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Joint Problems after Brain Injury
Fibromyalgia, Lyme Disease, Myofascial Pain, Chronic Fatigue Syndrome, Rheumatoid Arthritis

Fibromyalgia--An Overview

You hurt all over. Your muscles are so stiff in the morning it's hard to get moving. You feel constantly tired but have trouble sleeping. Yet your doctor can't seem to find anything specifically wrong with you. This is a familiar scenario for people with fibromyalgia. Recently, the diagnosis of fibromyalgia has increased. Some estimates suggest that as many as 2 percent of all Americans are affected.

But there's still much that remains unknown about fibromyalgia. For that reason, its controversial and a focus of medical debate. Here's what we know and don't know about the condition, and what you can do to try to relieve symptoms.

Signs & Symptoms

Fibromyalgia's main symptom is chronic pain an "aching all over." The pain may be a deep ache or a burning sensation. Stiffness and discomfort in your muscles, tendons and ligaments often accompany it. Fibromyalgia may be associated with:

Difficulty sleeping
Fatigue Anxiety
Stress
Depression
Numbness
Headaches
Tingling in your hands and feet
Digestive problems
Sensitivity to weather
Temperature changes

Before the American College of Rheumatology endorsed the term fibromyalgia in 1990, the condition was referred to by names such as fibrositis, chronic muscle pain syndrome, psychogenic rheumatism and tension myalgias.

Causes

Fibromyalgia has no known causes, only unproven theories. One theory is that certain factors such as stress, poor sleep, physical or emotional trauma or being out-of-shape may trigger the condition in people who are more sensitive to pain. Other theories include: Link to an injury or trauma that affects your central nervous system. Possible associations with chemical or hormonal differences, infections or psychological or psychiatric factors.

Screening & Diagnosis

Fibromyalgia is difficult to diagnose. There isn't a test that can confirm or rule out the condition. In addition, many of its symptoms mimic other diseases, such as low thyroid hormone production, Lyme disease and rheumatoid arthritis. Often, people with fibromyalgia will go through several medical tests, only to have the results come back normal yet their pain is very real. Typically, doctors diagnose fibromyalgia only after they have eliminated other conditions. Fibromyalgia is diagnosed much more often in women than men. Some doctors theorize that fibromyalgia may be more common in men than figures indicate, but that men are less likely to see a doctor for general aches and pains. The American College of Rheumatology has established some general diagnostic guidelines for fibromyalgia to help assess and study the condition. They include having widespread aching for at least 3 months and at a minimum of 11 locations on your body that are abnormally tender under relatively mild pressure. These areas are called tender points.

Treatments

There is no cure for fibromyalgia. Modest doses of over-the-counter pain relievers may eliminate some pain and stiffness. Your doctor may also prescribe small doses of certain antidepressant medications that help promote deep sleep. Side effects of these antidepressants can include dry eyes and mouth, constipation and increased appetite.

Self-Care

These lifestyle changes, sometimes coupled with medications, may relieve symptoms of fibromyalgia or even make them disappear: Control stress. Develop a plan to avoid or limit overexertion and emotional stress. Allow yourself time each day to relax. That may mean learning how to say "no" without guilt. But don't change your routine totally. People who quit work or drop all activity tend to do worse than do those who remain active. Some people get relief from massages, hot baths and relaxation techniques. Exercise regularly. At first, exercise may increase your pain. But doing it regularly often improves symptoms. Appropriate exercises include walking, swimming, biking and water aerobics. Aim for at least 20 to 30 minutes of exercise four or more times a week. Stretching and good posture are also helpful. Keep your activity on an even level. If you do too much on your "good" days, you may have more "bad" days. Get enough sleep. Fatigue makes symptoms worse. Try to develop regular sleep hours and get adequate rest each night. Learn more about fibromyalgia and its symptoms. You may find comfort from support groups.

Fibromyalgia and Sleep

Frequently Asked Questions

For many people with fibromyalgia, sleep offers no escape from the painful symptoms they experience during the day. Fibromyalgia is a chronic condition characterized by fatigue, musculoskeletal aches and disordered sleep. Many people with fibromyalgia experience a type of sleep disturbance called alpha delta sleep disorder. When a person is awake and resting, "alpha" brain waves are emitted at a frequency of 8 to 13 per second. When a person is in deep sleep, "delta" brain waves are emitted at a rate of less than 3.5 per second. People with alpha delta sleep disorder experience a disruption in these patterns. When they reach deep sleep, the phase in which muscles are repaired, alpha waves intrude and jolt them back to lighter sleep. They don't obtain enough deep sleep, and their body is not adequately refreshed. This condition aggravates fibromyalgia symptoms. People with fibromyalgia can take steps to improve their sleeping patterns. Here are answers to frequently asked questions about fibromyalgia and sleep:

Q: How does insufficient sleep affect fibromyalgia symptoms?

A: Lack of sleep accentuates the fatigue that most people with fibromyalgia experience. Musculoskeletal pain is also worsened by poor sleep. Most people who don't sleep well have muscle aches, regardless of the cause of their sleep disturbance. Because people with fibromyalgia achieve only light, non-restorative sleep, their body never fully relaxes. In addition, they often toss and turn all night, which keeps the muscles tensed and active. People with normal sleep patterns typically awaken feeling refreshed. But people with fibromyalgia may be in significant pain when they get out of bed in the morning.

Q: What behavioral changes can be made to improve sleep quality?

A: There are a number of behavior modifications that can help people attain more normal sleep patterns. It's helpful to go to bed and wake up at the same time each day to set the body's sleep clock, so your body 'expects' to sleep during those hours. Your bed should be used only as a place to sleep, so your body learns to sleep when it's there. Don't use your bed for other activities like eating, reading, paying bills or watching television. When you can't sleep, get up and go into another room to read or do something else relaxing. When you begin to feel sleepy, go back to bed and try again. You may need to repeat this pattern several times during the night. Getting regular exercise during the day or early evening promotes better sleep. Be sure to complete exercise several hours before bedtime. It's also best to avoid caffeine and alcohol within 6 hours of bedtime. Napping during the day may not be helpful and can even worsen nighttime sleep. If you do take naps, keep them to 30 minutes or less. Try skipping a nap one day to see whether that improves your nighttime sleep. Work out so you can sack out! - New study documents a relationship

Q: What prescription medications are used to help people with fibromyalgia sleep better?

A: Prescription medications may be tried if behavior modifications don't improve sleep patterns. Tricyclic antidepressants are the most commonly prescribed drugs to improve sleep in people with fibromyalgia. When these drugs prove helpful, they are frequently recommended for long-term use. For details from the drug database, see: Tricyclic antidepressants Prescription sleeping pills may provide short-term benefits for some people with fibromyalgia, but long-term use of these drugs is usually not advised. These medications tend to work for only a short time, after which the body becomes resistant to their effects. They are also very addictive. Ultimately, the use of sleeping pills tends to create even more sleeping problems in people with fibromyalgia.

Q: Can over-the-counter drugs and herbal medications improve sleep in people with fibromyalgia?

A: Some people with fibromyalgia experience moderate benefits from over-the-counter (OTC) sleep-promoting drugs, many of which can be found combined with acetaminophen for pain relief. It is very important to follow the directions on the label. These drugs should never be used in combination with alcohol or with other sedatives. Older people generally have slower metabolisms, so OTC drugs may stay in their systems longer and cause daytime sleepiness. Approach herbal sleep agents, like valerian root and melatonin, with caution. The U.S. Food and Drug Administration doesn't regulate these herbal substances, so there is little reliable research available about their safety, side effects and interaction with drugs. Always tell your doctor if you use any OTC drugs or herbal agents.

Coping with the Pain

You hurt all over. Your muscles are so stiff in the morning it's hard to get moving. You feel constantly fatigued but have trouble sleeping. Yet, your doctor can't seem to find anything specifically wrong with you. This is a familiar scenario for people with fibromyalgia.

