Factors Involved in Treatment:
A joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation. The joint inflammation
of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the joints. The inflammation of rheumatoid disease
can also occur in tissues around the joints, such as the tendons, ligaments, and muscles. In some patients with rheumatoid
arthritis, chronic inflammation leads to the destruction of the cartilage, bone and ligaments causing deformity of the joints.
Some scientists believe that the tendency to develop rheumatoid arthritis may be genetically inherited. It is suspected
that certain infections or factors in the environment might trigger the immune system to attack the body's own tissues, resulting
in inflammation in various organs of the body such as the lungs or eyes.
Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints
and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines,
such as tumor necrosis factor/TNF and interleukin-1/IL-1) are expressed in the inflamed areas.
The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are
inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). Remissions can
occur spontaneously or with treatment, and can last weeks, months, or years.
During remissions, symptoms of the disease disappear, and patients generally feel well. When the disease becomes active
again (relapse), symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid
arthritis varies from patient to patient, and periods of flares and remissions are typical.
When the disease is active, symptoms can include fatigue, lack of appetite, low grade fever, muscle and joint aches,
and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis
is common during disease flares.
During flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the
joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also
thickens with inflammation (synovitis).
In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected).
The small joints of both the hands and wrists are often involved. Simple tasks of daily living, such as turning door knobs
and opening jars can become difficult during flares.
The small joints of the feet are also commonly involved. Occasionally, only one joint is inflamed. When only one joint
is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis such as gout or joint infection.
Chronic inflammation can cause damage to body tissues, cartilage and bone. This leads to a loss of cartilage and erosion
and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function.
Rarely, rheumatoid arthritis can even affect the joint that is responsible for the tightening our vocal cords to change
the tone of our voice, the cricoarytenoid joint. When this joint is inflamed, it can cause hoarseness of voice.
Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than
Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as Sjogren's syndrome.
Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing or coughing. The lung tissue
itself can also become inflamed and sometimes nodules of inflammation (rheumatoid nodules) develop in the lungs.
Inflammation around the heart (pericarditis) causes chest pain which changes when lying down or leaning forward. The
disease can reduce the number of red blood cells (anemia), and white blood cells.
Decreased white cells can be associated with an enlarged spleen (referred to as Felty's syndrome) and can increase the
risk of infections.
Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure.
Even though these nodules usually do not cause symptoms, occasionally they can become infected.
A rare, serious complication, usually with long-standing rheumatoid disease, is blood vessel inflammation (vasculitis).
Vasculitis can impair blood supply to tissues and lead to tissue death. This is most often initially visible as tiny black
areas around the nail beds or as leg ulcers.
A advice I received from a friend : Don't do like I first,did,and waste your time and your money on too many of over-the-counter
vitamins and supplements. Make sure you get good medical care combined with exercise. Keep company with those who make you
feel better. Make sure you're around people who care. I have a wonderfully supportive family, and that's what keeps me going.
The ability for people to actually work with their physicians and take on some of the responsibility of managing their
disease on their own shoulders. I know in my own experience I have regular visits with my rheumatologist and my orthopedic
surgeon, but all the other time in between those visits pretty much the care is left on my shoulders. I have really worked
very hard in conjunction with my medical professionals to develop my overall plan, and I think that if people can do that
and learn to cooperate their care and manage it on a day-to-day basis, then the years and decades will become much easier.
Fatigue ;Well, I think one of the things that has helped me the most is really is to pay attention to what causes the
fatigue, and then be very good at scheduling your time or managing your time and plan ahead. Don't try to take on too much,
but just take on little bits at a time, building up to a bigger assignment or something. In other words, just sort of segment
your time out, and that way you won't have too much to do all at one time and become overly fatigued.
It's an ongoing battle, and when you wake up in the morning and you just think, "I can't do it," it's your attitude,
and you have to say, "I can." And it's just amazing once you do those sit-ups or that walk or whatever how you are able to
function and never give up that hope that you can function.
Sadness is an experience that all of us feel from time to time, usually having to do with some disappointment or some
loss. That will interrupt a person's mood intermittently, but gradually they get back to functioning in a normal sense.
If someone is beginning to develop a depressive illness, some of the biological things that happen are sleep begins to
be interfered with, eating habits change, and interest in every-day-life diminishes. Usually the normal things that the patient
is able to be involved in don’t seem as important.
They have decreased concentration, and they often feel irrationally guilty and ruminate about things. They're tearful;
they're crying; they feel more irritable. And, in an extreme sense, ther are people who are worried about self-destruction
but yet afraid to mention that to anyone that they're close to or to their physician.
Getting support from family members and friends is very important. Often, 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 physician. The doctor may suggest that they see someone like a psychiatrist so they can have an opportunity to
really pour their heart out about what's troubling them and what they're frightened of.
The other thing that
needs to be considered is 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 antidepressant,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.
People living with rheumatoid arthritis have normal life stresses, as we all do, but we know that one symptom of stress
is muscle tension. As these muscles in rheumatoid arthritis patients pull on the ligaments, the joints, and the tendons, they
decrease mobility. This can lead to more pain, more depression, and more stress.
