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Sock's Toxicity And Drugs In RA:
Coping With Pain
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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.

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.

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.

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.

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.

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.

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.

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.

              There are many things you can do to help control your arthritis pain. The goals of these methods are to control pain by:

              • learning new ways to reduce pain
              • taking as few pain medicines as possible
              • changing pain habits that disrupt your normal lifestyle
              • increasing your physical and social activity so you can return to an active life, as much as possible

              The methods listed here will work differently for different people. So, some methods may work for you, but some may not. Some methods are things you can do for yourself. Others require help from your doctor or other health professionals. Talk to your doctor about these methods. With a little practice, you will find the right ones for you.

              Taking control

              Your mind plays an important role in how you feel pain and in how you respond to illness. People with arthritis often feel helpless and depressed about their condition. With these feelings, come decreased activity, poor self-esteem, and increased pain. So, building a sense of control by adjusting your thoughts and actions is an important part of pain management.

              Below are some ways you can take control of your thoughts and actions to help control your pain. Thinking differently may not get rid of your pain entirely, but having a more positive attitude can help. Many of these methods are easier said than done. But with practice and patience, you can master them, too. Try to learn what causes your pain and how to control it.

              Find out about available medications. When taking medicine, be sure to follow your doctor's instructions and read the directions that come with the medication. Complementary  therapy can also be an option.

              Through exercise, you can help manage your pain and ease symptoms of chronic pain such as the pain from osteoarthritis. A doctor may recommend an exercise program or refer you to a specialist, such as a physical therapist or occupational therapist

              Ask a doctor about how to do routine tasks in a way that reduces stress on joints Listen to your body when it signals that it needs rest.

              Having arthritis and the pain that goes with it can lead to a life built around pain and sickness. One way to reduce your pain is to build your life around wellness, not pain or sickness. Live what is called a "wellness lifestyle." This means to think positive thoughts, keep a sense of humor, eat a exercise,balanced diet every day, and enjoy activities with others. It also means following your treatment plan, taking your medication properly, and practicing relaxation.

              Arthritis can limit you, but it doesn't have to control your life. Talk to your doctor, nurse, or therapist about how you can make your life more healthy. Get involved in a favorite activity or hobby. Remind yourself of what you can do rather than what you can't do. You'll feel better and your pain will not seem as severe.

              How often do you think about your pain? The amount of time you spend focusing on it has a great deal to do with how much discomfort you feel. People who dwell on their pain usually say their pain is worse than those people who don't dwell on it. One way to take your mind off the pain is to focus on someone or something else. Whether it's going to the movies, visiting with family or friends, volunteering, or dancing, follow through on planned activities. It will boost spirits and might even block some of those pain signals.

              Everyone has the ability to be distracted. The more you focus your attention on something outside of your body, the less you will be aware of physical discomfort. For example, get involved in an activity or hobby you enjoy, develop a new interest, or get involved with helping others. If you can't help but think about the pain, try to think about it differently. Think of the pain as your body's message to do something different.

              It's easy to slip into the habit of drinking alcohol or taking more medicines to escape your pain. If you answer "yes" to any of the questions below, you may need to find new ways to handle your pain.

              • Do you drink alcohol several times a day?
              • Do you use up pain medication faster than you used to?
              • Do you spend all day in bed?
              • Do you talk about pain or arthritis much of the time?

              Changing your pain habits will help you feel better. One way to make a change is to do something positive in place of the old habit and to reward yourself. Discuss these habits with your doctor, nurse or other health care workers who specialize in pain management. Ask them to help you find new ways to cope with your pain.

              You can make a chart of your own pain control methods. This will help you keep track of which methods you have used, and which ones work best for you. Adapt it often. Post it where you can refer to it often, such as on your refrigerator or medicine cabinet

              Share your successes and frustrations with others--whether it's with family, friends, loved ones, or others that have pain. Find out about support groups in the community and learn how others are overcoming their pain. Don't hesitate to ask for help when you need it.

              Take control of your pain, so it doesn't control you. Easier said  then done,but true.

              Relaxation is more than just sitting back and being quiet. Relaxation is an active process involving methods that calm your body and mind. Learning how to relax takes practice, just as learning how to ride a bicycle takes practice. Once you know how, it becomes "second nature."
               
              Keep in mind that there's no right way to become relaxed. Whatever works for you is what's important. Listed below are a few suggestions. Try out different methods until you find one or two that you like best. If you need help, see a mental health counselor or contact your local Arthritis Foundation chapter.
               
