Sjögren's Syndrome

Sjögren's syndrome is a chronic disorder that causes insufficient moisture production in certain glands of the body. It occurs when a person's normally protective immune system attacks and destroys moisture-producing glands, including salivary glands and tear glands. The lungs, bowel and other organs are less often affected.

Sjögren's syndrome is named after the Swedish eye doctor, Henrik Sjögren, who first described the condition.

Sjögren's syndrome may cause the following symptoms:

• Extremely dry eyes causing a feeling of grit or sand in the eyes or a burning redness.
• Extremely dry mouth and throat causing difficulty with chewing and swallowing, decreased sense of taste, difficulty speaking, an increase in dental cavities, and dry cough or hoarseness.
• Enlarged parotid glands (located at the angle of jaw) and sometimes infection of the these glands.
• Excessive fatigue
• Aches and pains in muscles and joints

Less common features of Sjögren's syndrome are:

• Irritation of the nerves in the arms, hands, legs or feet (neuropathy).
• Thyroid gland abnormalities
• Skin rashes
• Memory loss or confusion.
• Numbness or tingling.
• Gastrointestinal problems.
• Inflammation of the lungs, kidneys, liver or pancreas.
• Cancer of the lymphatic tissue (lymphoma)occurs in less than 1% of patients.

What Causes Sjögren's Syndrome?

Normally, the immune system (the body's defense against invaders) protects the body from infection and foreign substances such as bacteria and viruses.

In autoimmune diseases, such as Sjögren's syndrome, the immune system triggers an inflammatory response when there are no foreign substances to fight off. This inflammatory response causes the body's white blood cells to attack and destroy certain moisture-producing glands.

The exact cause for the abnormal immune response in Sjögren's syndrome is unknown. Some theories suggest that a virus or bacteria may alter the immune system, causing it to attack the glands. Some people may have a genetic or inherited factor that makes them more likely to develop Sjogren's syndrome.

What Are the Forms of the Disease?

Sjogren's syndrome occurs in two basic forms: primary Sjögren's syndrome - the disease by itself and not associated with any other illness; and secondary Sjögren's syndrome - disease that develops in the presence of another autoimmune disease such as rheumatoid arthritis, lupus, or vasculitis.

As many as 4 million people in the U.S. have Sjögren's syndrome. More than 90% of these are women. The disease can affect people of any race or age, although the average age of onset is in the late 40s.

How Is Sjögren's Syndrome Diagnosed?

The diagnosis of primary Sjögren's syndrome is based on several factors, including:

• Presence of dry eyes and mouth. An ophthalmologist can detect dry eyes by measuring tear production or carefully examining the cornea of the eye.
• Certain laboratory tests also suggest that dry eyes and mouth are caused by autoimmune mechanisms. Examples include the presence of auto-antibodies in the blood, known as anti-SSA or anti-SSB (also called anti-Ro or anti-La).
• Biopsy of the inner lip (performed in some cases to prove the diagnosis of primary Sjögren's syndrome). The biopsy may show inflammation damaging salivary glands.

Secondary Sjögren's syndrome is generally diagnosed when someone with an established autoimmune disease, such as rheumatoid arthritis or lupus, develops extreme dryness of the eyes and mouth. This diagnosis only rarely requires a lip biopsy.

Can Other Problems Mimic Sjögren's Syndrome?

Sometimes, the use of certain medications can cause side effects that mimic the symptoms of Sjögren's syndrome. Medications such as tricyclic antidepressants (like Pamelor) and antihistamines like Benadryl, radiation treatments to the head and neck, as well as other autoimmune disorders, can also cause severely dry eyes and mouth.

How is Sjögren's Syndrome Treated?

There is no cure for Sjögren's syndrome, but it can be treated and controlled. The goals of treatment are to decrease discomfort and reduce the harmful effects of dryness. The type of treatment prescribed will be tailored to each patient's symptoms and needs. The following are some of the main methods of treatment for Sjögren's syndrome.

• Good oral hygiene. Good mouth care may not prevent a dry mouth, but it helps prevent infection. Toothpastes and oral gels are available for people with dry mouth symptoms. These products contain low doses of peroxide. (High amounts can cause more severe dryness.) These products also may have antibacterial action to reduce the severity of dental cavities over a long period of time.

• Increasing eye moisture. Dry eyes are mainly treated with the use of artificial tears, and a wide variety of products are available. Artificial tears must be used regularly and more often in dry environmental conditions such as on airplanes, in air-conditioned buildings and on windy days.

  While artificial tears are helpful, they often do not last long enough. Thicker preparations are available that last longer. These often are used at bedtime because they sometimes cause blurry vision. Eye drops containing cyclosporine (Restasis) treat inflammation in the glands around the eyes and may help to increase tear production. Surgery to slow the disappearance of tears by blocking or sealing the tear ducts is another treatment option for more severe cases.

  Surgery to slow the disappearance of tears is another treatment option when artificial tears are not sufficient.

• Medications. Medications that tend to deplete body fluids should be avoided. Mild pain-relieving medications including acetaminophen (Tylenol) or Motrin or Aleve can reduce muscle or joint pain. Two prescription medications, Salagen and Evoxac, stimulate saliva production and may relieve the dry mouth symptoms.

