wax,microwaves,ultrasound,or mosit heat (placing warm towels or hot packs on the inflamed joint or taking a warm bath or shower).
 
During heat application,the patient should note a comfortable,soothing warmth. If the patient is noted to "move around" during the application,then the temperature of the heat needs to be checked to ensure that it is not too hot.
 
Cold therapy numbs the nerves around the joint (which reduces pain) and relieves inflammation and spasms in some patients. Cold therapy can involve cold packs, ice massage,soaking in cold water,or over-the-counter sprays or ointments that cool the joints and skin.
 
In the case of an acute inflammation resulting in a swollen joint,the benifits of cold may outweigh the benefits of heat. Except in cases where cold application is contraindicated (e.g. Raynaud's Disease),allow the patient to decide which modality works best.
 
Hydrotherapy involves exercising or relaxing in warm water,which helps relax tense muscles and relieve pain. Exercising in a pool is easier because water takes weight off painful joints. This type of exercise improves muscle strength and joint movement.
 
Mobilization therapies include traction (gentle,steady pulling),massage and manipulation (using the hands to restore normal movement in stiff joints). When done by a trained professional in rheumatic diseases,these methods can help control pain,increase joint motion,and improve muscle and tendon flexibility.
 
Relaxation therapy helps reduce pain by teaching patients various ways to release muscle tension throughout the body. In one method of relaxation therapy,known as progressive relaxation,the patient tightens a muscle group and then slowly releases the tension. doctors and trained physical therappists can teach patients other relaxation therapies.
 
A splint or brace should be used only when recommended by a doctor or therapist,who will show the patient the correct way to put the device on,ensure that it fits properly,and explain when and for how long it should be worn. The incorrect use of a splint or brace can cause joint damage,stiffness,and pain.
 
A person with arthritis can use other kinds of devices to ease the pain. The use of a cane when walking can reduce some of the weight placed on the arthritic knee or hip. A shoe insert (orthtic) can ease the pain of walking caused by arthritis of the foot or knee.
 
Surgery may  be required to repair damage to a joint caused by arthritis. The doctor may recommend arthroscopic surgery,bone fusion (surgery in which bones in the joint are fused or joined together),or arthroplasty (also known as total joint reolacement,in which the damaged joint is removed and replaced by an artificial one).
 
Exercise: The irony,of course,is that when people have a disease that causes pain and stiffness--such as rheumatoid arthritis--physical activity and exercise will not seem that appealing.
 
When the body aches,the thought of walking might be negative. A 1998 survey by the Arthritis Foundation revealed that 70 % of these respondents with RA give up exercise when their disease is at its worst. Unfortunately,that's the wrong course to follow. When a persons condition threatens to immobolize them,light-movement keeps them mobile, Even small movement helps.
 
The key to achieving many of the benefits is to take in a regular exercise program that includes flexibility,strengthening and aerobic exercise. Your exercise program should be tailored to your condition. This can increase your health benefits and decrease the chance of injury. Your doctor should be able to recommend specific activities to benefit your condition.
 
Remember to start low and progress slow. Do not push through severe pain. Consistency is more important than intensity.Exercise isn't a cure all so you will need to continue with your regular treatment regimen. But with proper guidance and dedication, exercise can be a effective part of your pain management program.
 
It's important to  remember that there is no quick fix for chronic pain and managing  pain isn't about making it disappear. Rather,it's about keeping pain tolerable. If pain appears while exercising,stop. Exercise should be enjoyable and soothing.
 
The sad fact is that despite the best intentions,many people who start a exercise program quit after six months. In RA  management and treatment  that should not be a option to follow.
 
Living with any type of arthritis day after day can be emotionally draining and cause depression. The stress of a illness may make you feel sad or blue.
 
You don't feel like doing anything going anywhere or being with friends and family. These feelings can make you feel tired. Being tired all the time in turn can contribute to depression. It's a cycle that at times can be difficult to escape.
 
Many patients will say-"After all my years of living with RA I still find it hard to pace myself. The fatigue is always there in varying degrees. Sometimes it is difficult to know when I've reached my limits. I don't always listen to the signals of pain and fatigue. When I feel good I push myself to hard. It will not be possible to keep up with our friends at times .Resulting in having to "pay" for it later.
 
With chronic-the real picture is not bleak as it sounds-you may find at first what's hardest isn't the physical pain but rather the emotional consequences it can bring. You may fear that chronic means you'll never experience any relief.
 
 Like many others,you may find strugglinng with thoughts such as - I'm losing control of my life-I'll lose my independence-I'll lose my appearance-I won't be able to work-I'll be in constant pain-I'm falling apart. The fact is,that most of these fears are never realized.
 