              Relaxation techniques
              To begin with, try to set aside time in a quiet place, away from people, TV, radio and other distractions. Close your eyes. Slowly tense and then relax muscles that feel tense. Begin with your feet and work up to your neck.
               
              Sit in a comfortable chair with your feet on the floor and your arms at your sides. Close your eyes. Breathe in, saying to yourself, "I am . . . ," then breathe out saying " . . . relaxed." Continue breathing slowly, silently repeating to yourself something such as: "My hands are . . . warm; my feet . . . are warm; my forehead . . . is cool; my breathing . . . is deep and smooth; my heartbeat is . . . calm and steady; I am . . . happy; I feel calm . . . and at peace."
               
              Light a candle, and focus your attention on the flame a few minutes. Then close your eyes and watch the image of the flame for a minute or two.
               
              Imagine a white cloud floating toward you. It wraps itself around your pain and stress. Then a breeze comes. It blows away the cloud, taking your pain and stress with it.
               
              Think about a place you have been where you once felt pleasure or comfort. Imagine it in as much detail as possible how it looks, smells, sounds and feels. Recapture the positive feelings you had then and keep them in your mind. Don't make any room for negative thoughts, stress or pain.
               
              Imagine that you've put all your concerns, worries and pain in a helium filled balloon. Now let go of the balloon and watch it float away.
               
              Sometimes simply letting your mind wander or "go on vacation" will help reduce your stress.
               
              Here are a few suggestions. Invent your own!
              Watch a sunset. Take your shoes off and walk in the grass. Sit in a park on a warm, sunny day and listen to the birds. Sit in front of a fire in the fireplace.
              Gaze at fish in an aquarium. Overcoming barriers to relaxationTo overcome barriers to relaxation, you must really want to learn to relax.
               
              Some common "stumbling blocks" to relaxation include these: Feelings of guilt for taking time from your busy schedule Being made fun of by others Not being able to stop and take time Fear of "loss of control." Remember that relaxation will help you gain better control of the demands made on you. If you devote time to relaxation, later you'll be able to do more and enjoy yourself more.
               
              From time to time it may seem impossible to stop and relax. You may find yourself in a rut--tense because you're so busy, and too busy to relax. If this happens, start wherever and whenever you can. If you're waiting in traffic, take a few deep breaths, and let the air out slowly. If you're at work, take a short break in the rest room, lounge or snack bar. Close your eyes, breathe deeply, and try to forget about everything, except your breathing. Notice which muscles are tense--perhaps your neck, forehead or shoulders--and relax them.
               
              You may think that a high level of body tension means that you're "in control," and that feeling relaxed seems like a loss of control. Realize that muscle tension drains your energy and can increase your pain. Relaxation actually helps you gain control over your stress and pain.
               
              It takes time and effort to learn a new skill. Therefore, don't give up before you have a chance to reap the benefits! Knowing how to relax can become part of your life. Remember, like any habit, learning to relax takes time to become automatic.
               
              More relaxation tips
              Practice every day, even for just 15 minutes. A new habit must be repeated often until it begins to feel as though it's a part of you. Choose your favorite methods. Be creative. Remember, there is no one, best way to relax. Work in short relaxation breaks during your day, whenever you can. Try using very simple methods such as deep breathing for even a minute or two.

              Person with hip problem who has pain and muscle spasms when sleeping on side; There appears to be a "protective muscular reflex" that causes muscle to contract or tighten to prevent further damage to an injured joint by stopping the joint from going beyond a certain range of motion.
               
              The sensory nerves in the joint tissues may sense pain. The impulses travel to the spinal cord and brain which then sends a message to the muscles across the affected joint to contract involuntarily. The muscle contraction restricts joint movement and influences joint position and stability. 
               
              Sometimes fear of pain leads to voluntary tensing of muscle too. Prolonged or excessive muscle activity during the day may lead to muscle spasm at night when the joint is no longer moving and stretching the muscles even partially. Even the lower back muscles could be affected by the strains on it caused by the arthritic hip.
               
              Changing your sleeping position may relax the muscles e.g. sleeping on your other side with 1 or 2 pillows between your legs or on your back with your legs over a bolster. Protecting your hip during the day with altered activities, less stairs, a cane, raised chairs and toilet seat and proper exercises etc. could help reduce nocturnal muscle pain. A bedtime nonsteroidal anti-inflammatory drug with a muscle relaxant may also help.