Recently, the diagnosis of fibromyalgia has increased. Some estimates suggest that as many as 2 percent of all Americans are affected. But there's still much that remains unknown about fibromyalgia. For that reason, it's controversial and a focus of medical debate. Here's what we know and don't know about the condition, and what you can do to try to relieve symptoms.

Widespread Pain

Fibromyalgia is a disorder involving chronic pain in your muscles, ligaments and tendons. It's often called fibromyalgia syndrome, meaning that it's not a specific illness but a condition that involves several symptoms that occur together. Before the American College of Rheumatology endorsed the term fibromyalgia in 1990, the condition was referred to by names such as fibrositis, chronic muscle pain syndrome, psychogenic rheumatism and tension myalgias. The main symptom of fibromyalgia is chronic pain an "aching all over." The pain may be a deep ache or a burning sensation. It's often accompanied by stiffness and discomfort in your muscles, tendons and ligaments. Although the condition may feel like a joint disease, it isn't a form of arthritis and it doesn't cause deformity in your joints. Fibromyalgia may be associated with difficulty sleeping, fatigue, anxiety, stress, depression, numbness, headaches, tingling in your hands and feet, digestive problems and sensitivity to weather and temperature changes. Symptoms may come and go but typically never disappear completely. They're often most severe during the first year you have the condition. Although it tends to be chronic, fibromyalgia isn't progressive, crippling or life-threatening.

Theories as to a Cause

Doctors have yet to learn what causes fibromyalgia. There are many theories, but none has been proven. One theory is that certain factors such as stress, poor sleep, physical or emotional trauma or being out-of-shape may trigger the condition in people who are more sensitive to pain. Some scientists believe the syndrome may be linked to an injury or trauma that affects your central nervous system. Researchers are also exploring possible associations with chemical or hormonal differences, infections or psychological or psychiatric factors. The condition is diagnosed much more often in women than men. Some doctors theorize that fibromyalgia may be more common in men than figures indicate, but that men are less likely to see a doctor for general aches and pains.

Not a Simple Diagnosis

Fibromyalgia is difficult to diagnose. There isn't a test that can confirm or rule out the condition. In addition, many of its symptoms mimic other diseases, such as low thyroid hormone production, Lyme disease and rheumatoid arthritis. Often, people with fibromyalgia will go through several medical tests, only to have the results come back normal yet their pain is very real. It's usually when other conditions have been dismissed that a diagnosis of fibromyalgia is made.

The American College of Rheumatology has established some general diagnostic guidelines for fibromyalgia to help in the assessment and study of the condition. They include having widespread aching for at least 3 months and at a minimum of 11 locations on your body that are abnormally tender under relatively mild pressure. However, not all doctors agree with the guidelines. Some believe that the criteria are too rigid and that you can have fibromyalgia even if you don't meet the required number of tender points.

Others question how reliable and valid tender points are as a diagnostic tool. There's also some controversy among physicians whether fibromyalgia is really a distinct condition or part of a larger group of disorders. What you can do

There's no known cure for fibromyalgia. But a combination of these steps may help reduce symptoms:

Stress Reduction

Develop a plan to avoid or limit overexertion and emotional stress. Allow yourself time each day to relax. That may mean learning how to say "no" without guilt. But, don't change your routine totally. People who quit work or drop all activity tend to do worse than those who remain active.

Regular Exercise

At first, exercise may increase your pain. But doing it regularly often improves symptoms. Appropriate exercises include walking, swimming, biking and water aerobics. A physical therapist may help you develop a home exercise program. Aim for at least 20 to 30 minutes of exercise four or more times a week. Stretching and good posture are also helpful. Keep your activity on an even level. If you do too much on your "good" days, you may have more "bad" days.

Adequate Sleep

Fatigue makes symptoms worse. Try to develop regular sleep hours and get adequate rest each night. Education Learning more about fibromyalgia and its symptoms is often helpful. You may also find comfort from support groups.

Medications

Modest doses of over-the-counter pain relievers may eliminate some of your pain and stiffness. Your doctor may also prescribe small doses of certain antidepressant medications that help promote deep sleep. Side effects of the antidepressants can include dry eyes and mouth, constipation and increased appetite. Avoid narcotics and sleeping pills, as these drugs have addictive potential.

Education

Learning more about fibromyalgia and its symptoms is often helpful. You may also find comfort from support groups.

Other Techniques

Some people get relief from massages, hot baths and relaxation techniques. Fortunately, doctors have found that these lifestyle changes, sometimes coupled with medications, can relieve symptoms or even make them disappear.

Who is affected: Fibromyalgia

Fibromyalgia is a very common disorder of the muscles and soft tissues. It affects 2% to 5% of people in the United States. It occurs most often in women age 20 to 50, but it may also occur in men and women of any age, including children.

Fibromyalgia sometimes occurs with other muscle or joint diseases or chronic pain conditions. This can make fibromyalgia difficult to diagnose. Fibromyalgia can also easily be mistaken for a psychiatric disorder (such as depression) or other conditions involving joint or muscle pain and fatigue, such as arthritis, chronic fatigue syndrome, or Lyme disease.

Lyme Disease

Lyme Disease: An Overview

A new vaccine against Lyme disease offers significant protection. But that doesn't mean you can tromp through the woods without being aware of tick-borne illnesses. For one thing, Lyme disease is only one illness transmitted by ticks. Others include Rocky Mountain spotted fever, Colorado tick fever, ehrlichiosis and tick paralysis.

You are likely to hear about people who suffer the worst consequences of tick-related infections. For a moment, you might consider banning all outings in the woods. Relax. The facts largely don't support such fears. Few people get tick-borne illnesses. Even fewer become seriously ill. Infections from ticks can be serious when left untreated. But with simple prevention, or with prompt treatment if you're infected, you can enjoy the outdoors without fear.

Chronic Fatigue Syndrome

We all get tired; most of us at times have felt depressed. But the enigma known as chronic fatigue syndrome (CFS) is not the ups and downs we experience in everyday life, or even the temporary persistence of such feelings in response to exceptional physical or emotional stress.

The early hallmark of the illness is a pronounced fatigue that comes on suddenly and is relentless or relapsing, causing debilitating tiredness or easy exhaustion in someone who has no apparent reason for feeling this way. Unlike the mind fog of a serious hangover, to which CFS has been compared, the profound weakness of CFS does not go away with a few good nights of sleep but instead slyly steals a person's vigor over months and sometimes years.

How It Begins

People diagnosed with CFS often describe its onset as sudden but not alarming because many of the syndrome's symptoms--headache, tender lymph nodes, fatigue and weakness, muscle and joint aches, inability to concentrate--mimic those of the flu. But whereas flu symptoms usually go away in a few weeks, CFS symptoms either persist or recur frequently for more than six months.

For many people, CFS begins after an acute infection such as a cold, bronchitis, hepatitis, or an intestinal bug. For some, it follows a bout of mononucleosis, the "kissing disease" that temporarily saps the energy of teenagers and young adults. In others, CFS develops more gradually, with no clear triggering event. Often a patient reports that the illness emerged during a period of high stress.

Who Gets It

Contrary to the popular stereotype, CFS is not a new "yuppie flu." Similar syndromes, known by different names, date back to the late 1800s. The modern stereotype arose because those who sought help for and stimulated scientific interest in CFS in the early 1980s were mainly well-educated, affluent women in their thirties and forties. Since then, physicians have seen the syndrome in people of all ages, races, and socioeconomic classes from several countries around the world. Still, CFS is diagnosed two to four times more often in females than in males, which may be the result of biological, psychological, and social influences.

For example, a real gender difference may exist in CFS, similar to diseases such as lupus and multiple sclerosis that affect more women than men. Or, women may be more likely than men to consult doctors about CFS-like symptoms. Also, some members of the medical community and the public remain unaware or skeptical of the syndrome. An increasingly diverse patient population will likely emerge as more physicians recognize CFS as a legitimate disorder.

