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Sock's Toxicity And Drugs In RA:
Musculoskeletal
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Musculoskeletal conditions affect over 40 million people in the U.S. The three most common are Osteoarthritis, RA and  Fibromyalgia.
 
OA is the most common form of all musculoskeletal conditions affecting more than twenty million people in the U.S.
 
RA and FM are not as common.
 
Rheumatoid arthritis is a inflammatory disease of the synovium,OA is a non-inflammatory disease of the cartilage.
 
There are many different types of musculoskeletal conditions that can have a significant impact on a patient's physical and pschological functioning. There are more than 100 joints connecting the body's 206 bones.
 
Tied together by ligaments,the bones of joints are capped with a smooth substance-cartilage. This tough elastic material acts as a shock absorber and allows the bone ends to glide smoothly across each other.
 
 If the cartilage is destroyed (as in OA),the bones of joint can grind against each other causing pain,loss of mobility,deformity and dsyfunction.
 
Between the bones is a joint cavity,which gives the bones room to move. The joint space between two bones is enclosed by a capsule that's flexibile,yet strong enough to protect the joint against dislocation.
 
The inner lining of this capsule,the synovium,produces a thick fluid that lubricates and nourishes the joint. In many forms of arthritis,the synovium becomes inflamed and thickened,producing extra fluid which contains inflammatory cells. The inflamed synovium and fluid can damage the underlying bone (RA).
 
Fibromyalgia is a condition characterized by widespread muscle pain and point tenderness at various sites around the body including the upper back,buttocks,upper arms, and knees.
 
The etiology of this illness is unknown,but it has been linked to psychological stress,and biochemical abnormalities in the central nervous system.

Current therapy is aimed at reducing the pain and other symptoms associated with these conditions. Non-pharmacologic therapies play an important role in the treatment of these disorders including weight loss,exercise and physical therapy.
 
Pharmacologic therapy is aimed at pain relief and,in the case of RA, disease modification and control,in addition to these therapies that have been available for years,new therapies with fewer side effects and a more specific mechanism of action are being studied and released.
 
Tissue transplants are being researched for their potential role in the management of OA. In patients with a specific defect in the knee joint,known as osteochondritis dissecans,autogenous cartilage implantation is being studied.
 
 Results to date promising,but caution is advised while more long-term and better designed studies are conducted.
 
A second procedure being studied is referred to as autogenous osteochondral grafting. Only 57 patients have been studied so far,but results have been encouraging. In this procedure,cylinders of bone and cartilage are transferred from a lesser weight-bearing position to the articular surface of the knee joint. The procedure is limited to areas where cartilage lesions are small.
 
Since cytokines have been thought to be potentially implicated that leads to OA,modulation of these compounds are being studied
 
Many of the treatment options for Fibromyalgia center around nonpharmacologic  therapies. Although this syndrome has a pain aspect, conventional treatments for pain are not always effective.
 
One of the most important aspects of the management of this disease is ensuring that patients understand this illness as much as possible and the importance of trying nonpharmacologic treatment approaches including exercise and relaxation techniques.
 
Narcotics are not recommended because of their potential for dependence and addiction with long-term use. Glucocortoids have been of little benefit and should be avoided. NSAIDs and other analgesics only partially improve symptoms for some patients with many people having no benefit.
 
Various other therapies have shown benefit in some patients with FM. The tricyclic antidepressants and the muscle relaxant,cyclobenzaprine,used before bedtime may help to restore a normal sleep pattern helping the patient to fell less fatigued. Patients should be started on regular doses of these medications and titrated upwards,based upon efficacy and side effects.
 
 Depression and anxiety should be treated with appropriate interventions including psychotherapy  and drugs. Trazodone may be a useful addition in a patient with cocomittant sleep disturbances and depression.
 
Other than alprazolam, benzodiazepines should be avoided in patients with FM because of their negative effects on the sleep cycle. First and foremost patients should be educated about the disease itself before therapy due to the nature of FM.
 
The way doctors diagnose and treat people with chronic back pain may change after a report is published,funded by the Arthritis Society. Rheumatoligist Dr John Esdaile's team of researchers have found that diffuse idiopathic skeletal hyperostosis (DISH)-traditionally considered a minor ailment-may actually be a disbling form of arthritis.
 