You may have a chronic condition that requires a new kind of awareness-and yes, in that case it is something you may need to pay attention to for the rest of your life. But chronic doesn't have to mean constant,most types of chronic arthritis flare up more then normal but it doesn't cause relentless pain every day. When you're hurting and searching for relief its easy to become discouraged. But hang in there.
 
It's important to understand that because the nature of chronic arthritis,medical treatment is based on a certain trial and error approach. That means that although there are many effective medicines and treatments for pain,it may take time to find the combination that's effective for you. Your doctor may have to try you on several different drugs,for several months each, for example.
 
And eventhough it's hard to wait for the most effective relief,this trial and error approach  is proper treatment. Have faith in the process,and realize that though the wait may be frustrating,it will pay off in the end. Therapy,often consists of "educated guesses".
 
Protecting your joints means using your joints in ways that avoid excess mechanical stress from daily tasks. benefits include less pain,and greater ease in doing tasks. e.g. when opening a door lean your body into the door.
 
Pacing,by alternating heavy or repeated tasks with easier tasks or breaks, reduces the stress on painful joints and allows weakened muscles to rest. Pacing and planning also provide you with ways to deal with the fatigue that is associated with RA.
 
Positioning joints wisely helps you use them in ways that avoid extra stress(e.g., use larger stronger joints to carry loads and change position frequently) Some people will be given splints or othotic deices that affected joints such as the fingers,to rest in a good position.
 
Using assistive devices,such as canes,raised chairs,grip and reaching aids,can help simplify daily tasks. Using grip bars and shower seats are important steps towards conserving energy and avoiding falls.
 
People with RA are generally not obese,and if so,it's usually become less active. Weight control means trying to maintain a recommended ,healthy weight. If you plan to lose weight try to discuss it with a dietician.
 
Relaxation--There are many ways to relax. Try deep breathing exercises. Listen to music or relaxation tapes,mediate or pray. Another way to relax is to imagine,or visualize a pleasant activity or thought.
 
Developing good relaxation and coping skills can give you a greater feeling of contol over the disease and a more positive outlook.
 
Many kinds of more immediate practical help are available. There are effective physical treatments for pain,trained-therapists-who can help modify your home or workplace(if it applies to you) so moving around is easier.Do visit the Arthritis Society so you'll know you are not alone., and abundant gadgets and copeing skills to assist you.
 
After a while,you may realize that managing  your RA is a little like dealing with rough weather, it comes and goes,but if you got your mental state in a positive position,"you'll manage". In the great majority  of cases,people with chronic RA will continue to live enjoyable , fulfilling lives that may be modified in certain ways to adapt to their individual condition. A lot depends on you,as a individual-how you approach your condition-it is a tough disease.but it can be controlled  with the proper guidance.
 
Remember,there are trained health care professionals (nurses etc.), specifically  trained in rheumatic disease treatment,and management-unfortunately,they are few in numbers,and often limited by the time-factor. Thus the further need for self-education.
 
According to a major market-research survey of people with arthritis conducted for the Upjohn Company of Canada in the 1990s,"while on the whole patients are complaint,almost half claim to take medication  only when they experience pain and inflammation",and "when (patients ) deviate,it's almost always in a pattern entailing lower frequency of use". Upjohn's inquiry didn't pretend to be highly scientific. It was a marketing survey,though one so large it's statistical significance and conclusions can't be easily dismissed.
 
A earlier study in the U.S. journal Medical Care,e.g.,reported that 50 to 75 % of patients do not follow their physician's prescribed therapy closely enough for the regimen to work. Part of the problem,is the too-brief time one actually spends with the doctor;a patient has to be extremely well prepared to take advantage of a ten-minute visit. Most people aren't,and don't.
 
Studies have shown that patients forget as much as half of what physicians tell them after an appointment. The visit is simply too stressful for many people,and they may not have clearly understood what the doctor was telling them.
 
The problem is especially acute with arthritis patients who only see their rheumatologist every three to six months. Many are so keyed up by the experience that they not only forget what the doctor said but what they wanted to ask about the medication they've been prescribed. The result may result in a communication gap,that may leave the patient without essential information that the patient requires and deserves..

The Arthritis Self-Management Program: (ASMP)
 
The program was an immediate success in the States and began as a pilot project in B.C. in 1989,then went nationwide in 1992,thanks in large part to a half-million-dollar Seniors Independance Program grant to the Arthritis Society (corporate donors have been underwriting it since then).
 
The six-week course is open to people with all forms of arthritis,their spouses and families,and anyone else who may be interested. (Participants are charged a nominal fee to cover the price of a book and other incidental costs.)
 