The Diagnosis

Diagnosing CFS is difficult because it shares symptoms with many other diseases. When evaluating patients, physicians must first rule out diseases that look similar, such as multiple sclerosis and lupus in which diagnostic symptoms can take years to develop. In follow-up visits, physicians need to be alert to any new cues or symptoms that might indicate a diagnosis other than CFS. After rigorously excluding people with other diseases, however, a large group of people with symptoms associated with debilitating fatigue remain. If they meet other criteria as well, these people can be considered to have CFS (see The CFS Case Definition).

How Many People Have It?

Note: For the latest CFS prevalence data, please consult the Centers for Disease Control and Prevention Web site.

The lack of a clinical or laboratory marker for CFS has muddled efforts to determine how many people the illness affects.

NIAID and the Centers for Disease Control and Prevention (CDC) fund prevalence studies.

Based on the first three years of an ongoing surveillance study in four U.S. cities, the CDC estimates the minimum prevalence rate of CFS in the United States is 4 to 10 cases per 100,000 adults or older (although children can have CFS, too.) This estimate, however, relies on cases referred to CDC study sites by primary physicians, a method that can result in either an underestimate or overestimate of actual cases.

Historical Perspective

Clinical portraits of diseases similar to CFS have been reported under different medical guises for more than a century. In the l860s, Dr. George Beard named the syndrome neurasthenia, believing it to be a neurosis characterized by weakness and fatigue. Succeeding generations have favored but not proved different explanations--iron-poor blood (anemia), low blood sugar (hypoglycemia), environmental allergy, or a bodywide yeast infection (candidiasis)--for this baffling malaise. In the mid-1980s, the illness became labeled "chronic EBV" when laboratory clues led scientists to speculate that this cluster of symptoms might be caused by the Epstein-Barr virus (EBV).

But new evidence casts doubt on the theory that EBV could be the sole agent causing CFS. Elevated levels of EBV antibodies have now been found in some healthy people as well as in some people with CFS. Likewise, some people who lack EBV antibodies, and who thus have never been infected with the virus, can display CFS symptoms.

The CFS Case Definition

The EBV work rekindled interest in the syndrome among a small group of medical researchers. It became apparent that a standard CFS case description was needed so that scientists could more easily compare research results. In the late 1980s, CDC convened a group of CFS experts to tackle this problem. Based on the best information available at the time, this group published in the March 1988

Annals of Internal Medicine strict symptom and physical criteria--the first case definition--by which scientists could evaluate CFS study patients. Not knowing the cause or a specific marker for the disease, the group agreed to call the illness "chronic fatigue syndrome" after its primary symptom. "Syndrome" means a group of symptoms that occur together but can result from different causes. (Today, CFS also is known in other countries as myalgic encephalomyelitis, postviral fatigue syndrome, and chronic fatigue and immune dysfunction syndrome.) After using this definition for several years, CFS researchers realized some criteria were vague or redundant. CDC had an international group of CFS experts review the criteria. This led to the first changes in the case definition, published in the same journal in December 1994 (see attached article).

Besides revising the CFS case criteria--which reduced the required minimum number of symptoms to four out of a list of eight possible symptoms--the new report also proposes a conceptual framework for studying the syndrome. This framework recognizes CFS as part of a continuum of illnesses that have fatigue as a major symptom. Although primarily intended for researchers, the new guidelines should help clinicians better diagnose CFS.

How to Manage and Cope With the Disease

No specific treatment has proved effective for CFS. Scientists hope that research will help them identify markers for the illness. These markers would enable them to target treatments to specific abnormalities and to objectively follow the course of the illness. How well different therapies work can then be gauged by measuring changes in those markers in treated patients.

Anecdotally, physicians have reported successes in small numbers of patients with various treatments including antivirals, antidepressants, and immunomodulators (drugs that boost the immune system). Few drugs have undergone rigorous clinical testing, however. NIAID researchers tested the antiviral drug acyclovir in a double-blind, placebo-controlled trial and found that as many CFS patients reported feeling better when taking a placebo as when taking acyclovir. This outcome lessens claims of a therapeutic role for acyclovir in CFS.

Carefully controlled studies also have revealed conflicting data regarding the value of high-dose intravenous immunoglobulin. Because well-designed clinical trials have found that patients with fibromyalgia (an illness similar to CFS) benefit from low-dose tricyclic antidepressants, doctors often prescribe these drugs for people with CFS with generally positive results. Some researchers believe that these drugs improve the quality of sleep. Patients also have benefited from other kinds of antidepressants, including the newer serotonin reup-take inhibitors.

Therapeutic doses of antidepressants often increase fatigue in CFS, so doctors may have to escalate the dosage very slowly, or prescribe the so-called more active antidepressants. In addition, some people with CFS benefit from the benzodiazepines, a class of drugs used to treat acute anxiety and sleep problems. Patients often try more than one drug before finding one that works and can be tolerated. Even though no specific CFS treatments exist, symptomatic treatment still can be quite helpful.

Nonsteroidal anti-inflammatory drugs may benefit the body aches or fever associated with the illness, and nonsedating antihistamines may help relieve any prominent allergic symptoms. Learning how to manage fatigue enables people with CFS to improve their level of functioning and quality of life despite their symptoms. A rehabilitation medicine specialist can evaluate individuals and teach them how to plan activities to take advantage of times when they usually feel better.

The lack of any proven effective treatment can be frustrating to both patients and their physicians. Experts recommend that people with CFS try to maintain good health by eating a balanced diet and getting adequate rest. Physical conditioning should be preserved by exercising regularly but without causing more fatigue. It is important that people with CFS learn to pace themselves--physically, emotionally, and intellectually--since too much stress can aggravate symptoms.

The course of CFS varies from patient to patient. For most people, CFS symptoms plateau early in the course of the illness and thereafter wax and wane. Some people get better but not completely. Others spontaneously recover. Emotional support and counseling can help patients and their loved ones cope with the uncertain prognosis and ups and downs of the illness.

Conclusion

Several different routes to chronic fatigue syndrome may exist. In some people, a persistent viral infection may provoke CFS symptoms, and virologists continue to explore this possibility. Vulnerability to CFS may be associated with a subtle immune system defect. It also appears likely, however, that CFS involves interactions between the immune and central nervous systems, interactions about which relatively little is now known. Scientists' concerted efforts to penetrate the complex neuroimmunologic events in CFS have created a challenging new concept of the pathology of this and other illnesses.

Lyme disease and Fibromyalgia

Lyme disease is a bacterial infection that is spread by ticks. Signs of Lyme disease include rash and flu-like symptoms such as fever, fatigue, headache, muscle aches, and joint pain. It is possible that Lyme disease may trigger Fibromyalgia in some people, but this has not been proven.

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Rheumatoid Arthritis: More than 'aches and pains'

The most common signs and symptoms of rheumatoid arthritis are joint swelling, stiffness and pain. The pain may be similar to that of a headache or toothache. Affected joints may also feel warm to the touch, and the skin covering them may appear reddish. On days when the disease is more active, you may actually feel "sick." Symptoms may include fatigue, loss of appetite, fever, sweats and difficulty sleeping. About one-fifth of people with rheumatoid arthritis also develop rheumatoid nodules lumps of tissue under your skin, often over bony areas such as your elbows.

The disease varies from person to person. Some people experience symptoms that come and go. These episodes are called flares and remissions. Others may have continuous symptoms that generally worsen with time.

The cause of rheumatoid arthritis is unknown and likely is due to multiple factors. Some researchers believe an infection triggers the disease among people who carry a genetic susceptibility. Researchers believe that you can't actually inherit the disease, but that you can inherit a tendency to develop it. But this hasn't been proven. Some people with rheumatoid arthritis have a protein in their blood called rheumatoid factor. High levels of rheumatoid factor tend to be associated with more severe forms of the disease. But, not everyone who has the protein develops the disease. And not all people who have rheumatoid arthritis carry the protein.