"These patients are now told there's nothing wrong with them because their x-rays appear normal to the untrained eye",said Dr. Esdaile director of research at The Arthritis Societ's British Columbia Yukon Division.
 
"Meanwhile they're enduring incredible pain." In fact 11 of 12 people who suffer from DISH receive either the wrong diagnosis,or no diagnosis at all.
 
 "The x-rays are very distinct," added Dr. Esdaile,"But it's sort of like looking at a painting-you won't notice some vital aspect until someone points it out,then you can't believe you missed it." "Because DISH doesn't fit with what the radiologists look for,they don't see it or report it,"he says.
 
Dr. Esdaile said DISH may be the second-most common type of arthritis. Before this study,fibromyalgia was considered the second-most-common form of arthritis,affecting three-in-100 Canadians.
 
The study compares patients with DISH to healthy subjects and those with lumbar spondylosis,a degenerative back disease. People with DISH suffered from more neck and back pain, difficulty swallowing,nerve abnormalities and difficulty moving their necks and backs.
 
"DISH is clearly a distinct disorder with signs and symptoms that distinguish it from other causes of spinal complaints and from healthy individuals. It has a potential to cause major disability."
 
Dr. Esdaile and his colleagues believe that DISH is also one of the few forms of arthritis to affect more men than women. While it's been nearly 100 years since scientists first described DISH this study is the first to show its considerable significance in the commmunity
 
"We have shown a tremendous need to educate rheumatoligists,from front-line physicians and radiologists as to the frequency of the disease and the tell-tale signs of it."said Dr. Esdaile.
 
"Now that we have separated it from the pack-it is its own disease-we need to research the causes and find out how to help these patients."
 
Dr. Esdaile hopes his team's research will change that as the medical community learns how to diagnose DISH through x-ray of the thoracic (mid-back) spine.----/98.

Alternate Therapy:
 
Glucosamine is an endogenous compound synthesized from sugar. It is an essential component for the synthesis of glycosaminoglycans (GA Gs), important  building blocks in the formation of connective tissues throughout the body.  
 
Specifically in the cartilage,GA Gs complex with proteins to form proteoglycans. Proteoglycans are present as gel in the cartilage and aid in the absorption of mechanical stress placed on the joint.
 
Glucosamine is available in the U.S. as a dietary supplement,and has gained some favor for the relief of pain associated with OA. It is associated with few side effects,namely GI symptoms,and appears to be working for some people with OA. For optimal efficacy,500 mg of glucosamine taken 3 times per day is needed,and it may take up to 4 to 6 months for full benefits to be realized by the patient.
 
Although glucosamine is often combined with chondroitin,there is no evidence that supports any benefit of this combination versus glucosamine alone.
 
So far glucosamine studies have been small and have lasted only a few weeks or months,furthermore,limited patients have undergone trials. Scientist's know if the results from one study looking at the effects on a specific joint area can be applied to other joints or all types of arthritis Although early works look promising further larger trials and testing is required. Glucosamine may raise blood insulin level in patients with diabetes.
 
S-Adenosylmethionine,more commonly referred to as SAM-e, is getting increased recognition for the treatment of OA as well as other conditions. First introduced to the U.S. market 2/99,as a dietary supplement,SAM-e is responsible for other biochemical reactions.
 
It is a naturally occurring substance containing 2 amino acids and is found in almost all body tissues and fluids. It acts as a methyl donor when it reacts with vitamin B12 and folic acid. Some evidence suggest that SAM-e may work as well as NSAIDs for OA but with fewer side effects,and may stimulate cartilage growth.
 
The most common side effects of this therapy is nausea,especially with higher doses. There are no known drug interaction with SAM-e and doses of 200 mg orally 3 times per day are needed for optimal effects.
 
Glucosamine and SAM-e as supplements are not federally regulated. The purity of content in the manufacturing process by different manufacturers is of concern.
 
Dimethyl sulfoxide (DMSO) is an indusreial solvent similar to turpentine. Some people believe that DMSO can relieve pain and reduce swelling when rubbed into the skin. Industrial grade DMSO,sold in hardware stores,contains poisonous contaminants,experts don't recommend using this solvent.
 