When a patient has an illness that's grossly interfering with their functioning, the important thing is to try and find
an area where the patient can feel some gain in what's happening - so they feel like some form of control is coming back into
their life. That often helps the mood. "At least I was able to do this much today. If I practice this, maybe by next week
I'll be able to do a little bit more."
There's a sense of pride and self-esteem in trying. There's a sense of gaining something over the illness. I think those
things are helpful. Learn to relax. I believe stress does have an impact on my symptoms, and I try to control that by exercise
and proper diet and enough rest, and when I do fill my days too full, I do find that I get overly tired.
I do have to stop sometimes and get just a little extra rest. And when I do get overly stressed, I think that the symptom
that crops up for me is that I do get a little bit tired. I don't immediately have aches and pains and swelling, but I do
feel it a little bit in the fatigue department.
People with arthritis are frustrated. They don't want to feel bad. They don't want side effects. They're not sure what
to do. So that's where you have to ask the expert. And we really don't have any proof that diet, as a single agent without
anything else, does anything to stop arthritis. We wish it did, but it doesn't.
Advice I received from my doctor : Whether a good diet in addition to medical care is important, I would never argue.
But as a sole therapy, I don't have any proof that it helps except maybe in the smallest minority (people allergic to certain
foods ), and I would feel bad if you went in that direction. Why don't you go in the direction of the majority?
Remember, you're not committing yourself for life. If you start to feel well, you can always stop it to see if you need
it. But that's the perspective. Put it in the same perspective that you would any other decision you'd make in your life about
anything else. Where would you go for information? How would you evaluate it? What would you do?
The harm with alternative therapies is not what it does to your body, but if you look across at a population study and
ask, "How much time from the onset of therapy did it take you to see the doctor to get the diagnosis, and what prevented you
from going to the doctor?" the number one thing that sticks out is alternative therapy.
The patients who take diet, the patients who take the copper bracelet, stay away from the doctor the longest period of
time and don't get a proper diagnosis. That's the harm in strictly, alternative therapies. It doesn't get you to the correct
I'm not saying that it may not have some role in addition to other therapy,( there are many good complementary therapies
that are helpful when used in conjunction with conventional medical therapy ) but it keeps you from the doctor.
After trying some scientifically unproven,alternative therapy and concluding that the disease is getting progressively
worse,the patient,visits the physician and expect him to reverse the now,deformed joint. That's what the harm of these
things really is. A joint once deformed can't be reversed !
Cooking dinner. Mowing the lawn. Mopping the floor. They may seem minor, but everyday tasks can take a toll on your body.
And when your joints are stiff and painful from arthritis, running a household can seem like an overwhelming job. The biggest
mistake many people with arthritis make is trying to do everything at once.
It's a cycle - they do too much, then they become over-fatigued or cause a flare. Once their energy is back and
the pain is gone, they try to make up for lost time - and then they get fatigued again and have another flare.
The good news is that you can take many steps to make the work in and around your home easier to manage. Follow these
Organize:By planning ahead you can organize your tasks in ways that will conserve energy. For instance, clean one area
or floor at a time. If you're doing laundry in the basement, combine tasks that can be done there to avoid hikes up and down
Ask yourself: How many tasks can I realistically accomplish in this room or on this floor without causing a flare or
Prioritize:Accept the fact that you won’t be able to get everything done in one day. Decide which are the most
important tasks to accomplish and focus on them. Other items can wait until another time.
Ask yourself: What chores really have to be done now? And what tasks can be delayed?
Distribute:Break tasks into smaller segments that can be accomplished over a number of days. For example, carrying laundry
can strain your joints. When clothes are wet, they can be heavy and hard to maneuver into the dryer. And if your washer and
dryer are in your basement, you can spend a lot of time running up and down the stairs.
To ease the strain, do a load of laundry every other day instead of all in one day. Another option -set time limits for
yourself. For instance, clean the closet for 30 minutes each day until the job is done.
Ask yourself: How can this job be spread over a number of days?
Alternate;Two ways to classify and alternate tasks are:
Light tasks and medium tasks. Alternate light tasks with medium
tasks. If you do a heavy task, plan on taking a break after completing it and follow it up with a lighter task. This gives
your joints a break and allows you to work longer.
Standing tasks and sitting tasks. If you stand up while washing the dishes, then plan on sitting down, when you can,
while preparing a meal. This keeps one set of joints from taking all of the strain.
Whether you do a chore standing or sitting often is determined by habit. You may be used to folding laundry while standing
by your bed, but remember that you can also do it while sitting.
Ask yourself: What order should I do these tasks in? ;Pace yourself
Remember to take regular rest breaks. This
doesn't mean you have to lie down and sleep, just make sure to relax the set of joints you just used. Length of rest varies
person by person - listen to your body. Stop for a break before you're tired or hurt.
Ask yourself: When will I take my breaks? Delegate;Another way to distribute work is to ask for assistance or hire someone
to help you. This is especially important with strenuous activities that put stress on your joints and can cause pain and
Family and friends are good sources for help. Don't forget that even young children can be given regular chores.