Common Questions

If you have rheumatoid arthritis, you may wonder about:

Diet

Some people claim that particular foods help their symptoms or make them worse. A few studies suggest benefits from low-calorie, low-fat and low-protein diets. Other studies indicate that eating large amounts of omega-3 fatty acids from cold-water fish (salmon, mackerel, herring) and plant oils may reduce joint tenderness. But check with your doctor before taking omega-3 fatty acid supplements (fish oil capsules). They can result in loose stools and abdominal discomfort, and possibly even increase your risk of stroke.

Climate

People often wonder if moving to a different climate will ease symptoms. In most cases, a change doesn't make a big difference. Alternative therapies There are many alternative treatments available everything from antioxidants to copper bracelets. Two popular therapies are the dietary supplements glucosamine and chondroitin sulfate. Some believe that magnets can play a role in the healing process and in pain control. A few small studies have suggested benefits. But no long-term, controlled studies have been done to prove safety and effectiveness. The Arthritis Foundation and most physicians don't recommend their use. Be careful when considering alternative therapies. Many are expensive and some may be harmful.

Medications

There is no treatment that can cure or reverse rheumatoid arthritis. However, there are medications that can relieve its symptoms and slow or halt its progression. The four types of drugs are:

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

This group of medications, which includes aspirin, helps relieve pain and inflammation. Side effects may include stomach upset and stomach bleeding. Therefore, NSAIDs should always be taken with food. NSAIDs - Helpful medications with serious side effects

Cox-2 Inhibitors

This new class of medications is similar to NSAIDs, but may be less damaging to your stomach. Like NSAIDs, cox-2 inhibitors suppress an enzyme called cyclooxygenase (cox) that triggers joint inflammation and pain.

Researchers believe that NSAIDs work against two versions of cox that are present in your body, cox-1 and cox-2. However, there is evidence that in suppressing cox-1, NSAIDs may cause stomach and other problems because cox-1 is the enzyme that protects your stomach lining. Cox-2 inhibitors work selectively, suppressing only cox-2, the enzyme involved in inflammation. Two versions of cox-2 inhibitors, celecoxib (Celebrex) and rofecoxib (Vioxx), have been approved by the Food and Drug Administration for pain related to arthritis.

Corticosteroids

These medications (cortisone, prednisone and others) reduce inflammation and slow joint damage. In the short term, corticosteroids can make you feel dramatically better. However, when used for many months or years, they may become less effective and also cause serious side effects. Side effects may include easy bruising, thinning of your bones, cataracts, weight gain, a round face, diabetes and high blood pressure. Doctors will often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering you off the medication.

Disease-modifying Antirheumatic Drugs (DMARDs)

These medications have been shown to slow or halt the progression of rheumatoid arthritis. In the past, they were used only if you had severe rheumatoid arthritis and noticeable joint destruction. Today, DMARDs are prescribed early to try to prevent destruction. When taken in proper doses, the drugs aren't as toxic as once believed. Depending on the drug used, side effects can range from blurry vision to increased susceptibility to infection.

Several of the most commonly prescribed DMARDs are hydroxychloroquine (Plaquenil), gold (Myochrysine, Solganal), sulfasalazine (Azulfidine), and minocycline (Minocin). Sometimes, a combination of DMARDs may be used if one alone isn't effective.

Because they don't relieve symptoms, DMARDs are taken in addition to an NSAID, a corticosteroid, or both. The drugs are slow-acting, so it may take a few months before you notice benefits.

Immunosuppressants

These medications are closely related to DMARDs and are known as immune system "tamers." In other words, they are used to try to keep the immune system under control. Several major types of immunosuppressant drugs include methotrexate (Rheumatrex), azathioprine (Imuran), cyclosporine (Sandimmune, Neoral), and leflunomide (Arava). Some of these drugs can decrease the body's ability to fight infections. Most of them should not be taken if you have kidney or liver disease.

TNF Blockers

One of the most talked-about new medications for arthritis is the TNF blocker. TNF (tumor necrosis factor) is a cytokine, or cell protein, which acts as an inflammatory agent in rheumatoid arthritis. "Anti-TNF" medications target or block this cytokine and can help reduce pain, morning stiffness and tender or swollen joints. These medications often are taken with methotrexate. Two TNF blockers approved for treatment of rheumatoid arthritis are etanercept (Enbrel) and infliximab (Remicade). If you have an active infection, you should not take these medications.

PROSORBA Column

Another new therapy approved for the treatment of rheumatoid arthritis is the PROSORBA column. This is a blood-filtering technique that removes certain antibodies that contribute to pain and inflammation in your joints and muscles. The treatment usually is given once a week for twelve weeks as an outpatient procedure. Some of the side effects include fatigue and a short increase in joint pain and swelling for the first few days after the treatment. The PROSORBA column treatment is not recommended if you are taking ACE inhibitors, have heart problems, high blood pressure, or blood clotting problems.

Arthritis Treatments - Promising Trends

Surgical Treatments

For about one-third of people with rheumatoid arthritis, treatment can't prevent joint destruction. When this occurs, surgery can often help restore joint function, reduce joint pain or correct a deformity. A synovectomy is a procedure designed to remove some of the inflamed synovial tissue that lines affected joints. You may need to have the entire joint replaced with a metal or plastic prosthesis. Surgery also may involve tightening tendons that are too loose, loosening tendons that are too tight, fusing bones to reduce pain, or removing part of a diseased bone to improve mobility. Knee replacement - Surgery can relieve pain and restore mobility

Self-care

Rest and exercise are also key parts of treatment. During times when your joints are more warm, swollen and painful, rest helps. You should continue to do range-of-motion exercises to keep your joints mobile, but don't get overly tired or aggravate your joints with unnecessary walking, housework or other activities. Schedule a time to lie down and rest at midday, even if you don't sleep. Increase exercise when your joints feel better and when you have less fatigue and morning stiffness. Weight-bearing exercises, such as walking and biking, were once forbidden. But studies have found they can strengthen weakened muscles without additional joint damage. Doctors and therapists frequently recommend that people with rheumatoid arthritis use only light weights or exercise without any added weights. If exercise produces more pain or joint swelling, next time do less.

Physiatric Treatment Modalities for FMS

Edited from a chat with PRC
DrP 4/14/97 PRC

DrP: I am a Physiatrist--That's physical medicine and rehabilitation and pain medicine. A physiatrist uses non-operative orthopedics, anesthesia, exercise physiology, neurology and a combination of other specialties to treat musculoskeletal, neurological and chronic pain problems.

As a specialist that is really a "Swiss Army Knife" of specialists, I have a unique perspective of how we can borrow from many disciplines to come up with a combination therapy that will help to provide the best possible all around "holistic" treatment of the patient. I assume that everyone here either has FMS or know someone who has it, so I won't waste your time telling you what it is. What you might not know is what it isn't. It isn't purely any one cause.

There are many things that contribute to it and seem to provoke it in certain susceptible individuals. It is partly sleep deprivation, partly autoimmune, partly injury-based, partly pain-provoked and partly "who knows what?" We really don't know what the heck it is. My talk tonight is to try to outline some of the treatments that we have come up with to treat it. Some work and some don't. Some of them work for most people but none work for all. Some work for a handful and not at all for others.

Our treatment, until about 2 years ago, hadn't changed since 1896. Yes, I really did mean 1896. 101 years ago. Back then, it consisted of medications (few), exercise, sleep, more exercise, manipulation, conditioning and muscle relaxers either chemical or electrical or heat and ice. Things haven't changed much even today except that our medicines have become better and they are directed at treating specific causes of the person's own personal FMS. By that I mean that we have to first figure out what provoked it in that person. Then we can treat whatever provoked it. If we try treating you with a muscle relaxer, but it wasn't tight muscles that provoked it... it won't work. If it was sleep deprivation that caused it and we fail to treat your sleep deprivation, then we missed the only thing that might work for you, personally.