The ASMP acts as a complement to traditional treatment, helping people to better understand their arthritis,cope more effectively with chronic pain and depression,and take a more responsible role in their arthritic care.
 
People with arthritis are trained as group leaders,and group work is emphasized, because peer pressure has been showen to enhance efficacy.
 
Another factor people learn to deal with is "learned helplessness",the erosion of confidence a chronic disease can impose. If you learn that climbing stairs is always a painful experience,i.e.,you may stop dropping in on a basement-level shop or visiting a friend who lives in a walk-up.
 
You'll learn to be not helpless in the face of those challenges.
 
And,if every time you experience a change in symptoms you feel you have to consult a doctor,you become dependent.
 
The ASMP teaches people how to avoid or avoid such hurdles. It also "injects" them with a healthy dose of self-efficacy,by giving them a take-charge attitude about every aspect of their arthritis.
 
To date,taking part in ASMP has taught thousands of people to "take charge" of their arthritis. They're more informed about their disease and better able to cope with it on a day-to-day basis than they were.
 
Because,they are better informed,they're also prepared and confident in their dealings with medical professionals.
 
They know what questions to ask,and they invitably come away with more information about medications and their side effects,potential prognoses for their condition, and exercises than someone without their training.
 
Knowledge is power. The more you know,the more able you're to cope-and the better you're able to live with arthritis. The big step is to learn about your medications. They're about to become a part of every patient's life.
 
You can do a ASMP of your own in your own home-if you like-with some-guidence-help, correct information,strong-will-power and determination to succeed.
 
It's your decision,body and future well-being at stake,no one else but you.
 
Protecting Your Joints:
 
The most recent Centre for Disease Control and Prevention suggest that 30 minutes of moderate-intensity activity for most days of the week. Depending upon your baseline,those 30 minutes can be spread out,so if one spends walking 15 minutes  in the morning then perhaps 15 minutes doing another activity in the afternoon,that amounts to the daily  quota .
 
We have to be careful of the differential effects of exercise for losing weight and for RA patients whose joints are aching all over or even for just overwell fitness for good well-being. There is a difference to consider. It has to do with intensity for one. i.e., If one schedules walking for 30 minutes and if your body says 5 minutes then it is better than doing nothing.
 
People need to look at what the factors are,that are contributing to fatigue, pain,depression or inflammation (common in RA). Is there another medical condition present? When one is able to isolate what these few things may be,then we apply treatment strategies based on the cause
 
People with arthritis are frustrated. They don't like or want to be feeling ill. Some patients try a variety of trials. Some turn to herbs and supplements without understanding the dangers involved or the treatment itself. Others may follow a strict dietary avenue.
 
Rheumatoligists are RA experts and they really don't have any scientific proof that diet,as a single agent without anything else,does anything to stop arthritis. They wish it did,but it doesn't.
 
A good well-balanced diet in addition to medical care is important,but as a sole therapy they don't hve any proof that it helps except in perhaps the smallest minority. Medication will be tapered or discontinued,depending upon the medication, when a person is in remission or feeling better. Some medications may be continued as a maintainence therapy.
 
The hallmark of a safe exercise program is a gradual progression in exercise intensity,complexity of movements,and duration. Often,patients with arthritis have lower levels of fitness due to pain,stiffness or biomechanical abnormalities.
 
 Too much exercise during a flare or the wrong type may result in increased pain,inflammation and damage to the joints. Thus,beginning with a few minutes of activity,and alternating activity with rest should be the initial goals.
 
Special emphasis should be placed on joint protection strategies and avoidance of activities that require rapid repititions of a movement or those that are highly percussive in nature. Because faster walking speeds increase joint stress, walking speed should be matched to biomechanical status.
 
Special attention must be paid to joints that are misaligned or unstable. Control of pronation and shock absorption through shoe selection or use of orthotics may be indicated.
 
Affected joints may be unstable and restricted in range of motion by pain, stiffness, swelling,bone changes or fibrosis. These joints are at high risk for injury and care must be taken to ensure that appropiate joint protection measures are in place. Activity during a flare is encouraged,concentrate on other unaffected joints,or try a different type of activity with least strain.
 
Beginning exercisers should be encouraged to identify the type of physical activity they feel most comfortable with,and then begin this activity in short sessions. If people have had a positive experience with a particular mode of exercise in the past,they are likely to have higher exercise self-efficiency. e.g.,Among those who have enjoyed swimming in the past,water aerobics may be an ideal method to increase physical activity.
 
On the other hand,if individuals are not fond of swimming,encouraging them to get into a pool regularly is less likely to be successful then to get into a pool regularily is less likely to be successful than encouraging them to begin a walking program.
 