  In some patients, the anti-rheumatic drug Plaquenil has been beneficial in decreasing pain and salivary gland swelling.

  For patients with generalized symptoms, particularly when the disease affects internal organs (including the gastrointestinal system, kidneys or brain or spinal cord), high doses of immunosuppressive medications may be necessary. These include medicines such as prednisone (a steroid) and, rarely, chemotherapy-type medications.

• Balance rest and exercise. Guided exercise programs can help patients overcome fatigue, maintain flexibility, and overcome joint and muscle pain.

Polymyalgia Rheumatica and Temporal Arteritis

Polymyalgia rheumatica is a rare, inflammatory condition that causes pain or aching in the large muscle groups, especially around the shoulders and hips. Polymyalgia literally means "many muscle pains." Rheumatica means "changing" or "in flux."

What Are the Symptoms of Polymyalgia Rheumatica?

Symptoms tend to develop quickly and in addition to muscle pain, other symptoms may include the following:

• Stiffness, especially in the morning and after resting
• Weakness
• Fatigue
• Generally feeling ill
• Mild fevers (occasionally)
• Weight loss

What Is Temporal Arteritis?

About 15% of people with polymyalgia rheumatica also have temporal arteritis and about half of people with temporal arteritis also have polymyalgia rheumatica. Temporal arteritis causes inflammation that damages large and medium-sized arteries. The name of the condition stems from the fact that some of the affected arteries provide blood to the head, including the temples. Temporal arteritis is also known as "giant cell arteritis."

What Are the Symptoms of Temporal Arteritis?

Temporal arteritis has several symptoms, including:

• Severe headaches are the most common symptom.
• Scalp tenderness.
• Jaw or facial soreness, especially with chewing.
• Vision changes or distorted vision caused by decreased blood flow.
• Stroke may occur in less than 5% of patients and is caused by decreased blood flow.
• The large blood vessels may become narrowed or enlarged (aneurysm). If narrowing occurs in the blood vessels leading to the arms or legs, patients may notice fatigue or aching in the limbs, due to a reduced blood supply. Your doctor may notice weak or absent pulses.
• Other symptoms may include fever, weight loss, night sweats, depression, fatigue and a general feeling of being ill.

Who Is Affected By Polymyalgia Rheumatica and Temporal Arteritis?

Polymyalgia rheumatica and temporal arteritis frequently affect the same types of people. People over 50 years old are most often affected. The average age of patients is 70. These diseases are more common among women, and Caucasians are more likely to get these diseases than other ethnic groups.

The exact cause of these illnesses is unknown.

How Are Polymyalgia Rheumatica and Temporal Arteritis Diagnosed?

If a doctor suspects polymyalgia rheumatica after hearing a patient's symptoms and the examination, then blood tests will likely be done to help confirm the diagnosis. The blood tests will help test for inflammation as well as help rule out other possible causes of the symptoms, such as rheumatoid arthritis or an underactive thyroid.

Everyone with polymyalgia rheumatica is also tested for temporal arteritis. This, too, would start with the examination and listening to the patient's symptoms.

If temporal arteritis is suspected, but less convincing features are present, a temporal artery biopsy may confirm the diagnosis. The biopsy is taken from a part of the artery located in the hairline, in front of the ear. In most cases the biopsy is helpful, but in some individuals it may be negative or normal, even though the person does have temporal arteritis.

Can Other Problems Be Confused With Polymyalgia Rheumatica?

Yes. Some other illnesses that may be confused with polymyalgia rheumatica include:

• Rheumatoid arthritis
• Infections
• Inflammation of blood vessels (vasculitis)
• Chemical and hormone abnormalities
• A variety of muscle diseases
• Cancer

How Are Polymyalgia Rheumatica and Temporal Arteritis Treated?

There is no known cure for polymyalgia rheumatica and temporal arteritis, but these diseases can be treated and controlled. Corticosteroids -- often called "steroids" -- help rapidly relieve the symptoms of both polymyalgia rheumatica and temporal arteritis.

Treatment with steroids -- usually in the form of prednisone -- is mandatory for temporal arteritis to prevent serious complications, such as blindness. Low doses of steroids are often successful in treating polymyalgia rheumatica. Higher doses are often required to treat temporal arteritis.

The excellent response to treatment is so uniform that the lack of dramatic improvement, within days, would make the diagnosis of temporal arteritis or polymyalgia rheumatica doubtful.

Steroids reduce the function of inflammatory cells that cause these illnesses. Consequently, steroids minimize tissue damage. Steroids also reduce the normal activity of the immune system -- thus increasing the risk of infection.

The decision to prescribe steroids is always made on an individual basis. Your doctor will consider your age, presence of other illnesses and medications you are taking. Your doctor also will make sure you understand the potential benefits and risks of steroids before you start taking them.

You will have frequent blood tests while taking steroids to monitor possible side effects and to evaluate the effectiveness of therapy. These blood tests can usually detect problems before you are aware of any symptoms. Your doctor will frequently evaluate your heart and lung function and blood sugar level, which may increase after you start taking steroids.

While taking steroids, it is important to keep all appointments with your doctor and the laboratory, and have your blood pressure checked regularly.

Because steroids increase your chance for developing infections, report symptoms such as a cough, fever or shortness of breath to your doctor.