We have to treat the INDIVIDUAL person, not the syndrome as though you are all alike. Each person has to be evaluated and treated as an individual... not as a textbook or a chart. Here's my usual set of treatments. Please bear in mind that this is NOT tailored to any one particular person, nor would it work for each person with FMS. You may find bits and pieces that will work for you and bits that won't.

Treat the sleep deprivation first with heavy duty sleepers to establish a sleep pattern. Once it is established, then it can be maintained with a mild sleeper like Doxepin. Doxepin, or its cousin Elavil, are both good sleepers but they have the added side effect of being able to modify pain as well! Not a bad side effect, huh? They are not pain killers, but they are pain modifiers. They can help to put a "lid" on pain to even out the peaks. They stimulate the brain to produce it's own natural pain killer called Beta endorphin. It's what gives a marathon runner his "runner's high."

I also like to treat the inflammation of the muscles with Azulphadine. It is a sulphur-based med that also has a non-sulphur based cousin available now. It is primarily used for people with colitis or irritable bowel. Since 60% of FMS patients also have irritable bowel syndrome, it is usually very helpful in treating two birds with one stone. Also, NSAIDS (glorified Motrin) are helpful but they can flare up the IBS if one is plagued with that too. Oxygen therapy is extremely helpful, too. This may be obtained in several different ways. Since MANY studies have shown that FMS patients have abnormally low concentrations of oxygen in the muscles, it is like that this plays a very big role in the development of FMS. We can improve oxygenation of the body through low-impact aerobic exercise, or water aerobics (probably the best) or through Tai-Chi or through medications that improve the oxygen carrying (absorbing) capacity of blood. Even transfusions to superpopulate you with red blood cells has been shown to be very helpful.

FMS is much more common in high altitudes, or in snorers (they don't breath right at night) and in people who are sedentary and do not exercise. If you happen to have a hyperbaric or decompression chamber in your basement, this has been shown to be very helpful, too. But aside from "Flipper" or "Seaquest", most do not have access to a chamber. Actually FMS is unheard of in SCUBA divers. They get water aerobics, concentrated oxygenation at depths, and they are always moving. I guess Michael Jackson also has his own chamber, too. There are many other meds that are useful for some people, but much less frequently.

For example, guifenessin (robitussin cough syrup) has been shown to play a very big role in preventing tolerance to opiate pain killers. (tolerance is like "immunity") As I said earlier, Doxepin or Elavil promotes the production of the brain's own natural opium called B-Endorphin. If someone has built up a resistance to his/her OWN B-E, it may only need to start taking small quantities to make ones self able to get benefit from our own natural opiate (pain killer). It's something to think about, but it is NOT a cure and it only works for a few people. Some people get benefit from medicines that restore blood flow to the brain like Amantadine. This is a med usually thought of for Parkinson's Disease or Multiple Sclerosis or trauma to the brain, but it is "almost harmless" and is often worth a try. Also, some blood pressure medicines work by dilating (enlarging) blood vessels and so this might be worth while to investigate. AVOID HEAT!!!!! It will make you worse. Sure, it increases blood flow to the area being he heated, but it also increases the metabolism and consumption of oxygen far beyond the ability to restore the oxygen to the muscle being heated. Too much cold does less damage than too much heat. Cold is almost never wrong. Mostly, sleep better, breath better, exercise better and try everything. One more thing... I have the name of a glorious book to give you... here it is: Fibromyalgia & Chronic MPS--A Survival Manual by Devin Starlanyl MD and Mary Ellen Copelan PRC (ISBN # 1-57224-046-6) New Harbinger Publications. $20.00
It's Great!

Juvenile Rheumatoid Arthritis

What is it?

In juvenile rheumatoid arthritis (JRA), as with adult rheumatoid arthritis, the lining of the joint is inflamed, and the joint itself becomes painful and stiff. If the inflammation is not relieved by medication, the joint can be damaged. Juvenile rheumatoid arthritis is an often painful and activity-limiting chronic disease. Overall, however, two-thirds of children with juvenile rheumatoid arthritis will reach adulthood without persisting arthritis or disability.

There are three types of juvenile rheumatoid arthritis, distinguished by their initial symptoms.

Systemic-onset arthritis usually includes fever and other whole-body (systemic) symptoms. Arthritis involving five or more joints at the time of diagnosis is called polyarticular-onset arthritis ("poly" means many and "articular" refers to joints). If one to four joints are involved, the condition is classified as pauciarticular-onset arthritis ("pauci" means few). These three categories are mainly useful for guiding therapy and suggesting what the long-term outcome is likely to be.

What are the symptoms?

The common symptom of all forms of juvenile rheumatoid arthritis is inflammation of the lining (synovia) of one or more joints. This inflammation is called synovitis. Affected joints are swollen, limited in motion, stiff, painful, and warm to the touch.

The course of the disease is unpredictable in all types of juvenile arthritis but most often follows a variable course with alternating periods of mild and worsening symptoms. During disease flares, there may be increased inflammation, an increase in the number of joints affected, or both.

Systemic-onset arthritis affects about 10-20 percent of all children with juvenile rheumatoid arthritis and may strike at any age in childhood or adolescence. Slightly more boys than girls have systemic-onset arthritis. The characteristic symptoms of this type of juvenile arthritis are high spiking fevers and a salmon-pink rash (usually over joints, palms, and soles) that may come and go with the fevers. Initially, joint involvement may range from none to many severely affected joints.

The great majority of children will develop arthritis by the end of their first year of illness. About two-thirds of patients will have enlargement of the spleen or liver. Some patients will have chest pain or discomfort with breathing due to inflammation of the membranes surrounding the heart and lungs. The fever and other non-joint symptoms generally continue for several months, usually not more than six. There may be repeat episodes of this fever, but these symptoms rarely recur in adulthood.

About 25 percent of children who have systemic-onset disease develop chronic arthritis that continues after the other symptoms have resolved. Polyarticular-onset arthritis is defined as arthritis affecting five or more joints at the time of onset. It accounts for more than one-third of all cases of juvenile arthritis. It affects girls more often than boys and can occur at any time in childhood. The child may have a low-grade fever, fatigue, mild loss of appetite, and early morning stiffness. The number of involved joints may increase over time. Usually involvement is symmetrical -- the same joint on both sides of the body -- and the small joints of the hands and feet are most commonly affected. If the knee is also involved, there is the chance of permanent joint damage. The jaw is sometimes affected, creating difficulties in eating unless effective treatment is provided.

Pauciarticular-onset arthritis is defined as arthritis affecting one to four joints at the time of the earliest symptoms. It accounts for up to 50 percent of all children with juvenile rheumatoid arthritis. Most often it strikes girls in early childhood, before age four. The first symptoms may be subtle, for example, refusal to walk in the morning, increased fatigue, or a return to crawling. The joint most often involved at outset is the knee, which may be swollen but not painful. Aside from the arthritis, there are few other symptoms for this form of juvenile rheumatoid arthritis. However, nearly one-third of these children will develop inflammation within the eye at some point during the first ten years of disease. Frequent eye checkups are essential for early detection and prevention of damage to the eye.

Another form of pauciarticular-onset arthritis tends to strike boys in later childhood. These children will tend to have arthritis in the lower limbs and they may also have painful swelling of the Achilles tendon that connects the calf muscle to the heel. About 80 percent of all children with pauciarticular arthritis will have no symptoms or limitations by adulthood, but 20 percent will eventually develop arthritis in multiple joints.

Risk factors: Who gets it, and why?

There are no diagnostic tests for juvenile rheumatoid arthritis. Tests are done mostly to rule out other possible causes of joint inflammation, such as leukemia or infection.