              Relaxation:
               
              Spending minutes of your day in quiet reflection can help you stick with your priorities and reduce stress. Meditation can relax your breathing, decrease muscle tension and slow your heart rate. It may also reduce your blood pressure.

              Here's how to get started:

              * Get into comfortable clothes.

              * Choose a quiet space where you won't be interrupted.

              * Sit comfortably. (The lotus position is not required!)

              * Close your eyes, relax your muscles and breathe slowly and naturally.

              * Repeat a focus phrase. It doesn't have to be "ohm." Try, "I am calm." When other thoughts intrude, bring your attention back to your focus phrase.

              * Start with 5-minute sessions, working your way up to 20-minute meditations.

              * When you're finished, sit quietly for a minute or two to make the transition back to the real world.

              * Use these techniques to meditate once or twice a day.



              People first have to acknowledge that medications alone cannot work and that they need to modify their activities.  There are a number of non-pharmacologic approaches. One is that people first have to acknowledge that medications alone cannot work and that they need to modify their activity. They need to learn to find how to offload inflamed joints and modify the way they do tasks to protect those joints. A good example of that would be that if fingers are really sore, to find a way maybe to grasp which is different than just grasping or if someone has a problem with their wrist, perhaps use a splint which is a way of supporting that when they're doing a task that might irritate it, like vacuuming.
               
              There are a number of other types of approaches, like using adaptive footwear,  like shoe orthotics or adaptive shoes. And of course as you know there are a number of exercise-directed therapies which can really reduce muscle tension, improve sense of well-being and general conditioning.
               
              The issue is learning to respect pain, and sometimes people use what's called the two-hour rule, that individuals can do what they feel comfortable doing as long as they don't have pain that persists more than two hours after the activity and they're not stiff and sore the next day.
               
              Like anything, adaptation starts with doing something. And usually people get so excited about starting an exercise program that they often will kind of wear themselves out and not persist with it.
               
              People need to return to the games and the activities of their youth. Having some type of activity that a person enjoys on a daily basis is a good thing, but, research would suggest that you could exercise intermittently and have a lot of benefits from that, too. Everything should be done in moderation and what your condition will permit without excessive demands.
               
              There are lots of different ways that people cope with pain which are kind of interesting. Some of these are sort of short-term interventions, and some are longer-term, but certainly distraction, and changing what you're doing, and changing your physical activity you're doing at a time is a good technique. Sometimes people will meditate or pray.
               
               There's some pretty interesting research written about reflective writing, where people who are experiencing pain will write essays, and this activity often brings insight into the experiences people have but also reduce pain because it distracts the brain from really focusing on the pain itself. Essays about anything except pain
               
              Heat and cold treatments are time-honored, which many people find provide temporary benefit, and always the question people have is, "Which should I use, hot or cold?" The most important thing is you do what feels comfortable. Some people, in fact, alternate between the two.
               
              Then the whole other question is how do I safely apply heat and cold? And there are many ways. You could use radiant heat from a heat lamp. You could use a moist heating pad. One can could use paraffin baths using paraffin wax that's heated. There are a lot of different ways to do this, and it's just a matter of what people find works for them.

              The non-pharmacologic approaches need to be started, and they need to be started early. But nowadays we realize that rheumatoid arthritis is a disease that can cause damage early and that one needs to add appropriate therapies with pharmacologic agents or biologic agents early in disease. And it's not a good idea to let people just say, "Okay, I can tough it out a little bit longer." There's no reason to tough it out.
               
              What they need to realize is that while they're toughing out the pain, inside their joints are many little proteins that cause inflammation, and the inflammation will often eat away some of the bone or eat away some of the cartilage, and that would be a change in their x-ray or if one looked at their joint surgically which would be a change that you couldn't fix. Before they get these changes that can't be fixed,patients need therapies which will slow down if not stop these kinds of X-ray damages.
               
              Comfort is important. The ultimate is that in five or ten years you want to be able to function as well as you can because you've got joints that are as close to normal as they can be, but in the meantime, you want to feel well enough that you can get up and go to work in the morning and earn, a living for your family or go out and do that things that you enjoy.
               
              The other thing is that often people have fatigue. And so if you control the disease process and you have less pain but also less fatigue, you'd be more likely to live a full life.
               
              Another important marker is sleeping. Often because people feel poorly, they have impaired sleep and, if you're tired and have pain and you don't sleep well at night, it's pretty tough to enjoy what you're doing.
               
              A well balanced nutritious diet is also very important. We may not feel like eating,at times,but we don't want to get run down because of poor diet,and compound the situation at hand.
               