Unfortunately,most people without arthritis begin a exercise program,and despite the best intentions,discontinue within the first six months. This is not an option that rheumatoid arthritis patients can afford to follow.
 
Physical activity is essential to optimizing both physical and mental health and can play a vital role in the management of arthritis. Regular physical activity can keep the muscles around affected joints strong,decrease bone loss,help control joint swelling,and pain in most patients.
 
Regular activity replinishes lubrication to the cartilage of the joint ,reduces stiffness and pain. Exercise also enhances energy and stamina,decreasing fatigue and improvin sleep.
 
The goals of an exercise program for individuals with arthritis are to:
 
1) preserve or restore range of motion and flexibility around aaffected joints.
 
2) increase muscle strength and endurance.
 
3) to increase aerobic condition to improve mood and decrease health risks associated with a sedetary life.

Mind and body are very closely connected,and for this reason cognitive behavioral therapy (CBT) employs two basic strategies to produce significant improvements in stress,anxiety,and pain. Patients are taught to adjust their behaviour to minimize physical stress and fatigue,and they are trained to ignore negative thoughts and emphasize positive ones.
 
At first,many patients dismiss the idea that "positive thinking" can limit pain,but research has proved it to be amazingly effective. Several studies at Duke university and man others have found that CBT works very well,especially when spouses or others emotionally close to patients accompany them to therapy sessions. Many physicians and mental health professionals,trained in pain management can help patients with CBT. Relaxation lessens stress,and less stress usually means less pain.
 
Physiatrist are medical doctors,who specialize in musculoskeletal rehabilitation. They can design a tailored program of exercises to strengthen joints and know hoe to alleviate neuromuscular pain in tense,painful ischemic (oxygen-derived ) muscles.
 
Occupational therapists can show you how to adjust your approach to tasks and how to use tools and movement aids,(assistive devices ),to ease stress on joints. Most can also design and construdt assistive devices to fit your needs.
 
Physical therapists can improve physical functioning and limit pain by strengthening and stabilizing joints. Most licensed physical therapists are well equipped to evaluate your condition and prescribe a customized schedule of exercises,treatments and changes to daily routines.
 
There are specialized nurses trained in the management and care of rheumatic diseases,but unfortunately outside of a hospital setting,or you are fortunate to access one,they are scarce. Some general nurses will not have the experience or training to cope with the differences in rheumatoid arthritis and other rheumatic diseases, like osteoarthritis.
 
Some patients have dietary needs,but if you are one of them,make sure they are licensed,and come from a accreditted institution of learning. Any one can call themselves a "dietician"
 
Most physicians,as they are necessary and valuable to our general well-being,do not take special training in diets,exercise,or pain control. Some do not  even take the basic option offered at medical school in rheumatology,and unfortunately or not some internists are in the same category. They are not trained in basics like "bone-count"("feeling" the number of inflamed joints involved). A rheumatologist is trained in most aspects of all rheumatic diseases.

The Cox-2 inhibitors have less stomach troubles then the older NSAIDs like Ibuprofen,Naproxen or Feldene. The Coxibs include Vioxx and Celebrex. They improve inflammation in arthritis in patients with RA.
 
Aceteminophen works in different ways. It's really more of a pure analgesic or pain medicine,and its not a NSAID. It can be taken along side a NSAID. Two NSAIDs shouldn't be taken at the same time. But one can take,say,Vioxx or Celebrex with Acetaminophen and receive extra pain relief.
 
If some patient's who doesn't respond to the standard NSAIDs or the coxibs and acetaminophen was added to that without noticeable results,physicians might add a combination of acetminophen with a mild narcotic analfesic such as codiene (Tylonol). Tylonol comes in different strength,the stronger ones have a codiene additive.
 
Vicodin,Lortab,Lorcet are common drugs that can be mixed. Patients need to know that there is a risk of bleeding ulcers,and stomach problems,when they start a new NSAID such as the coxibs,that there's still a slight chance that it might raise the blood pressure ( Vioxx ) or affect the kidneys in certain patients.
 
Patients need to know that acetaminophen has been shown,recently,through clinical trials that in higher doses of 2 to 4 grams per day,it can cause bleeding ulcers and stomach problems,which is a new finding. Before it was considered perfectly safe on the stomach.
 
Physicians and patients worry about habituation with narcotics where patients feel like,they must take them. They can cause light headiness or make them feel a little fuzzy,and it can cause constipation,especially,in older persons.
 