Ask yourself: Who else can do this task? Duplicate. Keep several sets of cleaning supplies distributed around the house
so that you won't have to carry them far. For example, keep a toilet brush and cleanser in each bathroom.
Ask yourself: What cleaning supplies do I use in more than one room?
Here are some additional tips for functioning
in and around your home. Depending upon which joints are most affected, some tips may be more helpful than others:
In the kitchen:Use electric appliances. For instance, use a food processor to do your chopping. Buy prepared foods and
convenience items. For example, buy salad mix that is pre-washed and shredded.
Use scissors to open a package instead
of tearing it open with your hands. Ask for groceries in a paper versus a plastic bag. You can carry it between your forearm
and hip to avoid straining your hands.
Plan ahead to avoid multiple last-minute tasks when preparing a large
meal. Reduce stress on your joints by placing your mixing bowl on a damp cloth in the sink while you stir. The cloth will
keep the bowl from slipping, and holding the spoon like a dagger takes stress off your hands.
Use nonstick sprays, foil and disposable baking pans to make cleaning up easier. Use a cart with wheels to move heavy
items from one place to another. Buy a cutting board with a gripping surface that holds food firmly as you cut. Use a microwave
whenever possible to avoid stooping at the oven. Use hot water to loosen a jar lid and pressure from your palm to open it,
or use a jar opener. Buy lightweight pots, pans, bowls and dishes.
Around the house:Organize closets and cabinets so that the heavy and most frequently used objects are easy to reach -
between the middle of your thigh and shoulder. Insert a dish towel in drawer or door handles to make them easier to pull open.
Leave your most frequently used items out on the counter in the kitchen and bathroom and on your dresser in the bedroom.
Limit yourself to one major cleaning task a day. Use long-handled tools for reaching.
Outside:Gather your tools together in a wheelbarrow so that you're not making several trips back and forth. Use tools
that are going to minimize stress on your joints. Examples are ergonomic rakes and shovels. Tape yardsticks onto your gardening
utensils so that you won't have to bend over as much to use them.
Put pipe insulation tubing around tool handles to make them easier to hold. Leave the hose in the yard instead of dragging
it out of storage each time you use it. Put a chair at each end of a garden row. It will help you get up from the ground.
Do your gardening in small containers that you can keep at an accessible level or use raised beds. Weed after it rains
or the garden has been watered -soft soil means less tugging.
Using assistive devices can make performing many daily activities - such as reading a book, opening a jar or buttoning
a jacket -less frustrating. Contact your pharmacy or health care professional for information on ordering these items. Many
aids can also be purchased at a medical supply store.
Use thick, padded grips. Many kitchen tools are now available with thick, padded handles. You can devise your own creations
by wrapping foam tubing, the kind used for pipe insulation, around all kinds of hand-held household items -from toothbrushes,
hairbrushes and combs to pens, key rings and kitchen utensils.
Learn tricks for turning lids, handles and knobs. The key is leverage - the longer the handle, the less force you
need. You can buy extended handles for doorknobs and stove controls, gadgets to open car doors and under-the-counter jar openers
that grip a jar’s lid as you physically turn the jar.
Use aids to help you dress. These can help if you have trouble bending and reaching. Aids include shoehorns with an extension
handle, devices that help you pull up hosiery, shoes you close with Velcro rather than shoelaces and tools that grip buttons
and zippers. You can also have elasticized Velcro tabs sewn onto shirt cuffs or have buttons sewn on with elasticized thread.
Use a walking stick or cane.
One thing to emphasize is that rheumatoid arthritis is a very complicated and varied disease, so that each individual
will present different challenges. In different people there may be different parts of what's causing inflammation so that
in some people it may be driven by one factor more than another.
In all likelihood it's going to be the exception rather than the rule, where physicians can use a single medication.
With rheumatoid arthritis, since the immune system is so complicated, we should look at it as conducting war.
We may be successful in one front and then be losing on another front, so that as in any war we have to fight it on a
number of different levels, and that's why physicians may have to use combination therapies.
The anti-inflammatories are there to catch any inflammation that breaks through the primary defenses, which are the disease-modifying
drugs, and doctors try to use just one, but if that doesn't work, they'll use others, and they work at different levels.
Whereas Enbrel inhibits TNF, methotrexate inhibits T-cells so we can attack the immune system - not attack, but control
the immune system in a lot of different ways at the same time. But doctors always try to keep it as simple as they can.
One important factor overlooked in medication,and efficacy is that there is pain caused by mechanical and inflammatory
forces involved. As we grow older there is a lot of mechanical pain caused by on-going degenerative forces ( degenerative
osteoarthritis -secondary OA.) Our current conventional and biologic medications aren't going to eliminate that part of the
complex pain equation.
Many RA patients have this so called "secondary OA" or mechanical problem. We as patients will in all probability will
not be able to escape that part of pain. In other words,is pain caused by mechanical,or inflammatory forces. If it a mechanical
problem we have to attack the problem in different other ways; exercise,heat,cold,anagesics etc.