               Keeping stress to a minimum is another important job. Set priorities for yourself. Organize your time so that you do the things that are most important to you first. Let less important things go.
               
              Identify things that cause you the most stress. Then, look for ways to get around them. For example, if you find traveling stressful, see if you can make a phone call instead.
               
              Concentrate on doing one thing at a time. Once you have finished a task, take a moment to let yourself feel good about getting it done. Take a rest if you need it, and then move on. If you are running late, or if you feel overwhelmed, cancel or reschedule your appointments.
               
              Learn to say "no". Save your energy for the things that are most important to you. Get support. Don't try to do everything yourself. Ask your friends and family members to help with some of your responsibilities.
               
              Talk about your feelings with family and friends. Make sure you take time for social activities and exercise. You'll be more prepared to deal with situations that cause you stress if you've taken time for fun! Plan ahead.
               
              Think about which situations cause you stress. Then, plan ahead to minimize or avoid these predictable sources of stress. For example, if waiting in line is stressful for you, bring a book to help pass the time. If you find the morning rush stressful, get up 15 minutes earlier so that you don't feel so rushed.
              Schedule breaks for yourself throughout the day. This will give you a chance to rest, and will also prevent the stress that comes from getting "behind schedule".
               
              Relaxation techniques should be investigated. self-meditation is a good examp;e,or deep breathing techniquew. There are many ways to relax and avoid stress.
               
              Exercise is of paramount importance in rheumatoid arthritis therapy. Keep joints moving and protect your joints by adaptaing to your present conditiom, do what you can do now.  Majority of patients will have to learn to adapt to their present environment and condition.
               
              Worry is a waste of time. The only thing we can control is ourselves,both medically and mentally. What will happen,otherwise, will happen.
               
               

              The patient may become less responsive to a pain medication but generally does not become "immune" to it.  If the cause of the pain is not changing, then you wouldn't expect that whatever dose of pain medicine somebody is taking would wear off. If the disease changes and it gets worse, then the level of the dose of the drug may not be sufficient.

              If there are other things contributing to the pain, whether it be a number of issues - emotionally, psychologically, physically, etc. - then those things have to be dealt with individually
               
              There are four stages of sleep and if you're coming out of Stage IV to Stage II, you're going to have what we call non-restorative sleep. You're going to wake up tired and you're going to feel like falling asleep during the day. So the key is to make sure that you're not having pain at night that's waking you up. If you're not getting adequate rest or adequate sleep, you're going to have fatigue and you're going to feel like falling asleep during the day.
               
              For energy during the day, there is an herbal supplement that is called N-A-D-H and that stands for Nicotinamide Adenine Dinucleotide Hydrochloride. A brand name is Enada. I have my patients take the 5 milligrams for about a week, see what kind of response. If no response, then increase to 5 milligrams twice a day.
               
              A rheumatologists response to complementary therapy:
               
              I have naturopath doctors that I refer patients to. I have chiropractic doctors I refer patients to. I have acupuncturists, I have massage therapists. But guess who's in control? I am. As a rheumatologist, I feel that I know more - and I should know more - about arthritis than the other providers. But I'm in control and those people that I refer my patients out to, they give me feedback and there's that constant communication.
               
              But when the patient decides that, "Oh, I don't want those bad medicines that everyone associates with RA-I'm not going to get my liver killed", or "I'm not going to do this, and I'm not going to do that…" But guess what? When you look at a hundred patients, maybe two or three out of the hundred might have a problem, so you've got to look at it from an optimistic standpoint.
               
              Have a balanced integrative approach from the start and be open. Patients can talk to their rheumatoligists about supplements and whatever complementary therap they are complementing of taking,but the key is to talk it over with the physician. Make sure it does not interfere with current therapy.
               
              Side effects depends on the kind of medications that you're using. Often patients on methotrexate, hydroxychloroquine or Plaquenil -- they feel sick. They feel nauseated. And seemingly, it doesn't go away. And if you take, say for example, enteric-coated type, they don't feel sick. So there are some people that just don't tolerate certain medications very well  that can contribute to that feeling.
               
              Enteric-coated medicines have a coating that prevents them from dissolving in the acid chemical environment of the stomach, but they dissolve in the "base" environment of the small bowel. That may help to avoid irritation and nausea caused by exposure of the stomach to the drug.
               
              And two natural things that physicians often use to kind of help with that to maintain or to keep the methotrexate and the Plaquenil is what is called diglyceride ginger. And the other supplement, other than the ginger, is glutamine.  Those two tend to help settle.
               