For example, the joint fluid is sampled and cultured to detect septic (infectious) arthritis if present. X-rays help in ruling out the possibility of leukemia.

Two laboratory tests help to identify the specific type of arthritis present and the likelihood for complications or progressive arthritis: the tests for rheumatoid factor (RF) and antinuclear antibodies (ANA). Children with pauciarticular arthritis who test positive for ANA are at the greatest risk for eye inflammation and so require more frequent eye checkups. Children who are positive for RF are likely to develop more severe arthritis. How is it treated?

Early diagnosis, well-tolerated anti-inflammatory drugs, physical therapy, and psychological support offer the majority of affected children the ability to attend regular schools, enjoy most of the normal childhood activities, and -- most importantly -- go on to adulthood with little or no lasting disability.

Medications

Nonsteroidal anti-inflammatory drugs (NSAIDs) remain the first choice for treatment of juvenile rheumatoid arthritis. NSAIDs approved for children are naproxen (Aleve, Naprosyn), tolmetin (Tolectin), and ibuprofen (Advil, Motrin). Indomethacin (Indocin) is also frequently used in children with arthritis.

In formal studies, no one NSAID was clearly superior to others for the treatment of juvenile rheumatoid arthritis. In these studies, about half of children who will have a good response to an NSAID get relief by week two of treatment, but some 25 percent may require 12 weeks of continued treatment before improvement is noted. If the first NSAID tried is not effective, about half of patients will improve on a different NSAID. All of the NSAIDs can irritate the stomach and potentially cause ulcers.

Fortunately, this side effect appears to be much less common in children compared to adults. With prolonged use, NSAIDs may cause problems with kidney and liver functioning, and monitoring is needed to detect these complications early on.

Naproxen in particular can produce a facial rash, especially in fair-skinned children, and the doctor should be promptly notified if this occurs.

Methotrexate, taken by tablet or injection, is the medication most often used for severe juvenile arthritis or for arthritis that has not responded to NSAIDs. Low doses appear to have few serious side effects for children, even after treatment periods of up to five years. Mouth sores are a common side effect of methotrexate, but these can be avoided or minimized by daily folic acid supplements.

Sulfasalazine (Azulfidine) and hydroxychloroquine (Plaquenil), two drugs used for adult rheumatoid arthritis, are also being used in children, alone, in combination, or with methotrexate. Injection of steroids -- usually triamcinolone (Aristospan) -- directly into inflamed joints can be very beneficial for children with arthritis limited to a few joints, particularly when NSAIDs have failed to give satisfactory results.

Oral or injectable steroids are sometimes used for managing flares but are problematic to use on a continued basis. The side effects of chronic steroid use in children include growth retardation and osteoporosis.

Tricyclic antidepressants can help lessen pain regardless of whether the person is depressed or not. Low-dose amitriptyline (Elavil, Etrafon) is sometimes prescribed for this purpose in children, and it may also help promote sleep when given at night.

Non-drug management and lifestyle issues

Children with arthritis should be encouraged to stay as active as possible and to participate in as many of the normal activities of childhood as they reasonably can take on. Activities such as swimming and tricycle or bicycle riding promote strength and a sense of well-being.

If children complain of morning stiffness, a hot morning bath to warm and loosen joints can be beneficial. Children who have difficulty sleeping may be made more comfortable by a waterbed or by wearing sweat clothes or very warm pajamas. Simply being physically active is not enough.

Physical therapy and occupational therapy are extremely important to preventing long-term impairment. Although it can be difficult for parents to be therapists to their own children, following a daily program of prescribed active and passive stretching exercises is essential to maintaining or recovering joint range of motion and muscle strength. Some children may need daily or near-daily sessions with a physical therapist.

Unless an appropriate physical therapy program is followed, children may lose the ability to extend severely affected joints -- producing a frozen joint or fixed contracture, which can be very difficult to treat. Occupational therapy is aimed at helping children maintain age-appropriate activities of daily living, using special devices as needed to assist with activities such as dressing or writing and also splints to correct or prevent deformities and contractures. Resting splints for wrists, knees, or ankles can help maintain good joint positioning and avoid pain with movement during the night. Working splints for an arthritic wrist can provide support for writing and other hand use.

Children with arthritis must deal with many stresses that can affect their well-being and sense of self-worth, including physical disability, dependency on parents and siblings, isolation from other children, uncertainty about the future, and the hassle of complying with complex treatment programs. They may also have to deal with some degree of occasional or even daily pain, despite use of daily medications.

To help in managing stress and pain, even quite young children can benefit from being trained in relaxation exercises, guided imagery, biofeedback, and cognitive-behavioral therapy -- all techniques frequently used to help adults with arthritis improve their coping skills and pain tolerance. Relaxation exercises and guided imagery (which uses calming mental images to relax and distract) may be particularly useful in helping children get to sleep.

Children can be trained in biofeedback and cognitive-behavioral coping skills by a psychologist experienced in working with children who have painful conditions. Through biofeedback, children learn to relax their muscles and relieve physical tension, which can improve mood and pain perception. Cognitive-behavioral therapy can help children who feel helpless and dependent to develop more positive ways of viewing and dealing with pain and disability.

Surgery

Orthopedic surgery can help children who have suffered deformity or loss of joint function as a result of severe arthritis. A relatively simple surgery can be performed to relieve contractures (frozen joints) that have not responded to splinting or casting.

For the very small number of children who have had progressive joint destruction over the course of their disease, total joint replacements can be performed once they have reached reasonably full growth. Arthritis in one knee will sometimes result in temporary leg length inequality that can usually be managed by a shoe lift, but surgery can be performed if the discrepancy persists.

Research

Children with arthritis will also benefit from the intensive research now being done in adult rheumatoid arthritis. New biological agents (as opposed to pharmaceuticals or chemicals) are being developed to block the inflammatory process. New treatments currently under investigation target molecules called cytokines that are known to be involved in the inflammatory process of the disease.

As the mechanisms causing juvenile rheumatoid arthritis become better understood, it may be possible to provide early treatment to block the disease process, minimizing the pain and disability suffered by the youngest arthritis patients.

Osteoarthritis

What is it?

Osteoarthritis is the most common type of arthritis, affecting an estimated 16 to 20 million adults in the United States. It is a slowly progressive disorder in which the cartilage that lines and cushions the joint gradually deteriorates. Eventually the bone underlying the cartilage is also weakened. New bone forms in abnormal locations at the margins and surface of the joint, often impairing joint function.

Osteoarthritis can be painful and very disabling, but it is not inevitably so. Often there is little or no pain and disability, even when joint damage is extensive. Good self-care can go a long way in easing symptoms and reducing reliance on pain medications.

What are the symptoms?

Pain associated with using a joint is often the earliest symptom of osteoarthritis. There may also be joint stiffness in the morning or after any long periods of inactivity. Usually this stiffness goes away within a few minutes when the joint is used. Pain can also be increased by prolonged joint use and can be relieved by rest. Gelling -- a stiffness that is relieved by flexing the joint a few times -- is particularly common with osteoarthritis of the hip or knee. Crepitus -- a crackling or grating sound -- may be noticed when the joint is moved.

Muscle spasms and reduction in joint motion can develop as the disease progresses. Bony growths (osteophytes) and loose bone fragments within the joint can also interfere with normal joint use. Flares -- inflammation and a sudden worsening of pain -- can occur if crystals form in the joint fluid (synovitis).

Risk factors: Who gets it and why?

If you live long enough, you will likely have some degree of osteoarthritis. Roughly two-thirds of people in their 60s and 70s have osteoarthritis of the knee. Up to age 50, men are more prone to osteoarthritis than women, but after age 50, women are more likely to have osteoarthritis, often generalized arthritis affecting many different joints.