Long-term steroid treatment (for a few months to several years) requires additional testing and monitoring. Long term use of steroids can cause osteoporosis (bone loss). Taking supplements of calcium and vitamin D, sometimes along with prescription medication is recommended to prevent osteoporosis. Discuss the potential side effects caused by long-term steroid therapy with your doctor.

What Is the Long-term Outlook?

With careful monitoring and appropriate treatment, most patients with polymyalgia rheumatica or temporal arteritis have a normal life span and lifestyle. The success of treatment is related to prompt diagnosis, aggressive treatment and careful follow-up to prevent or minimize side effects from the medications.

Fibromyalgia

Fibromyalgia is a condition characterized by aching and pain in muscles, tendons and joints all over the body, but especially along the spine. The body also is tender to touch in specific areas-called tender or trigger points.

Fibromyalgia is not associated with muscle, nerve or joint injury; inadequate muscle repair; or any serious bodily damage or disease. Also, people who have fibromyalgia are not at greater risk for any other musculoskeletal disease.

What Causes Fibromyalgia?

Researchers have not been able to pinpoint one identifiable cause for fibromyalgia, but there are many theories. One theory suggests that stress contributes to the onset of fibromyalgia. Other possible causes are:

• Disordered sleep patterns, which can lead to fatigue and a lower pain tolerance.
• Abnormal production of pain-related chemicals in the nervous system.
• Low levels of growth hormone in the body.

What Are the Symptoms of Fibromyalgia?

Bodily pain is the primary symptom of fibromyalgia. Although the pain of fibromyalgia can be felt all over the body, there usually are certain areas of the body that are tender even to light touch. In addition, the pain is usually worse when a person is trying to relax and is less noticeable during busy activities or exercise.

Other symptoms often are associated with the pain, including:

• Sleep disturbance
• Depression
• Daytime tiredness
• Headaches
• Alternating diarrhea and constipation
• Numbness and tingling in the hands and feet
• Feelings of weakness
• Memory difficulties
• Dizziness

Stress often makes the symptoms of fibromyalgia worse.

Who Gets Fibromyalgia?

Women are affected by fibromyalgia seven times more commonly than men. People typically first develop symptoms in their 20s or 30s. In the U.S., about 5 million people, or 2% of the population, have fibromyalgia.

How Is Fibromyalgia Diagnosed?

The diagnosis of fibromyalgia is based on the results of a combination of tests and symptoms, including:

• Complete medical history and physical exam (to exclude other illnesses that may have similar symptoms such as rheumatoid arthritis, muscle inflammation, bursitis or tendonitis).
• Presence of widespread pain together with some of the other symptoms of fibromyalgia.
• Presence of very tender areas ("tender/trigger points") at specific locations. (People who have fibromyalgia experience abnormal sensitivity when light pressure is applied to at least 11 out of 18 specific areas on the body.)

How Is Fibromyalgia Treated?

People with fibromyalgia receive individual treatment based on several factors, including their overall health, medical history, number of tender points, severity of pain and presence of other symptoms. Treatment for fibromyalgia includes:

• Medications that decrease pain and improve sleep (see below)
• Lifestyle changes, including stress reduction
• Exercise to improve heart and lung health, flexibility, and strength
• Relaxation techniques to relieve muscle tension.

What Medications Are Used to Treat Fibromyalgia?

Medications that increase restful sleep may help. These include low doses of antidepressant medication taken before bedtime. Other kinds of sleeping pills are not very helpful for people who have fibromyalgia.

Nonsteroidal anti-inflammatory drugs (NSAIDs) -- including ibuprofen and naproxen -- may help decrease pain, but should be used long-term only under the care of a doctor. These drugs have many side effects, such as stomach upset and swelling from fluid retention. They also may interact unfavorably with other drugs, such as medications for high blood pressure. Tylenol (acetaminophen) may be helpful, and it is easier on the stomach and less likely to cause drug interactions than NSAIDs. However, acetaminophen should only be taken as recommended. Too much acetaminophen can lead to liver problems.

Muscle relaxants, such as Flexeril, may provide some relief of muscle pain when taken at bedtime.

Steroids (such as prednisone) used to treat inflammation associated with other rheumatic conditions have been tested in people with fibromyalgia and did not appear to improve symptoms. However, a steroid injection directly into a muscle spasm may sometimes be used when other treatments have failed.

What Exercises Should People With Fibromyalgia Consider?

Participating in aerobic exercise for 30 minutes at least four times each week is an important step to improve fibromyalgia symptoms. Exercise increases heart and lung function and stretches tight, sore muscles. Brisk walking, biking, swimming and water aerobics are good activities to choose when starting your exercise program. Your doctor can help you choose an exercise program that is right for you.

What Are Some Techniques I Can Use to Reduce Stress and Relax?

Evaluating the causes of stress and learning new ways to handle stress should help improve fibromyalgia. Relaxation exercises can help you cope with stress.

What Is the Long-Term Outlook for People With Fibromyalgia?

Although fibromyalgia is not caused by stress, stress can make symptoms much worse. Occasionally, if the situations that caused the initial stress are resolved, the condition may spontaneously improve and medications may not be necessary.

Many people with fibromyalgia will continue to have symptoms despite treatment, especially when life is stressful. However, medications that can alter the balance of pain-producing chemicals, such as anti-depressant drugs, should improve symptoms.