              Patients using methotrexate; A vitamin called folic acid is almost always prescribed with that. That does help to abate some of the nuisance side effects, and if that's not sufficient, there is a more potent vitamin like it called leucovorin that can be useful.
               
              To begin as just some background, we need to recognize that foods themselves are not nutritious by themselves, but a balanced or a nutritional diet is one that meets certain criteria, such as it should be adequate in essential nutrients such as fiber, nutrients and energy. It should be controlled in its energy allotment, so we need to think in terms of what an individual person's needs are in terms of calories, and a variety of foods should be eaten in moderation. That's just a general, global view of what is considered a nutritious or balanced diet.
               
              A balanced diet helps support your immune system.  And one might ask, why is this important for people with rheumatoid arthritis? Well, one, the very important reason is that a balanced diet helps support your immune system. And it's already in the face of rheumatoid arthritis in what one might refer to as high gear, working to combat the increased number of inflammatory cells that are present. Therefore, to have a good dietary intake such that it maximizes the functioning of your immune system is very important.
               
              The second is the fact that one should try to maintain an appropriate weight. And of course weight is based on an individual's height, and it's desirable to not to be either over or underweight if you have RA. It's not uncommon for some patients with RA to have poor intake, and they have poor appetite that can persist over a long period of time. Of course, this is due to the fact that RA is a chronic disease, and the loss of appetite and poor nutritional intake can result in the development of malnutrition that can in turn decrease a person's or an individual's immune function. It can also lead to the loss of muscle mass and cause muscle weakness, making a patient with RA at increased risk for falling and possible fractures, such as the hip.
               
              Now, in the opposite direction, excessive weight increases the burden on joints, especially those weight-bearing joints such as knees, ankles and feet. So, eating a variety of foods daily in adequate amounts that permits the maintenance of a desirable weight is a dietary goal that patients with RA should work to achieve.
               
              The treatment of rheumatoid arthritis is really the treatment of the patient with rheumatoid arthrit.We need to think about the patient's intake. Many patients with rheumatoid arthritis actually lose weight because they're spending so much time and energy making all this inflammation and immune-mediated cytokines or proteins. As a result, one does need to consider all of these issues. But diet alone, nor anything alone, really is the treatment for rheumatoid arthritis.
               
              There are really two goals that rheumatologists have when they take care of a patient. One is to make them feel better and carry on their activities of daily living such as taking care of their children, going to work and school, or whatever else they need to do. And again, diet may give them symptomatic relief.
               
              However, the other thing with rheumatoid arthritis is it's a disease that can cause crippling and deforming changes and x-ray damage even if the patient on the outside is feeling reasonably well.
               
               Checking with your physician and making sure that one doesn't need a disease-modifying treatment that would actually stop the bone and cartilage damage in addition to either diet or other medicines or treatments that would be making the patient feel better is very important.
               
              Having already mentioned about added stress to the joints that can occur as a result of obesity, especial those weight-bearing joints, obesity is not only detrimental in terms of this added joint stress, but it can contribute to many additional diseases, many of which individuals with RA face. And these include diseases such as chronic heart disease, stroke, elevated lipid levels, and diabetes, to name a few. And we know that obesity is in epidemic proportions at the current time here in North America.
               
              An 11-pound weight loss is beneficial in terms of reduction in joint pain. It's also noteworthy to think about that no matter one's initial weight that an 11-pound weight loss is beneficial in terms of reduction in joint pain, specifically those that may have osteoarthritis, a different form of arthritis than rheumatoid. But it also can lower lipid levels. It can reduce blood pressure and also blood glucose levels. So, even a modest amount of weight loss, such as an 11-pound weight loss or five kilograms, can be very beneficial. Therefore, working to achieve and maintain weight loss is desirable from many health-related viewpoints, including arthritis.
               
              Another point is that people with rheumatoid arthritis get what we call secondary osteoarthritis, meaning the rheumatoid gives them wear-and-tear arthritis sooner than they would for their age, and again, watching one's weight is very important for the weight-bearing joints there. Some of the therapies that are used for rheumatoid arthritis such as prednisone or cortisone will change the lipid level or the blood sugar level in our patients, so again one needs to take care of the whole patient, both with looking at the medications as well as with the diet.