Oxy Contin is in the national news,where people abuse it recreationally and some states ban sale of the product. Drug outlets have been broken into to get access to the product. If patients have long-standing,delibilitating RA-which,now is not common as in the past. Our newer therapies,specifically,our DMARDs such as Enbrel,MTX,and Arava,have slowed the disease process down,and most patient's don't have significant enough arthritis to require something like Oxy Contin and wheel chairs.(wheel chairs were once common to RA patients)
 
Darvon is a mild analgesic. We can mix it,with the NSAIDs. We can mix it with the newer coxibs. And,there are Davon compounds. Darvon can be taken with acetaminophen at the pharmacy and its an analgesic.
 
Ultran or Tramadol,which is the genetric name,and now a newer version of it,called ULtracet,which was approved in the summer of 2002,which is a combination of Tramador or Ultram,plus acetaminophen,again,have been effective,its a non-narcotic analgesic,foud effective for pain relief,less constipation problems,less central nervous problems in older patients who have problems with their heads,and feeling like they can't think quite as well. The good news it can mix with DMARDs and NSAIDs.
 
All of these medications work,some of them better than others,for different people,in different situations. But,again,they can have some side effects. The patient and physician must decide on the individual situation and come up what is best for the patient.

As far as I am concerned,number one is a good night's sleep and rest because if you're not getting adequate sleep,you're going to have more pain. You're going to have more fatigue. It has been proven that the average North American gets about 4 to 5 hours of RESTFUL sleep. And many times when one has RA you'll roll over on one side and your hips hurts when you come out of a deep slep and you're fatigued-you have more pain. Often people pin their wrists or arms under their body during sleep and that results in pain all day,at times.
 
Scientific studies may show that any food,any diet does nothing for arthritis but many people with RA don't get get a wholesome,all-around-nutritious diet because they don't feel well and a result nibble at that and this. Good health,regardless of condition contributes to overall good health,so why not RA patients ?
 
We are supposed to drink 8 glasses of water a day. The average person only drink 2 glasses of pure water and when we don't drink a lot of water the probability of side effects with all that medication is greater.
 
Stress management is very important. If it isn't controlled properly the result is more pain and fatigue.
 
Many times with arthritis we get atrophy of the muscles;decondition. The more deconditioned you get the more pain and fatigue. Patients have to get involved with exercise because the weaker muscles and ligaments around joints become,the more pain you're going to have.
 

Start by trying to find out where the individual who has rheumatoid arthritis is with the particular illness. Different things affect people in different ways. Some people may be very anxious about the future and be coping with the present very well. Others may have difficulty even thinking about how to get up in the morning and proceed with their day. Often start with where the patient is.
 
The initial thing is try to find out is whether they have support from their husband, wife, or other family members. If they're employed, does their boss understand what's going on with them? People need a sense that this illness is not going to isolate them. They need to be understood and have a feeling that other people care about them.
 
Getting support from family members and employers is very important. Oftentimes, feeling understood gratifies people so much - they feel like other people care about them. It's often very important that they discuss the frustration and the depression with their primary physician. The doctor may suggest a referral, so they can have an opportunity to really pour their heart out about what's troubling them and what they're frightened of.
 
A psychiatrist,may suggest the use of antidepressant medication, though not necessarily right away. This often can be quite helpful in lifting someone's mood and also can be helpful in terms of pain control even though it doesn't necessarily do anything for the underlying arthritis process.

Not everyone needs a antidepressent,it depends on their coping skills. It depends on what their previous history has been. If you have someone who has never been ill and all of a sudden has this diagnosis mentioned to them, the way that they react to it will often reflect how they've dealt with other traumas in their life. If there is someone who has had multiple illnesses, this additional illness can often give them an overwhelming sense of "What's going to happen to me?" and a complete loss of control.
 
People like to feel like they're in control of themselves and in control of their health. When this starts to be preyed upon, everyone feels a little bit of loss of self and somewhat of a loss of self-esteem. But we're talking about degrees here.
 
Depression and anger go hand-in-hand, as we all  know. What do you tell a person who's living with rheumatoid arthritis and who's frustrated with their inability to do the simple things that they used to be able to do?
Number one,try and empathize with them about how difficult that must be. Number two,tell them express themselves, how angry they're feeling, even if they tell the therapist they're not angry. The therapist try to get to the point where they understand that it's very normal to be angry, and they don't need to be afraid of their anger or feel guilty about their anger.
 
The therapist then work with them on how they're going to begin to get some of their expectations met and how they're going to go on in life with a more positive focus rather than being so consumed with the idea that this disease is going to take everything away from them.  "It's very normal to be angry. Patient's are encouraged to get involved in learning about their illness and in learning about good health in general."  
 