 It is important to note if alternate therapies are tried they should cause no harm to the patient or delay in time in seeking appropriate medical aid. These therapies look promising but keep in mind that more rigourous and larger clinical trials are needed before these therapies should be recommended on a widespread basis.
 
There has been a few small trials,but larger trials are needed and accuracy of claims by manufacturers verified-regeneration of cartilage etc.
 
Patients with OA,especially of weight-bearing joints,who are overweight should be encouraged to lose weight and use assistive devices,such as canes,grab bars,and splints.
 
Exercise also plays an important role in maintaining function and flexibility. Muscle conditioning to ease the burden on weight-bearing joints is encouraged along with water exercise because of the lessening stress on muscle and joint in water.
 
Patients with severe disease and limitation in a joint may benefit from surgery.
 
Similar approaches should be used in patients with FM. Education about rest and sleep hygiene is imperlative due to the high rate of sleep disturbance in this population.
 
Patients should not go overboard with activities on days when their disease is mild. 
 
Cognitive behavior therapy and stress-reduction techniques may be beneficial in helping FM patients reduce stress.

Pain and stress go hand in hand. When you're in pain, you're less able to handle the stress of everyday life. Common hassles turn into major obstacles. Stress may also cause you to do things that intensify your pain, such as tense your muscles, grit your teeth and stiffen your shoulders. In short, pain causes stress, and stress intensifies pain.

The first step in breaking this pain-stress cycle is to realize that stress is your response to an event, not the event itself. It's something you can control. That's why events that are stressful for some people aren't for others. For example, your morning commute may leave you anxious and tense because you use it as worry time. Your co-worker, however, finds her commute relaxing. She enjoys her time alone without distractions. Understanding that you have control over your stress can help you develop positive strategies for dealing with stress.

How you respond to stress:

When you encounter stress, your body responds in a manner similar to a physical threat. It automatically gears up to face the challenge or musters the strength necessary to get out of trouble's way. This fight-or-flight response results from a release of hormones that causes your body to shift into overdrive. Your heart beats faster, your blood pressure increases and your breathing quickens and becomes more shallow. Your nervous system also springs into action, causing your facial muscles to tighten and your body to perspire more.

Stress can be negative or positive:

  • Positive stressprovides a feeling of excitement and opportunity. Positive stress often helps athletes perform better in competition than in practice. Other examples of positive stress include a new job or birth of a child.
  • Negative stressoccurs when you feel out of control or under constant or intense pressure. You may have trouble concentrating, or you may feel alone. Family, finances, work, isolation and health problems, including pain, are common causes of negative stress.

Continued stress can have a negative effect on your health. In addition to the strain it puts on your cardiovascular system, the hormone cortisol released during stress may suppress your immune system, making you more susceptible to infection and disease. Stress can also cause headaches and worsen intestinal problems and asthma.

What are your triggers?

Stress is often associated with situations or events that you find difficult to handle. How you view things also affects your level of stress. If you have unrealistic or high expectations, chances are you'll experience more than your fair share of stress.

Take some time to think about what causes you stress. Your stress may be linked to external factors, such as:

  • Community
  • Unpredictable events
  • Environment
  • Work
  • Family

Stress can also come from internal factors, such as:

  • Irresponsible behavior
  • Poor health habits
  • Negative attitudes and feelings
  • Unrealistic expectations
  • Perfectionism

Jot down what seem to be sources of stress for you. And then ask yourself if there's anything you can do to lessen or avoid them. There are some stressors you can control and some you can't. Concentrate on events you can change. For situations that are beyond your control, look for ways to adapt — to remain calm under trying circumstances.

Strategies for reducing stress

It's one thing to be aware of stress in your daily life, but it's another to know how to change it. As you look through your list of stressors, think carefully about why they're so bothersome. For example, if your busy day is a source of stress, ask yourself if it's because you tend to squeeze too many things into your day or because you aren't organized.

The following techniques can help you reduce those sources of stress you can control and better cope with those you can't.