              Fatigue is really a common daily occurrence for many people, and for individuals who are healthy, fatigue can result from strenuous physical activity, a busy day at work, some stress, or tension. But typically for people who are well, if they get some rest, if they follow a good diet, they actually get relief from their fatigue, and so they find out that the fatigue is really short-period, and they can move on with their life. But for people with chronic illnesses, in particular people with rheumatoid arthritis, the fatigue that they experience really doesn't get relieved so quickly. The fatigue lasts much longer, and it impacts their function in a much broader way.
               
              There's probably multiple causes of fatigue,there is probably not just one single cause of fatigue. I think when we're looking specifically at rheumatoid arthritis, we're looking at things such as pain, the inflammatory process itself, depression, other chronic illnesses that may not be treated or even diagnosed, and sleep problems. All of these can contribute to the fatigue, as well as being deconditioned, that people with rheumatoid arthritis experience.
               
              Many patients with rheumatoid arthritis have what's called the anemia of chronic disease. As people with rheumatoid arthritis know as well as their providers, probably pain and fatigue are the two most common symptoms that people experience,and they frequently go hand in hand. Patients have said,they would actually rather have the pain than the fatigue because with the pain they can find different ways of doing things, but with the fatigue, they don't even have enough energy to mount a certain effort.
               
              What happens when people are in pain is they spend a lot of energy doing everyday activities. The pain interferes with their sleep, and therefore they feel a lot more daytime fatigue. The pain also makes people carry their body in different positions. As the result of carrying their bodies in different positions, that can be more fatiguing for them.
               
              Research really has shown that there are different things that people can do. First of all, they really need to identify the causes of their fatigue. Someone who may be seeing a rheumatologist and be getting appropriate management of their inflammatory process associated with the disease may still have other causes like pain or depression or anemia or other conditions such as thyroid problems.
               
              People must look at ways to enhance their energy in their life. Look at things such as doing some what's called "cognitive restructuring" where they re-think things. They think about themselves differently than they did before. This is called "re-normalizing," where they look at themselves differently; having different skills and different talents than perhaps what they had before they had the disease. There's a whole piece about constant comparisons where people really look at themselves relative to other people, and they feel like they really aren't that bad, that they really have some strengths.
               
              There are things such as energy audits,  where people really take stock of how much energy they have and what activities they've yet to do, and they see how much energy they need to use for the activities remaining in the day. And it's very much like a dieter may do in regards to counting calories. They actually count their fatigue level, or energy level.
               
              The inflammation when it's been controlled, such as with drugs like Enbrel or methotrexate, patients' fatigue often gets better as does their pain and swelling of their joints. Too often patients, spend too much energy thinking arthritis and not enough having a good time, and that does contribute definitely to their fatigue.
               
              Rheumatoid arthritis and anemia go hand in hand. Sometimes thyroid problems can go hand in hand with rheumatoid arthritis. There are other medical conditions that often are part and parcel of the inflammation that cause fatigue in patients.
               
              Also,not just a clinical depression but a subclinical depression where people may feel a little like they're losing interest in some of their activities. They might feel a little blue, but they may or may not have an actual full clinical depression. That feeling of being blue can really contribute to people's fatigue and vice versa. The fatigue can contribute to someone's feeling really sad and very low. Those two are wound up and depending upon the level of depression may require someone to go seek counseling, or they may figure out some strategies that they need to change in their own life about how they see themselves and what they can do as far as what they can accomplish.
               
              People who have rheumatoid arthritis and are at least not blue about it, then they possibly might need a psychiatrist because rheumatoid arthritis can be a depressing disease. We have fabulously great treatments nowadays, a lot of new treatments for this disease. But still we don't have the cure, and it's a disease thats "ongoing" -- but it is a chronic disease. So, depression is or at least feeling blue about having this, having to come to the doctor, having to take medication, is very common.
               
              What physicians try to do is address the issue because many of these people are depressed or blue mainly because they can't do the kinds of activities of daily living that they want to do such as going to work, taking care of their kids, playing golf or doing the vocational and avocational kinds of things that they want. And people in pain get down and depressed as well.

              One of the things that patients do is they learn to use fatigue as a signal, and so they start to reinterpret it. And  if they have otherwise been well and their rheumatoid arthritis has been well managed, when the fatigue comes back, they can use it as a signal. And when you use it as a signal or as a cue, you can say, "Ah, my disease may be flaring again," and they use that sort of as an advance warning to do something about it, and that's very empowering for them that they can be in tune to their body and the symptoms like that.
               