As somebody coping with diabetes, which is another long-term chronic condition, sometimes it's not the disease that’s the problem, it's the stress of coping with the disease.  It always depends on the degree of involvement and how much rheumatoid arthritis takes away from a person's everyday functioning. It is helpful is to get people involved with other rheumatoid arthritis patients so that they hear that their complaints are similar to other patients struggling with the illness. Try to encourage patients to do as many things as possible that they like to do and things that they used to do.
 
Patients need encouragement to get involved in learning about their illness and in learning about good health in general.  There are a lot of things like exercise and proper diet which we hear a lot about today that really do make some sense for people who don't have a particular illness. But especially if you have a chronic illness, that's something that you have to watch. The more you can help a person focus on the positive things about their life, the better they're going to be able to tolerate having this particular illness

Some positions and movements can put extra stress on involved joints. Even when these joints are not hot, swollen, and painful, they need to be used in their most stable positions.
 
Avoid activities that involve a tight grip. If your hands are affected by arthritis, holding an object tightly can harm the weakened joints. You can buy items with enlarged handles to lessen the strain on your hands. You can also build up the handles on pens, eating utensils, tools, or brushes by taping a layer or two of thin foam rubber around the handles (or by using a foam rubber hair curler or pipe insulation).
 
Avoid activities that put too much direct pressure on your fingers or thumbs. Pushing down on your dinner knife with your finger when cutting meat is an example of direct pressure. Instead, try holding the knife like a dagger or using a pizza cutter. Use a knife to open a milk carton or a box, instead of pushing with your thumb. To avoid opening push-button car doors with your thumb, use a door opener aid with a lever handle.
 
Avoid tight pinching, squeezing, or twisting motions. Spread your hand flat over a sponge or rag, instead of squeezing. To open a screw-top jar, lean on the jar lid with the palm of your hand and turn the lid with a shoulder motion to reduce stress to your fingers. Use a rubber gripper, or use a drawer to hold the jar while you twist the cap. You can also purchase a jar opener that allows you to hold the jar with two hands while turning it. Remind the family not to close jar lids so tightly the next time! Use push type ratchet or power screwdrivers, instead of twisting the standard type handles.
 
Use good posture to protect your neck, back, hips, and knees. When you have pain or stiffness in any of these areas, you need to pay special attention. Use a book rack, so you don't have to strain your neck looking down.
 
Whether you sit or stand to work surfaces should be at a correct height. Your elbows should be at right angles and your shoulders should be relaxed when you work. To make it easier to get out of a chair, use pillows to make a seat higher. Learn proper body mechanics for lifting, bending, reaching, and rising from a chair.
 
Control your weight
Extra pounds put more stress on weight-bearing joints (hips, knees, back, and feet). This extra stress can lead to further joint pain and damage. Losing weight will be helpful to your joints. Check with your doctor to find the best weight-loss program for you. You'll also look better, probably have more energy, and feel healthier, too!
 
Avoid staying in one position for a long time
When joints or muscles are kept in the same position for a long time, pain and stiffness may increase. For example, writing a long letter or doing needlework keeps your hand in the same position for a long time. Do a quick body check of your jaw, neck, shoulders, arms, hips, legs, and ankles. It's a good idea to frequently relax and stretch these areas, especially any area that feels tight or stiff. Shrug or rotate your shoulders in big circles to reduce the tension that collects there.
 
Use your strongest joints and muscles
Remember to use the strongest joints and muscles whenever possible. By using larger joints or your whole body, you can reduce the stress on smaller joints.
 
 Here are some examples:
Carry a purse with a shoulder strap, rather than holding it in your hand, or use a backpack or fanny pack. Push open a heavy door with the side of your arm, not with your hand, or lean into it using your body or hip. Add cloth loops to drawer pulls and the refrigerator door handle so they can be opened using your forearm.When using stairs, go up with your stronger leg first and go down using your weaker leg first. Always use a hand rail if available.
 
Pay attention to body mechanics
When lifting something that is low or on the ground, bend your knees and lift by straightening your legs. Try to keep your back straight.  Use reachers instead of bending to get something from the floor or cupboards. If you have to bend, try to keep your back straight.
 
To get up from a chair, slide forward to the edge of the chair. Keep your feet flat on the floor. Lean forward, then push down with your palms-not your fingers-on the arms or seat of the chair. If you have wrist pain, you can push off with your forearms against the top of your thighs. Stand up by straightening your hips and knees.
 
Distribute weight
Spread the weight of an object over many joints to reduce the stress placed on any one joint. For example, use the palms of both hands to lift and hold cups, plates, pots, or pans, rather than gripping them with your fingers or one hand only. Use padded oven mitts for hot dishes. Carry heavy loads in your arms close to your body, instead of gripping them with your fingers or hands.
 