Osteoarthritis occurs most commonly in the hands, feet, knees, and hips, in that order. Multiple joint involvement is much more common in women, while osteoarthritis of hips, wrist, and spine is more frequent in men.

Generalized osteoarthritis, which includes bony enlargement of finger joints in addition to other joint involvement, tends to run in families. The enlarged joints so commonly seen in the hands of middle-aged or elderly women are called Heberden's nodes.

Osteoarthritis increases with age because of changes in the bones and joints that occur with aging. Cartilage is 80 percent water and this water is lost with aging. Aging cartilage is more vulnerable to injury and less able to repair or rebuild after injury. The ligaments supporting joints are weakened so that the joint is less stable and more easily injured.

Severe injury to the joint or repetitive joint overuse are possible underlying factors in the development of osteoarthritis. In one study, osteoarthritis of the knee was more common in people whose occupations involved heavy labor. Some sports, such as soccer, appear to increase risk, at least at the professional or elite athlete levels. There is no evidence that recreational jogging increases risk, and good overall fitness is probably protective.

Population studies have revealed obesity to be the single most important risk factor and also the most preventable. Abnormalities in joints or bones present from birth, gout, diabetes, and hormonal disorders are other potential risk factors for the development of osteoarthritis.

How is it diagnosed?

Diagnosis of osteoarthritis is based on clinical examination, supplemented by x-rays (radiographs) to assess the extent of joint damage. X-rays of affected joints will reveal joint space narrowing and the presence of bony growths (osteophytes) in the joint. These signs are generally considered to be the most reliable indicators of disease severity and progression. However, the joint damage shown on x-ray is not always linked to the severity of symptoms. Only 40 percent of people with severe osteoarthritis as seen on x-rays actually have significant discomfort and pain.

How is it treated?

Lifestyle issues

:Protect Joints: Good self-care generally involves protecting the painful joints, for example, using a cane or walker if necessary for severe osteoarthritis. For many people with osteoarthritis of the hip or knee, the most important step in protecting the joint is to lose weight. Weight increases the amount of force on a weight-bearing joint, which can accelerate cartilage breakdown. In one major study of osteoarthritis risk factors, a weight loss of roughly 11 pounds cut the risk of developing symptomatic knee osteoarthritis by 50 percent for women of average height.

Exercise: Protecting the joint doesn't mean avoiding use of it. In fact, prolonged immobilization results in further deterioration of the joint cartilage. While sports or activities that stress or overuse the affected joints should be avoided, an appropriate exercise program consisting of fitness walking, swimming, bicycling, or other low-impact activities can be extremely helpful in improving muscle strength, mobility, and general well-being. Improving muscle strength may help to stabilize a joint and to distribute weight-bearing more evenly across the joint, again reducing the risk of further joint injury. Exercise is important because older people with osteoarthritis tend to reduce their activity level, leading to loss of strength and mobility in other joints. For example, people with osteoarthritis of the knee commonly show a reduction in motion and strength in the ankle, which is rarely a site of osteoarthritis. Once ankle conditioning is reduced, the individual will begin to lose the strength and balance needed for normal walking, stair climbing, and getting up from a chair.

Apply heat and cold: Applications of either heat or cold can soothe aching or swollen joints. For swelling or pain due to inflammation, cold packs are more likely to help. Heat applications can be good for relieving joint stiffness. Otherwise, there is no clear advantage of one treatment over another, and the use of heat, cold, or alternating heat and cold is based on the individual's preference. Cold can be applied in the form of cold packs or vapocoolant sprays, and hot packs, warm baths, and radiant heat all make good at-home heat treatments. Avoid applying hot or cold treatments to open wounds or sensitive areas of the body and do not leave the packs in place for more than 20 minutes. Some types of hot and cold packs should not be applied to bare skin, so follow directions in using these products to avoid tissue damage.

Vitamin supplements and nutraceuticals

Vitamins: Some evidence suggests that optimal intake of the antioxidant vitamins A, C, D, and E may help treat or prevent osteoarthritis. Vitamin C is required for synthesis of collagen, a major component of cartilage. Vitamins D and A are both essential for healthy bones. Oxygen free radicals are believed to contribute to deterioration of cartilage in inflamed arthritic joints, so these antioxidant vitamins may have protective effects in slowing progression of the disease. Since the evidence supporting a role for vitamins and other antioxidants is based on laboratory studies and not clinical trials involving patients, significant proof that taking vitamin supplements will have an impact on osteoarthritis is lacking. However, a diet that emphasizes whole foods rich in these vitamins has multiple health benefits, including improved weight control. Good sources for these vitamins include:

Vitamin C: Citrus fruits and juices, strawberries, red bell peppers, broccoli
Vitamin D: Milk, eggs, liver, tuna, salmon
Vitamin A: Milk, eggs, liver, fish, carrots, broccoli, cantaloupe, tomatoes
Vitamin E: Nuts, vegetable oils, wheat germ, leafy greens

Nutriceuticals: Over the last few years, two "nutriceuticals," glucosamine and chondroitin, both derived from animal products, have become extremely popular as treatments and even as "cures" for osteoarthritis. A number of small studies have documented good results with these two nutriceuticals, taken alone or in combination. However, most of these studies were sponsored by manufacturers of these nutriceuticals, and some experts express skepticism about the degree of improvement achievable with these products.

Glucosamine is a natural component found in most body tissues, including cartilage.

Chondroitin is an extract prepared from the cartilage of cattle. Both glucosamine and chondroitin may take several weeks to produce any benefits. Taken orally as directed, these substances appear to be extremely safe. However, these nutriceuticals are often sold in combination formulas with other substances that have never been tested for safety. The most commonly used dosages are glucosamine 1500 mg and chondroitin sulfate 100 mg daily, for an average cost of $30-$45 per month.

As with other herbal and nutraceutical preparations, some commercial brands of glucosamine or chondroitin have been found to contain much less of the active ingredients than claimed on the label.

Collagen hydrolysate (or hydrolized collagen) is another nutriceutical promoted for the treatment of osteoarthritis. It is basically a form of gelatin (a food) and therefore is very safe, but there is little scientific evidence indicating that it is effective. It is now being formally studied as a treatment for arthritis.

Medications

The over-the-counter pain relievers available for short-term relief of arthritis pain are acetaminophen (Excedrin, Tylenol); aspirin (Bayer, Bufferin, Ecotrin); and the nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen (Advil, Motrin, Nuprin), naproxen sodium (Aleve), and ketoprofen (Actron, Orudis). Despite the fact that they are available without prescription, none of these medications are risk-free if taken for prolonged periods of time. If taken for prolonged periods of time, aspirin and the conventional NSAIDs can cause ulcers or potentially severe gastrointestinal bleeding. Acetaminophen is generally considered the safest option for long-term use. The elderly, in particular, should consult their doctor about the proper dosage before taking any over-the-counter medication on a daily or near-daily basis.

Topical capsaicin cream is another over-the-counter option that appears to be both safe and effective. Capsaicin is derived from capsicum, the substance that puts the "heat" into hot peppers. It is applied to the skin over the joint two to four times per day. When first used, it produces a stinging or burning in the skin where applied, but this goes away with continued use.

Two important new arthritis drugs became available in 1999: celecoxib (Celebrex) and rofecoxib (Vioxx). These are the first of new class of nonsteroidal anti-inflammatory drugs, the COX-2 inhibitors, that have proved to be relatively free of gastrointestinal side effects (ulcers and gastric bleeding) compared to the older NSAIDs. While safer than conventional NSAIDs, the COX-2 inhibitors are equivalent in efficacy and are considerably more expensive.

In addition to prescription-strength NSAIDs and the new COX-2 inhibitors, the less addictive narcotic analgesics, such as codeine and propoxyphene (Darvon, Wygesic), have also been prescribed on a short-term basis for relief of osteoarthritis in combination with acetaminophen or other nonnarcotic pain-relievers. It is also sometimes helpful to supplement pain-relievers with tricyclic antidepressants. These drugs have analgesic effects of their own and can improve pain relief even for people who are free from depression or other mood disturbances.