              Its a known fact that exercise has many benefits for all of us, whether it's cardiovascular, whether it's for the musculoskeletal system, whether it's for bone strength, weight control. There's multiple ways that exercise helps us, and it also can help people with rheumatoid arthritis.
               
              Sometimes what people initially feel if they've been sedentary and they do start on an exercise program under the supervision of a physical therapist or an exercise specialist is they may initially get tired because they are really having to work their muscles harder. But in fact they find out that they begin to sleep better and that their pain actually improves, and we have plenty of research that really shows the benefits of exercise for people with rheumatoid arthritis. It's clear then that people's fatigue levels actually can be improved as they build up a program that gets them more fit.
               
              We have plenty of research that really shows the benefits of exercise for people with rheumatoid arthritis. And again, it's increasing one's overall physical activity, not necessarily just an exercise program. It's getting people to walk around the block. It's getting them to maybe park a little bit further in the mall parking lot and walk to the mall. And then it's getting them into a regular program, whether it's at a YMCA, whether it's to an Arthritis Foundation swimming class, whether it's mall walking, but building up so that one can get much more physically active and fit.

              When you are under stress, your muscles become tense. This muscle tension can increase your pain. A vicious cycle of stress, pain, and depression may develop. However, if you learn how to manage stress, you can help break that cycle.
               
              Some of the body's reactions to stress are easy to predict. At stressful times, the body quickly releases chemicals into the blood. This sets into motion a series of physical changes. These include a faster heartbeat and breathing rate, higher blood pressure, and increased muscle tension.
               
              These physical changes give the body added strength and energy. They prepare the body for dealing with stressful events such as giving a speech, aiding an accident victim, or fighting or fleeing from an attack. When stress is dealt with in a positive way, the body restores itself and repairs any damage caused by the stress. However, most of the time, people don't deal with stress in a positive way. Thus, stress-related tension builds up and, with no outlet, takes its toll on the body.
               
              The mind's reaction to stress is harder to predict. These mental reactions vary according to the situation and the person. They may include feelings of anger, fear, anxiety, annoyance or frustration. A small amount of stress can help people perform their best--during an exam, an athletic event, or on stage. With too much stress, people may become accident-prone, make a lot of mistakes, and may not be able to function. Stress can be compared to a violin string. If the string is too loose (not enough stress), it won't produce music. If the string is too tight (too much stress), it will break. Some degree of stress is necessary to function properly.
               
              Realize that people respond in different ways to events and situations. Some people like to be busy, with lots of activity. Other people may prefer a slower pace, with less activity. What one person finds relaxing may be stressful to another.
               
              Managing stress begins with learning the signs and symptoms of stress. Tiredness/exhaustion -Muscle tension -Anxiety -Indigestion
              Nervousness/trembling -Sleeplessness -Cold, sweaty hands -Loss of or increased appetite -Grinding teeth/clenching jaws -General body complaints, such as weakness, dizziness, headache, stomachache, or pain in the back or muscles.
               
              It's possible that some of these symptoms may be caused by problems other than stress, such as the flu. Ask your doctor about symptoms that last for more than a week. If your doctor decides that stress is the problem, you can work together to understand and relieve it.
               
              Make stress work for you. The key to managing stress is to get stress to work for you instead of against you. A complete program for managing stress has three parts: -Learn how to reduce stress. -Learn how to accept what you can't change. -Learn how to overcome the harmful effects of stress.  Remember that relaxation will help you gain better control of the demands made on you. If you devote time to relaxation, later you'll be able to do more and enjoy yourself more.
               
              From time to time it may seem impossible to stop and relax. You may find yourself in a rut--tense because you're so busy, and too busy to relax. If this happens, start wherever and whenever you can. If you're waiting in traffic, take a few deep breaths, and let the air out slowly. If you're at work, take a short break in the rest room, lounge or snack bar.
               
              Close your eyes, breathe deeply, and try to forget about everything, except your breathing. Notice which muscles are tense--perhaps your neck, forehead or shoulders--and relax them.
               
              You may think that a high level of body tension means that you're "in control," and that feeling relaxed seems like a loss of control. Realize that muscle tension drains your energy and can increase your pain. Relaxation actually helps you gain control over your stress and pain.
               
              It takes time and effort to learn a new skill. Therefore, don't give up before you have a chance to reap the benefits! Knowing how to relax can become part of your life. Remember, like any habit, learning to relax takes time to become automatic.
               