When other forms of treatment, such as acetaminophen (Tylenol) and aerobic exercise, are combined to treat fibromyalgia, even more improvement can be expected.

Those who are able to continue working and fulfilling their social obligations, despite their pain, end up doing best.

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome

The carpal tunnel is the passageway in the wrist and is made up of the arching carpal bones (eight bones in the wrist) and the ligament connecting the pillars of the arch (the transverse carpal ligament). The median nerve and the tendons that connect the fingers to the muscles of the forearm pass through the tightly spaced tunnel.

Carpal tunnel syndrome occurs when the median nerve becomes pinched due to swelling of the nerve or tendons or both. The median nerve provides sensation to the palm side of the thumb, index, middle fingers, as well as the inside half of the ring finger and muscle power to the thumb. When this nerve becomes pinched, numbness, tingling and sometimes pain of the affected fingers and hand may occur and radiate into the forearm.

While there are many possible causes of carpal tunnel syndrome, the vast majority of people with the condition have no known cause.

However, we do know that excessive repetitive movements of the arms, wrists or hands can aggravate the carpal tunnel bringing out the symptoms of carpal tunnel syndrome. Untreated, this can become chronic, but when detected early, carpal tunnel syndrome can be treated and recovery is possible in a few months. Severe carpal tunnel syndrome can also be treated, but recovery may take up to a year or longer and may not be complete.

What Are the Symptoms of Carpal Tunnel Syndrome?

Usually, people with carpal tunnel syndrome first notice that their fingers "fall asleep" and become numb at night. They often wake up with numbness and tingling in their hands. The feeling of burning pain and numbness may generally run up the center of the person's forearm, sometimes as far as the shoulder. As carpal tunnel syndrome becomes more severe, symptoms are noticed during the day.

What Happens in Severe Cases of Carpal Tunnel Syndrome?

When chronic irritation occurs around the median nerve, it becomes constricted and is continually pushed against the ligament above it. When the nerve is continually constricted, it can become compressed to the point that it begins to deteriorate. This results in a slowing of nerve impulses, which may cause a loss of feeling in the fingers and a loss of strength and coordination at the base of the thumb. If the condition is not treated, it could result in permanent deterioration of muscle tissue.

Do Certain Medical Conditions Make People More Likely to Develop Carpal Tunnel Syndrome?

People with rheumatoid arthritis, diabetes or other metabolic conditions like thyroid disease may be more likely to develop carpal tunnel syndrome. These conditions affect the nerves directly, making them more vulnerable to compression.

What Tests Help Diagnose Carpal Tunnel Syndrome?

Two useful clinical tests for diagnosing carpal tunnel syndrome are the Tinel and Phalen maneuvers. Tingling sensations in the fingers caused by tapping on the palm side of the wrist is a positive Tinel test, whereas reproduction of symptoms by flexing the wrist is a positive Phalen test. (Dr. Phalen created this maneuver many years ago when he was a hand surgeon at The Cleveland Clinic.)

If needed, an electromyogram, which includes nerve conduction studies, is done to document the extent of nerve damage. An electromyogram is a test that measures the electrical activity in your nerves and muscles. Nerve conduction studies measure the ability of specific nerves to transmit electrical impulses or messages.

The nerve conduction studies, however, will not become positive until there is significant nerve damage. In addition, the severity of a person's symptoms is often not correlated with the findings of a nerve conduction study.

How Is Carpal Tunnel Syndrome Treated?

There are several ways to treat carpal tunnel syndrome:

• Lifestyle changes. Treatment first involves adjusting the way the person performs a repetitive motion: Changing the frequency with which the person performs the motion and increasing the amount of rest time between movements.
• Immobilization. Treatment also includes immobilizing the wrist in a splint to minimize or prevent pressure on the nerves. Splints that support the wrist in a comfortable neutral position can be of great value if worn at night to relieve painful numbness or tingling. This can provide a restful sleep and allow the median nerve to endure daytime activities.
• Medication. Patients may be given short courses of anti-inflammatory drugs or injections of cortisone (steroids) in their wrist to reduce swelling. Injections are most successful when people have mild to moderate carpal tunnel syndrome as a result of an acute (sharp or severe) flare-up.
• Surgery. If carpal tunnel syndrome does not respond to conservative treatment, then surgery is the next treatment option. During surgery, your surgeon will open the carpal tunnel and cut the ligament, relieving the pressure. Carpal tunnel surgery is quite effective at relieving painful symptoms when the condition involves only nerve constriction.

When carpal tunnel syndrome is just one manifestation of repetitive stress, the surgery cannot be expected to relieve symptoms that are not attributable to carpal tunnel syndrome. The difficulty is not in recovering from the operation, but in recovering the ability to return to work, especially to the same job that caused the repetitive disorder to occur. Whether or not true carpal tunnel symptoms recur in these patients, many continue to have pain and are unable to use their hands to any great extent.

What Can I Do To Prevent Carpal Tunnel Syndrome?

To help prevent carpal tunnel syndrome:

• Sleep with your wrists straight or use a splint.
• Keep your wrists straight when using tools but try not to use splints.
• Avoid flexing and extending your wrists repeatedly.
• Perform conditioning and stretching exercises.