Balance rest and activity
Both work and leisure activities are important for people with arthritis, but you can overdo them. It is wise to take short breaks and alternate heavy and light activities throughout the day. Learn to balance periods of work with rest breaks, so you don't place too much stress on your joints or get too tired. You may need to take longer and perhaps more frequent rest breaks when your disease is more active.
 
Part of this balancing includes pacing yourself during the day, and also from day to day. Allow plenty of time to finish the things you start, so you won't feel rushed. Don't try to do too much at one time. Pacing also includes doing the hardest things when you're feeling your best.
 
Plan ahead
You can make your life easier by planning ahead. Perhaps each night you could prepare a written schedule of the next day's tasks. Think about what the tasks involve--the amount of time they require and how tiring they are. Remember to build in rest periods, and to alternate heavier with lighter tasks.
 
Be realistic. Look at all of the activities you do in a normal day and week, and eliminate the ones that are not necessary. Delegate some of the others. Set priorities for the remaining tasks, but remember that you can change your priorities if needed.
 
Organize your tasks. Combine steps and find shortcuts. For example, you can save time and energy by fixing simple meals that require little preparation. If you want to serve more complex dishes, choose a day when you have more time. Cook extra portions and freeze them to use on days when you don't feel like cooking.
 
If you have a basement laundry area, bag your laundry and drop or drag it down the steps to avoid carrying heavy loads and making several trips. Plan to stay there until the laundry is finished. Have a place to relax while waiting, or use the time to catch up on reading or letter writing.
 
Organize work and storage areas: Keep all the equipment necessary for any task together in one area, within easy reach. For example: Keep your baking equipment in one place. Keep pots by the stove. Keep the same cleaning supplies in several places: kitchen and bathrooms, both upstairs and downstairs.  
 
Store heavy jars and boxes at elbow level. If you must store objects up high, be sure they are lightweight. Use a long-handled reacher or tongs to get them down. Keep appliances that you use most often (such as a toaster) out on the counter. Keep shelves shallow (preferably only one row deep), or use space savers, such as Lazy Susans and pullout shelves. Use a pegboard at the workbench for easy access to tools. Sit to work

If possible, sit at a comfortable height to work. Many of the tasks you usually do standing can be done seated, and this will take the weight off your hips, knees, and ankles. For example, sit to cook, iron, wash dishes, work at your tool bench, and even to dress. A high stool may be useful for some of these tasks. Use good posture to avoid straining your shoulders and neck.
 
Use labor-saving devices
Many different devices have been developed to make tasks easier and more efficient. You can find these in local hardware and variety stores, pharmacies, and medical supply shops. Check with an occupational therapist who can answer your questions and help you choose the best device for you. It can be costly to order from catalogues and find the item doesn't work for you.
 
Use devices that  can: provide leverage to give you more force,keep joints in the best position for functionm extend your reach when range of motion is limited, help you avoid strain on joints
 
Ask for help
While it may be hard to admit that some things are more difficult to do than before, it is important to get help when needed, especially for activities that are particularly stressful to your joints. Your family and friends will understand you better if you share your feelings with them and let them know how they can best help you. You might try telling them on a scale of one to ten (with "ten" being the worst}, how much pain or fatigue you're having.
 
You may even find that your family and friends have some of the same emotional reactions to your arthritis as you do. They may feel shut out or frustrated when they aren't able to help. Tell them that the amount of pain and stiffness you feel varies throughout the day and from day to day. Try to involve your family in decisions about sharing chores and making new arrangements of shelves and furniture. Ask your friends for their understanding if you have to change or postpone plans you've made.
 
Respect pain: Try to avoid or modify activities that cause pain. If you have painful hands but must work at a computer, try to rest your hands frequently or talk to your supervisor about making changes. These might include adjusting the level of your keyboard or using a wrist support at the edge of the keyboard.
 
Avoid activities that involve a tight grip or squeezing. Use tools with built-up handles. Build up pens and pencils with foam rubber. Use scissors that spring open. Use good posture. Use work surfaces that allow you to keep your back straight and your shoulders relaxed. If you work at a desk, you can use a slanted top, a drafting table, or a document holder to reduce the strain on your neck and upper back.
 
Avoid staying in one position: Change your body position and move your neck, shoulders, arms, hips, and legs often to avoid stiffness. If your job requires a lot of standing, shift your weight from one leg to the other by placing one foot on a box, footrest, or stool in front of you. Wear comfortable, supportive shoes.
 
Use your strongest joints and muscles: Remember proper body mechanics. To lift something, bend with your knees, not your back. Carry your briefcase with a shoulder strap.
 
Balance rest and activity: If your job requires a lot of standing or walking, take frequent rest periods. Try to lie down for a while during your lunch break, or sit if lying down is not possible.
 