              Practice every day, even for just 15 minutes. A new habit must be repeated often until it begins to feel as though it's a part of you.  Choose your favorite methods. Be creative. Remember, there is no one, best way to relax.  Work in short relaxation breaks during your day, whenever you can. Try using very simple methods such as deep breathing for even a minute or two.
               
              Managing stress can help you have less pain and feel healthier. It can also help you cope with the extra demands made on you by your disease. By following these suggestions, you may be able to get stress to work for you instead of against you.  Learn to identify those situations you can do something about and those you can't. Work at reducing the cause of your stress by communicating better, and respecting your limits of energy and pain. Simplify your life, "look on the bright side," and develop and keep a sense of humor. Prepare for stressful events by getting extra rest.
               
              Remember that you can't change others. Keep in mind that no one is perfect. Seek professional help for serious problems. Practice relaxation methods to overcome the effects of stress that you can't avoid. Engage in hobbies and simple pleasures that give you joy.  Remember that managing stress is your job. With stress under control, it'll be easier to keep your arthritis under control.
               
              Learning how to relax is one of the most important ways to cope with stress in a positive way. Relaxation is more than just sitting back and being quiet. Relaxation is an active process involving methods that calm your body and mind. Learning how to relax takes practice, just as learning how to ride a bicycle takes practice. Once you know how, it becomes "second nature."
              Keep in mind that there's no right way to become relaxed. Whatever works for you is what's important. Try out different methods until you find one or two that you like best. If you need help, seek professional help.
               
              To begin with, try to set aside time in a quiet place, away from people, TV, radio and other distractions. Close your eyes. Slowly tense and then relax muscles that feel tense. Begin with your feet and work up to your neck. Sit in a comfortable chair with your feet on the floor and your arms at your sides. Close your eyes. Breathe in, saying to yourself, "I am . . . ," then breathe out saying " . . . relaxed." Continue breathing slowly, silently repeating to yourself something such as: "My hands are . . . warm; my feet . . . are warm; my forehead . . . is cool; my breathing . . . is deep and smooth; my heartbeat is . . . calm and steady; I am . . . happy; I feel calm . . . and at peace."
               
              Light a candle, and focus your attention on the flame a few minutes. Then close your eyes and watch the image of the flame for a minute or two.  Imagine a white cloud floating toward you. It wraps itself around your pain and stress. Then a breeze comes. It blows away the cloud, taking your pain and stress with it.
               
              Think about a place you have been where you once felt pleasure or comfort. Imagine it in as much detail as possible how it looks, smells, sounds and feels. Recapture the positive feelings you had then and keep them in your mind. Don't make any room for negative thoughts, stress or pain.
               
              Imagine that you've put all your concerns, worries and pain in a helium filled balloon. Now let go of the balloon and watch it float away. Sometimes simply letting your mind wander or "go on vacation" will help reduce your stress.
              Here are a few suggestions. Watch a sunset. Take your shoes off and walk in the grass. Sit in a park on a warm, sunny day and listen to the birds. Sit in front of a fire in the fireplace. Gaze at fish in an aquarium.
               
              To overcome barriers to relaxation, you must really want to learn to relax. Some common "stumbling blocks" to relaxation include these: Feelings of guilt for taking time from your busy schedule Being made fun of by others Not being able to stop and take time Fear of "loss of control." Remember that relaxation will help you gain better control of the demands made on you. If you devote time to relaxation, later you'll be able to do more and enjoy yourself more.
               
              From time to time it may seem impossible to stop and relax. You may find yourself in a rut--tense because you're so busy, and too busy to relax. If this happens, start wherever and whenever you can. If you're waiting in traffic, take a few deep breaths, and let the air out slowly. If you're at work, take a short break in the rest room, lounge or snack bar. Close your eyes, breathe deeply, and try to forget about everything, except your breathing.
               
              Notice which muscles are tense--perhaps your neck, forehead or shoulders--and relax them.  You may think that a high level of body tension means that you're "in control," and that feeling relaxed seems like a loss of control. Realize that muscle tension drains your energy and can increase your pain. Relaxation actually helps you gain control over your stress and pain.
               
              It takes time and effort to learn a new skill. Therefore, don't give up before you have a chance to reap the benefits! Knowing how to relax can become part of your life. Remember, like any habit, learning to relax takes time to become automatic.
               
              Practice every day, even for just 15 minutes. A new habit must be repeated often until it begins to feel as though it's a part of you.  Choose your favorite methods. Be creative. Remember, there is no one, best way to relax. Work in short relaxation breaks during your day, whenever you can. Try using very simple methods such as deep breathing for even a minute or two.