Ankylosing Spondylitis

Ankylosing spondylitis is a type of arthritis that affects the spine. Spondylitis may cause pain and stiffness from the neck down to the lower back. The bones of the spine, called vertebrae, may grow or fuse together, resulting in a rigid spine. These changes may be mild or severe, and may lead to a stooped-over posture. Early diagnosis and treatment helps control pain and stiffness and may reduce or prevent significant deformity.

Who Is Affected by Ankylosing Spondylitis?

Spondylitis affects about 0.1 to 0.5% of the adult population. Although it can occur at any age, spondylitis most often affects men in their 20s and 30s. It is less common and generally milder in women and most common in Native Americans.

 

What Are the Symptoms of Ankylosing Spondylitis?

The most common early symptoms of spondylitis include:

• Pain and stiffness. Constant pain and stiffness in the low back, buttocks and hips that continue for more than three months. Spondylitis often starts around the sacroiliac joints, where the sacrum (the lowest major part of the spine) joins the ilium bone of the pelvis in the lower back region.
• Bony fusion. Ankylosing spondylitis can cause an overgrowth of the bones, which may lead to abnormal joining of bones, called "bony fusion." Fusion affecting bones of the neck, back or hips may impair a person's ability to perform routine activities. Fusion of the ribs to the spine or breastbone may limit a person's ability to expand his or her chest when taking a deep breath.
• Pain in ligaments and tendons. Spondylitis also may affect some of the ligaments and tendons that attach to bones. Tendonitis (inflammation of the tendon) may cause pain and stiffness in the area behind or beneath the heel, such as the Achilles tendon at the back of the ankle.

Ankylosing spondylitis is a systemic disease, which means symptoms may not be limited to the joints. People with the condition also may have fever, fatigue and loss of appetite. Eye inflammation (redness and pain) occurs in some people with spondylitis. In rare cases, lung and heart problems also may develop.

What Causes Ankylosing Spondylitis?

Although the cause of spondylitis is unknown, there is a strong genetic or family link. Most, but not all, people with spondylitis carry a gene called HLA-B27. Although people carrying this gene are more likely to develop spondylitis, more than 75% of these people never develop the disease.

How Is Ankylosing Spondylitis Diagnosed?

The diagnosis of spondylitis is based on several factors, including:

• Symptoms
• Findings on physical examination
• X-rays of the back and pelvis

How Is Ankylosing Spondylitis Treated?

There is no cure for spondylitis, but there are treatments that can reduce discomfort and improve function. The goals of treatment are to reduce pain and stiffness, maintain a good posture, prevent deformity and preserve the ability to perform normal activities. When properly treated, people with ankylosing spondylitis may lead fairly normal lives. Under ideal circumstances, a team approach to treat spondylitis is recommended. Members of the treatment team typically include the patient, doctor, physical therapist and occupational therapist.

• Physical and occupational therapy. Early intervention with physical and occupational therapy is important to maintain function and minimize deformity.
• Exercise. A program of daily exercise helps reduce stiffness, strengthen the muscles around the joints and prevent or minimize the risk of disability. Deep breathing exercises may help keep the chest cage flexible. Swimming is an excellent form of exercise for people with ankylosing spondylitis.
• Medications. Certain drugs help provide relief from pain and stiffness, and allow patients to perform their exercises with minimal discomfort. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used drugs for spondylitis treatment. Many NSAIDs are currently available. In moderate to severe cases, other medications may be added to the treatment regimen. Disease modifying anitrheumatic drugs (DMARDs) such as Azulfidine and Rheumatrex can be used when NSAIDs alone are not enough to reduce the inflammation, and help to prevent joint stiffness and pain. In addition, the relatively new drugs Enbrel and Remicade have been FDA approved for treating ankylosing spondylitis. A similar drug, Humira has also been shown to improve the pain and stiffness of ankylosing spondylitis.
• Surgery. Artificial joint replacement surgery may be a treatment option for some people with advanced joint disease affecting the hips or knees.

In addition, people with spondylitis are urged to not smoke or chew tobacco products because of the increased risk of lung problems and reduced ability to expand the rib cage. Certainly, all of the other reasons why doctors discourage smoking also apply here as well.

People with spondylitis are encouraged to sleep on a hard mattress with the back straight. Placing large pillows under the head is discouraged, since it may promote neck fusion in the flexed position. Similarly, propping the legs up on pillows should be avoided because it may lead to hip or knee fusion in the bent position. Choose chairs, tables and other work surfaces that will help avoid slumping or stooping. Armchairs are preferred over chairs without arms.

Since those with ankylosing spondylitis could easily hurt their rigid necks or backs, special care should be taken to avoid sudden impact, such as jumping or falling.

Gout

Gout is a form of arthritis (an inflammation of the joints) that causes sudden, severe attacks of pain, tenderness, redness, warmth and swelling (inflammation) in some joints. It usually affects one joint at a time.

The large toe is most often affected, but gout also can affect other joints in the leg (knee, ankle, and foot) and, less often, joints in the arm (hand, wrist, and elbow). The fingers are rarely involved and the spine is almost never affected.

What Are the Symptoms of Gout?

The symptoms of gout include:

• Sudden, intense joint pain, which often can wake a person from sleep.
• Swollen joint that is warm to touch.
• Red or purple skin around the joint.