Change your lifestyle

Consider these changes to your normal routine:

  • Plan your day. This can help you feel more in control of your life. You might start by getting up 15 minutes earlier to ease the morning rush. Do unpleasant tasks early in the day and be done with them. Keep a written schedule of your daily activities so that you're not faced with conflicts or last-minute rushes. Because a pain flare-up can happen at any time, have a backup plan — decide what you can do now and what can wait.
  • Simplify your schedule. Prioritize, plan and pace yourself. Learn to delegate responsibility to others at home and at work. Say no to added responsibilities or commitments if you're not up to doing them. And try not to feel guilty if you aren't productive every waking moment.
  • Get organized. Organize your home and work space so that you know where things are. Keep your house, car and personal belongings in working order to prevent untimely and stressful repairs.
  • Take breaks. Take time to relax, stretch or walk periodically during the day.
  • Exercise regularly. Regular physical activity helps loosen your muscles and relieves emotional intensity. Try to exercise for a total of at least 30 minutes most days of the week.
  • Get enough sleep. This can give you the energy you need to face each day. Going to sleep and awakening at a consistent time also may help you sleep more soundly.
  • Eat well. A diet that includes a variety of foods provides the right mix of nutrients to keep your body systems working well. When you're healthy, you're better able to control stress and pain.
  • Change the pace. Occasionally break away from your routine and explore new territory without a schedule. Take a vacation, even if it's just a weekend getaway.
  • Be positive. There's no room for "Yes, but .... " Avoiding negative self-talk can be difficult. It helps to spend time with people who have a positive outlook and a sense of humor. Laughter actually helps ease pain. It releases endorphins — chemicals in your brain that give you a sense of well-being.
  • Stay connected. Recognize when you need the support of family and friends. Talking about your problems with others can often relieve pent-up emotions and lead to solutions you hadn't thought of on your own.
  • Be patient. Realizing that improvements in your health may take time can help reduce anxiety and stress.

Relief through relaxation

You can't avert all sources of stress, such as an unexpected visit from family or friends or a problem at work. But you can modify how you react to these situations by practicing relaxation techniques. Relaxation can help relieve the stress that aggravates chronic pain. It also helps prevent muscle spasms and reduces muscle tension.

Relaxation won't cure your pain, but it can:

  • Reduce anxiety and conserve energy
  • Increase your self-control when dealing with stress
  • Help you recognize the difference between tense muscles and relaxed ones
  • Help you physically and emotionally handle your daily demands
  • Help you remain alert, energetic and productive

Keep in mind, though, that the benefits of relaxation are only as good as your efforts. Learning to relax takes time.

Techniques to try

There are many ways to relax, so pick the ones that work best for you.

  • Deep breathing. Unlike children, most adults breathe from their chest. Each time you breathe in, your chest expands, and each time you breathe out, it contracts. Children, however, generally breathe from their diaphragm — the muscle that separates their chest from their abdomen. Deep breathing from your diaphragm — which adults can relearn — is relaxing. It also exchanges more carbon dioxide for oxygen, which gives you more energy. Try to incorporate 20 minutes of deep breathing every day for good health, not just when you're stressed.
  • Progressive muscle relaxation. This technique involves relaxing a series of muscles one at a time. First, raise the tension level in a group of muscles, such as in a leg or an arm, by tightening the muscles and then relaxing them. Concentrate on letting the tension go in each muscle. Then move on to the next muscle group. Be careful, though, not to tense muscles near your pain sites.
  • Word repetition. Choose a word or phrase that is a cue for you to relax, and then repeat it. While repeating the word or phrase, try to breathe deeply and slowly and think of something that gives you pleasant sensations of warmth and heaviness.
  • Guided imagery. Also known as visualization, this method of relaxation involves lying quietly and picturing yourself in a pleasant and peaceful setting. You experience the setting with all of your senses, as if you were actually there. For instance, imagine lying on the beach. Picture the beautiful blue sky, smell the salt water, hear the waves and feel the warm breeze on your skin. The messages your brain receives as you experience these senses help you relax.

Tips to help you succeed

The following tips will help you grow accustomed to relaxing:

  • Practice. If relaxation is new to you, you may not notice immediate benefits. In fact, you may feel uncomfortable at first. Work on your relaxation skills at least once or twice a day until they come naturally. When you're beginning, a quiet place and a relaxation tape often help.
  • Get comfortable. Loosen tight clothing and remove your shoes and belt, if necessary.
  • Vary your schedule. Practice relaxation at different times throughout the day. The idea is to learn how to relax whenever you need to.
  • Be patient. A wandering mind is normal when you start out. Just keep bringing your attention back to relaxation.