Corticosteroids and hyaluronate have both shown effectiveness when injected directly into the joint. Cortisone injections are useful for inflammation, but they can produce temporary synovitis or "flare" as a side effect. This flare usually resolves within a few hours and can be managed with cold compresses. Hyaluronate or hyaluronic acid derivatives injected into the joint are reported to reduce pain for extended periods of time (2-12 months) and to improve joint mobility.

Surgery

Surgery can be considered to relieve intractable pain or to restore joint function. Good to excellent long-term results are reported for more than 90 percent of patients undergoing total hip or knee replacement. Osteotomy (surgery to remove part of the bone) may decrease stress on the joint and serve as an alternative to arthroplasty (reconstructive joint surgery). However, only half of patients with knee osteotomy maintain satisfactory results ten years after surgery. Surgical arthroscopy is useful for repair or partial removal of damaged knee cartilage. Surgical abrasion of cartilage can stimulate partial cartilage repair. Joint lavage (irrigating or washing out the joint) can be used with good short-term results to remove loose bone fragments or other debris in the joint space.

Research

The Decade of the Bone and Joint

The first decade of the new millennium has been declared the "Decade of the Bone and Joint" in recognition of both the disability caused by joint diseases such as osteoarthritis and the promise of ongoing research in relieving or preventing that disability.

Objectives for the decade include: Raising awareness of the growing burden of bone and joint disorders on society Empowering patients to participate in decisions on their care Promoting cost-effective prevention and treatment Advancing understanding of bone and joint disorders through research to improve prevention and treatment Current osteoarthritis treatments, ranging from aspirin to COX-2 inhibitors, generally only relieve symptoms and have little impact on the course of the disease itself. Newer treatments currently under investigation offer the potential of modifying the course of the disease and preventing or slowing its progression.

Treatments now being investigated include: Tetracycline derivatives that inhibit the enzymes that degrade cartilage Pentosan polysulfate and other glycosaminoglycans

Growth factors (such as insulin-like growth factor I) and cytokines (such as TGF beta) Avocado/soy nonsaponifiables (a derivative of the oils), which may enhance cartilage synthesis and repair.

Psoriatic Arthritis

What is it?

Psoriatic arthritis is a type of inflammatory arthritis associated with psoriasis.

There are five types: Arthritis involving primarily the small joints closest to the ends of the fingers and toes. Arthritis involving joints of the extremities. Arthritis in many joints resembling rheumatoid arthritis. The arthritis is usually present in the same joints on both sides of the body. Arthritis mutilans, a rare but very deforming and destructive form of arthritis that erodes the bone. Arthritis of the spine and sacroiliac joint (psoriatic spondylitis). The sacroiliac is the joint between the lower back and the hip bones. The word psoriasis (pronounced so-RY-a-sis) comes from the Greek word for itching.

What causes it?

The cause is unknown, but genetic factors are important. As many as 40 percent of people with psoriatic arthritis have a family history of skin or joint disease.

Psoriatic arthritis facts In the United States, psoriatic arthritis is found in about ten percent of the three million people with psoriasis.

Psoriatic arthritis affects both men and women in equal numbers.

Diagnosis

Skin and nail changes characteristic of psoriasis must be present before a definitive diagnosis can be made. A blood test for the rheumatoid factor is negative in about 95 percent of patients with psoriatic arthritis. Some people with psoriatic arthritis may have an elevated erythrocyte sedimentation (SED) rate (a test indicating the presence of inflammation). Other people with psoriatic arthritis may have anemia or an elevated level of blood uric acid.

Medication and treatment

Treatment of psoriatic arthritis usually consists of nonsteroidal anti-inflammatory drugs (NSAIDs), but methotrexate can be used for psoriatic arthritis that does not respond to NSAIDs. Gold therapy and hydroxychloroquine (Plaquenil) can be beneficial for the arthritis, but may exacerbate the skin disease. Sulfasalazine (Azulfidine) has been found to be very beneficial for some patients.

Systemic corticosteroids are often used for psoriasis, but the patient should be closely monitored because of side effects and because tapering the dose can cause a flare of skin disease. Joint injections can be useful. If a patient suffers joint destruction despite aggressive medical therapy, surgery can be helpful.

Reiter's Syndrome

What is it?

Reiter's syndrome is named for the German physician Hans Conrad Julius Reiter (pronounced like "writer"). It is a form of arthritis characterized by an inflammation of the joints, eyes, and genital, urinary, or gastrointestional tract.

Reiter's syndrome is also called "reactive arthritis."

What causes it?

Some researchers think that it involves an immune system that is reacting to the presence of bacterial infections in the genital, urinary, or gastrointestinal systems.

Reiter's syndrome is thought to be partly genetic, and exposure to certain infections triggers the onset of the disease. Reiter's syndrome facts Reiter's syndrome is more common in young males, but it can affect females, in whom the disease is usually less severe.

Diagnosis

Reiter's syndrome is diagnosed based on the presence of arthritis symptoms and the presence of inflammation of the eyes, and the genital, urinary, or gastrointestinal systems. The rheumatoid factor is usually negative in Reiter's syndrome. The HLA-B27 genetic marker is commonly present.

Medication and treatment

Treatment of Reiter's syndrome is based on where the symptoms are in the body. For joint inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) are usually the method of treatment. Alternatively, corticosteroids such as prednisone can be helpful to reduce inflammation. In some patients with Reiter's syndrome and persistent arthritis, sulfasalazine (Azulfidine) has been shown to be effective. Methotrexate can also be used.

Eye inflammation can be treated with anti-inflammatory drops. Some patients with iritis -- severe inflammation of the colored part of the eye -- require local injections of cortisone to prevent eye damage that can lead to blindness. Inflammation around the penis can be helped by cortisone creams. If bacteria are present in the bowel or urine, antibiotics are used.

People with arthritis took their message to Washington, DC, on Arthritis Action Day to urge Congress to take immediate action to expand access to prescription drug coverage.

People from across the United States stand before a sample of the 30,000 letters and bottles that were collected as a part of the Arthritis Foundation's Message in a Bottle campaign, which called for increased access to medications for people on Medicare.

Access to Medications People often ask if they can really make a difference. THEY CAN.

You can prompt Congress to take action to ensure that people with arthritis have full access to necessary medications and other forms of treatment. Make your voice count.

Use the sample letter below (or create one of your own) and send a message to your representatives in Congress. We encourage you to add your personal stories about living with arthritis, too.

If you need to look up the addresses for your representatives in Washington, or if you would prefer to send an email message (you can highlight, copy and paste the sample letter into the email's text box or compose your own), please go to the Legislative Action Center.

Sample Letter

The Honorable_________________ United States Senate
Washington, DC 20510
Or The Honorable _________________ U.S. House of Representatives
Washington, DC 20515

Dear Senator/Representative:

I am writing to ask that you support passage of meaningful Medicare reforms to ensure that people living with arthritis have access to prescription drugs. Failure to act means that millions of Americans living with the pain and disability caused by arthritis will continue to be denied access to medications that can measurably improve their quality of life.

Innovative prescription drugs and biological therapies are playing an increasingly important role in the treatment of arthritis. While not cures, these new medications can help alleviate the pain, slow the progressive destruction of the disease, and prevent disability. Unfortunately, 35 percent of Medicare beneficiaries do not have access to prescription drug coverage and many others lack adequate coverage.

It is imperative that Congress takes action to expand access to prescription drug coverage for Medicare beneficiaries and ensure coverage for innovative, higher-cost therapies. By increasing access, we can improve the quality of life for people living with chronic diseases like arthritis and enable these individuals to live full, productive lives. Please do not let election year politics stand in the way of this important progress. Thank you for your time and consideration of my request.

Sincerely,

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