If someone has gout on and off for years, eventually uric acid crystals may accumulate in the body to form gritty nodules called "tophi." These nodules can appear as lumps under the skin near joints, at the rim of the ears or in the kidneys.

Uric acid comes from the natural breakdown of the genetic material in cells, RNA (ribonucleic acid) and DNA (deoxyribonucleic acid). Some foods contain large amounts of uric acid, especially red meats and organ meats (such as liver and kidneys), as well as some shellfish and anchovies.

Uric acid in normal amounts remains dissolved in the blood and easily passes through the kidneys, leaving the body as waste. However, uric acid in high amounts makes a person more likely to develop gout.

The amount of uric acid in your blood can change depending on what you eat, your overall health, how much alcohol you drink and what medicines you are taking, as well as in response to a sudden illness.

What Causes Gout?

Gout was once incorrectly thought to be a disease of the rich and famous, caused by consuming too much rich food and fine wine. Although diet and excessive drinking contribute to gout, they are not the main cause of the condition.

Gout results from abnormal deposits of uric acid crystals in the joint cartilage. The crystals are later released into the joint fluid.

Not everyone with high levels of uric acid will develop gout. The kidneys' ability to rid the body of uric acid is partly determined by heredity. Yet, just because someone in the family suffers from gout does not mean everyone in that family will have the disease. This risk varies from person to person.

How Frequent Are Gout Attacks?

Gout attacks can recur from time to time in the same joint. The initial attack may last several days to two weeks unless treated.

Over time, gout attacks may occur more often, involve more joints, have more severe symptoms and last longer. Repeated attacks can damage the joint.

Some people will have only a single attack. However, most people who have one gout attack will have at least a second attack, although it may not occur for several years after the initial onset. Others may have attacks every few weeks.

Who Is Affected By Gout?

Gout affects more than 2 million Americans -- most commonly men between the ages of 40 and 50, people who are overweight, people who frequently drink alcohol and people who use diuretics ("water pills") to lower blood pressure or treat heart failure.

When gout affects women, it usually is after menopause, especially in women who are taking certain medications. Less often, younger people may be affected by gout if they have been taking certain medications for long periods of time, frequently drink alcoholic beverages or have certain genetic disorders.

In addition to diuretics, there are some medications that reduce the body's ability to flush out uric acid, thus increasing the risk for developing gout. These medicines include:

• Anti-inflammatory medications made from salicylic acid, such as aspirin.
• Cyclosporine, a medicine used to suppress the body's immune system (Cyclosporine often is used to prevent the rejection of transplanted organs.).
• Levodopa, a medicine used to treat Parkinson's disease.
• Niacin, a vitamin that is part of the vitamin B complex and sometimes used to treat high cholesterol.

How Is Gout Diagnosed?

Gout cannot be diagnosed simply from a blood test, because many people have elevated blood uric acid levels but do not have gout. Rather, gout is diagnosed from the fluid of an inflamed joint. The fluid is observed under a microscope for uric acid crystals.

Fluid is removed through a needle during a procedure called arthrocentesis. Extracting the fluid not only aids in diagnosing the condition, but it may also reduce pressure within the joint, thereby reducing pain.

If crystals are not found in the fluid, the diagnosis of gout cannot be made with certainty. Occasionally, crystals may not be seen the first time, but may be seen if additional fluid is removed during a subsequent attack.

Since gout can cause chronic joint pain and involve other joints, it is extremely important that an accurate diagnosis be made so your doctor can prescribe the appropriate treatment.

How Is Gout Treated?

There is no cure for gout, but it can be treated and controlled. Symptoms often are relieved within 24 hours after treatment has begun.

The type of treatment prescribed will depend on several factors, including the person's age, type of medications he or she is taking, overall health, medical history and severity of gout attacks. Gout is mainly treated with anti-inflammatory drugs. These include:

• NSAIDs (nonsteroidal anti-inflammatory drugs), such as ibuprofen or naproxen, are generally prescribed to treat sudden and severe gout attacks. They usually reduce inflammation and pain within hours.
• Corticosteroids (also called steroids), may be prescribed for people who cannot take NSAIDs. Steroids also work by decreasing inflammation. Steroids can be injected into the affected joint or given as pills.
• Colchicine is often used to treat gout and usually begins working within a few hours of taking it.

Medicine that lowers uric acid levels, such as allopurinol (Zyloprim) or probenecid (Benemid), also may be prescribed to help prevent a gout attack. These drugs are recommended for people who have had multiple attacks of gout or kidney stones due to uric acid. The goal of lowering the blood uric acid is to slowly dissolve deposits of uric acid in the joint.

Sudden lowering of the uric acid level may cause an attack of gout. To prevent attacks in people who are taking uric acid-lowering drugs, colchicine or an NSAID is temporarily prescribed.

In addition, uric acid-lowering therapy (with allopurinol or probenecid) is not started during a gout attack, since sudden lowering of the uric acid can cause a new attack or prolong an existing one.

What Are the Side Effects of Gout Medicine?

Upset stomach, indigestion and headaches are the most common side effects of antiinflammatory NSAIDs. Taking these medications with food can help reduce stomach upset. NSAIDs also can cause vomiting, constipation, ulcers and bleeding in the stomach, although these side effects are not common.