Organize work areas: If you use tools, place them at a convenient level. Use a Lazy Susan or desktop organizer to keep items within easy reach. Sit to work, when possible: A well-designed chair for working should provide good back support, and should swivel or be easily moved. It also should be adjustable to the proper height for any activity.
 
Use labor-saving items: Use specially designed tools such as pistol grip ratchets and ergonomic hammers that keep your wrist in a stable position. Use a rolling cart or luggage tote instead of carrying heavy objects in your hands.
Ask for help: Have a talk with your supervisor (or the personnel director) about your needs. Most employers will want to protect their investment in your training and experience. An occupational therapist may be able to help sort out your needs.
 
In the kitchen
Plan meals ahead to lessen last minute tasks. Use electric appliances such as can openers, mixers, blenders, fry pans, crockpots, microwave ovens, knives, and dishwashers to get the job done with less time and energy. Place a mixing bowl in the sink when stirring. A damp cloth underneath will help to keep it from slipping. Hammer rust-proof nails through a cutting board to secure vegetables while cutting.
 
Use a French Chef's knife, which keeps hands in good position for cutting, slicing, and chopping. Use disposable aluminum baking pans for easier cleanup. Spray a nonstick product on pans or line with foil before baking or frying. Let dishes drain and dry in a rack. Use lightweight baking dishes, plates, pots, and pans, and serve from them. Use a wheeled cart to move heavy items from place to place. Sit on a high stool while cooking or washing dishes. Use convenience foods such as precut potatoes and onions.
 
Laundry and housecleaning Do only the tasks that are really necessary. For example, buy permanent-press items that don't need ironing. Use separate laundry baskets to sort clothes before taking them to the laundry room. After the clothes come out of the dryer, sort them into different baskets for each family member to put away. Sit to sort, fold, and iron clothes.
 
Put casters on furniture. Use a sponge mop with an easy squeezer, a "janitor's pail" with a wringer, or a pail on a wooden dolly. Use a long-handled feather duster. Dust with a mitt, using circular motions with your hand extended. Wear an apron with big pockets for carrying cleaning supplies. Store cleaning supplies everywhere they are used.

Use an automatic toilet bowl cleaner and spray-on mildew remover so you won't need to scrub. Alternate heavy tasks, such as mopping floors, with light ones, such as dusting. Just do one major cleaning task a day, such as washing clothes or cleaning the bathroom
.
In the bathroom
Sit on a bath stool in the shower or tub. Wash with a bath mitt or a long handled brush. Extend or build up handles on brushes and combs with rulers, foam rubber, or pipe insulation. Install lever-type faucets which can be controlled with the palm, or build up faucet handles or use a non-skid pad.
Put grab bars around the tub and toilet. Use a rubber suction mat or nonskid strips in the tub or shower.

Squeeze a toothpaste tube between your palms or put a washcloth under the tube and lean on it. You can also buy toothpaste in a pump dispenser. Use an electric toothbrush or one with a built-up handle. Use a raised toilet seat, if you have trouble sitting or rising from the toilet. Use a free-standing mirror to put on makeup, so you don't have to lean over the sink and strain your back.
 
In the bedroom
Use long-handled shoe horns and sock aids. Wear shoes that fit and provide good support. Some shoes have velcro closures or elastic shoelaces. Wear pre-tied neckties. If possible, replace buttons with velcro or use a button hook. Use a zipper pull or add a loop, chain, or large paper clip to make a zipper easier to grasp. When making the bed, finish one side at a time.
 
Leisure
Use a card rack or holder or a brush to hold playing cards. Lay newspapers open on a table to read; use a book stand. Use felt-tip pens, which require less pressure, or larger pens, which are easier to grip. Use a push-button phone or a pen tip to dial. Get a headset so you don't have to hold the receiver.

Use specially-made, lightweight tools with built-up or extended handles for gardening and other yard work. Use a gardening stool designed to reduce the stress on your back and legs. Break up long shopping trips into several shorter ones. Use a fishing rod holder or camera strap to free your hands. Play golf for nine holes and then rest before starting the second set. Ride a golf cart and use lightweight clubs. Use a three-wheeled bike for greater stability.
 
In the car
Have power steering, brakes, windows, and seat controls. Build up tops of keys or use key holders to make turning easier. Use a car door opener (self-help device) to reduce stress on your hands. Use a wide-angled mirror if you have trouble turning your neck.
 
Although it is important that you use your affected joints wisely all the time, it may take a while before this seems natural to you. If you continue to find things too hard or painful to do, talk to your doctor or therapist. There are many techniques, aids, and devices other than the ones described here that might help solve your problems

Gov.: National Institute of Health

Health Topics: Search Government Library