Side effects of corticosteroids include weight gain, increased appetite and mood swings. Corticosteroids can have serious side effects when taken for a long period of time. Possible serious side effects include osteoporosis (thinning of the bones) , diabetes , high blood pressure and decreased resistance to infection.

Possible side effects from colchicine include diarrhea, nausea and abdominal cramps.

The most common side effects of allopurinol and probenecid are upset stomach, diarrhea, headache or dizziness and a skin rash.

Not everyone will develop side effects from gout medications. How often any side effect occurs varies from person to person. The occurrence depends on the dose, type of medication, concurrent illnesses or other medications the person may be taking.

Some side effects are more serious than others. Before any medication is prescribed, your doctor will discuss with you the potential benefits and risks of taking the medication.

Should I Change My Diet?

Dietary changes for most people do not play a major role in controlling their uric acid levels. However, limiting certain foods that cause an increased production of uric acid -- such as red meats and organ meats (for example, liver and kidneys), as well as some shellfish and anchovies -- and reducing alcohol intake is often helpful.

What Is the Outlook For People With Gout?

Although there is no cure for gout, it generally can be controlled with medication. Controlling gout can help prevent permanent damage to the joint.

Psoriatic Arthritis

Psoriatic arthritis is a form of inflammatory arthritis that affects 10-30% of the millions of Americans who have the skin condition psoriasis, according to the National Psoriasis Foundation. Psoriasis is an inflammatory skin disorder characterized by frequent episodes of redness and itching; thick, dry, silvery scales on the skin; and nail abnormalities.

There are five types of psoriatic arthritis. It is important to know which type of psoriatic arthritis you have and to understand its characteristics so that it may be treated properly.

1. Symmetric Psoriatic Arthritis.
   Symmetric arthritis affects the same joints -- usually in multiple matching pairs -- on both sides of the body. Symmetric arthritis can be disabling, causing varying degrees of progressive, destructive disease in 50% of people with this type of arthritis. While symmetric arthritis resembles rheumatoid arthritis it is generally much milder.

2. Asymmetric Psoriatic Arthritis.
   Asymmetric arthritis typically involves one to three joints in the body -- large or small -- such as the knee, hip, or one or several fingers. Asymmetric arthritis does not affect matching pairs of joints on both sides of the body.

3. Distal Interphalangeal Predominant (DIP)
   Distal interphalangeal predominant psoriatic arthritis involves primarily the small joints in the fingers and toes closest to the nail. DIP is sometimes confused with osteoarthritis, a chronic disease that causes the deterioration of joint cartilage and tissues and bone spurs at the joints.

4. Spondylitis.
   Spondylitis affects the spinal column, and may cause inflammation and stiffness in the neck, lower back, spinal vertebrae, or sacroiliac region (pelvic area), making motion difficult. Spondylitis also may attack connective tissue, such as ligaments, or cause arthritic disease in the joints of the arms, hips, legs or feet.

5. Arthritis Mutilans.
   Arthritis mutilans is a severe, deforming and destructive form of psoriatic arthritis that primarily affects the small joints in the fingers and toes closest to the nail but also is frequently associated with lower back and neck pain.

Symptoms of Psoriatic Arthritis

Psoriatic arthritis symptoms may vary. For some, the onset of symptoms may be gradual and subtle; and for others, it may be sudden and dramatic. Generally, the signs and symptoms of psoriatic arthritis include some or all of the following:

• Discomfort, stiffness, pain, throbbing, swelling or tenderness in one or more joints.
• Reduced range of motion in joints.
• Morning stiffness and fatigue.
• Silver or gray scaly spots on the scalp, elbows, knees or the lower spine.
• Inflammation or stiffness in the lower back, wrists, knees or ankles, or swelling in the small joints in the fingers and toes closest to the nail, giving these joints a sausage-like appearance.
• Pitting of the nails (small depressions).
• Detachment of fingernails or toenails.
• Tenderness, pain or swelling where tendons and ligaments attach to the bone.
• Inflammation of the eye.

Who Is At Risk For Psoriatic Arthritis?

Affecting men and women equally, approximately 10 to 30% of people with psoriasis develop psoriatic arthritis. Psoriatic arthritis may develop at any age, but usually affects people between ages of 30 and 50. While the cause is not known, genetic factors, along with the immune system, infection and physical trauma play a role in determining who will develop the disorder.

As many as 40% of people with psoriatic arthritis have a family history of skin or joint disease. Having a parent with psoriasis triples the chance of getting psoriasis yourself and thus increases the chance of developing psoriatic arthritis.

How Is Psoriatic Arthritis Diagnosed?

The diagnosis of psoriatic arthritis is based on the following:

• Appearance of symptoms (as described above)
• Complete evaluation of your medical history
• Physical examination
• Blood studies
• X-rays of the joints

Diagnosis may be easier for your doctor to confirm if psoriasis is also present with arthritis symptoms. However, in some cases, symptoms of psoriatic arthritis appear before the skin rash of psoriasis. Symptoms of psoriasis may include frequent episodes of redness and itching; thick, dry, silvery scales on the scalp, elbow, knees or the trunk; and nail abnormalities.

Because psoriatic arthritis closely resembles rheumatoid arthritis, a blood test to check for rheumatoid arthritis is required to make an accurate diagnosis. Tests for rheumatoid arthritis are usually negative in patients with psoriatic arthritis. People with psoriatic arthritis may have a mild anemia. Blood tests can also reveal an elevated erythrocyte sedimentation rate, a marker of inflammation. ( http://www.webmd.com/content/article/78/95618.htm)

A definitive diagnosis of psoriatic arthritis cannot be made until skin and nail changes associated with psoriasis appear.

Treating Psoriatic Arthritis

Psoriatic arthritis treatment is intended to relieve the symptoms of the disorder and may include any combination of the following:

Medication

Non-steroidal anti-inflammatory drugs (NSAIDs) can provide long-term relief from chronic pain and inflammation. NSAIDs work by blocking the production of certain body chemicals that cause inflammation. There are many different NSAIDs to choose from and your doctor may have to try several to find the right one for you.

Long-term use of NSAIDs can cause stomach irritation, ulcers and even bleeding by inhibiting the production of the protective mucus layer. Cytotec (misoprostol) reverses this effect on the stomach, so some doctors recommend taking this medication along with NSAIDs. Other doctors prefer to protect the stomach by giving stomach acid blockers. Not everyone will need something to protect the stomach.

Corticosteroids (commonly referred to as steroids) are powerful anti-inflammatory medications that can be injected directly into a joint to relieve severe pain and inflammation. They are chemically different from the muscle-building type of steroids.

Prednisone is the steroid most commonly used to treat certain rheumatic diseases. However, steroids are used only when absolutely needed because long-term use may cause serious side effects such as bone deterioration and joint weakness.

Disease modifying anti-rheumatic drugs (DMARDs) have been shown to slow the progress of psoriatic arthritis. Available only by prescription, DMARDs are more powerful, yet slower acting, than NSAIDs and must be closely monitored by a doctor for side effects. DMARDs include methotrexate, sulfasalazine and the newer drugs Enbrel and Remicaide.

Exercise

Moderate, regular exercise may relieve joint stiffness and pain associated with psoriatic arthritis. A tailored program of range-of-motion and strengthening exercises, combined with cardiovascular exercise, can help:

• Relieve arthritis symptoms.
• Maintain normal joint movement.
• Increase flexibility and muscle strength.
• Maintain weight to reduce pressure on joints.
• Improve endurance and cardiovascular fitness.
Hydrotherapy or aqua therapy (water therapy) is a program of exercises performed in a large pool. Aqua therapy may be easier on painful joints from psoriatic arthritis because the water takes some of the weight off the affected areas. Appropriate recreational exercise also may be beneficial, but only if it is preceded by a program of range-of-motion, strength and aerobic exercises to reduce the chance of injury. Regardless of the exercise program you select, it's important to choose one you enjoy so that you maintain it.

Before beginning any new exercise program, discuss exercise options with your doctor. Also, begin new exercise programs under the supervision of a physical therapist or qualified professional, preferably one who has experience working with arthritis patients.

Improper exercise programs may make psoriatic arthritis worse. Check with your doctor or therapist and adjust your program if you experience any of the following:

• Unusual or persistent fatigue
• Increased weakness
• Decreased range of motion
• Increased joint swelling
• Continuing pain (lasting more than an hour after exercising)

Heat and Cold Therapy

Heat and cold therapy involves alternating moist heat and cold to affected joints to provide temporary relief of pain and swelling associated with psoriatic arthritis. Moist heat -- supplied by a warm towel, hot pack, or warm bath or shower -- can help relax aching muscles and relieve joint pain and soreness.

Your doctor also may recommend ultrasound therapy for deep heating in some joints, depending on your condition.

Cold therapy -- supplied by a bag of ice or even frozen vegetables wrapped in a towel -- can reduce swelling and relieve pain by numbing the affected joints.

Joint Protection and Energy Conservation

Daily activities should be performed in ways that reduce excess stress and fatigue on joints. Proper body mechanics (the way you position your body during a physical task) may not only protect joints, but also conserve energy. People with psoriatic arthritis are encouraged to frequently change body position at work, at home, and during leisure activities. Maintaining good posture -- sitting and standing up straight and not arching your back -- also is valuable for preserving function.

Three techniques can help distribute workloads and stress throughout the body to prevent overworking affected joints:

• Pacing. Alternate heavy, hard or repetitive tasks with light or easy tasks, or with breaks from the activity.
• Conservative Joint Use. Use joints in a manner that produces the least amount of stress on them, such as using larger, stronger joints in place of smaller ones whenever possible. For example, use a shoulder bag rather than a hand-held purse.
• Assistive Devices. A variety of helpful devices, such as canes, grab bars, extra-thick pens, luggage carts or sit/stand stools can relieve stress on joints and make daily activities more comfortable. An occupational therapist can help you select devices that are appropriate for your type of psoriatic arthritis.

Splinting

Your doctor may recommend splinting to help with inflammation or problems with joint alignment or stability. Splints also can help minimize joint destruction that can be seen with psoriatic arthritis. Wrist or finger splints may help rest joints at night or hold them in a comfortable position during work or exercise. However, joints should not be totally immobilized. Splints should be removed periodically to perform gentle range-of-motion exercises to maintain mobility in those joints.

Surgery

Most people with psoriatic arthritis will never need surgery. However, when all other treatments fail, a surgical procedure called synovectomy may be required to restore joint function or remove diseased portions of the joints. Severely damaged joints may require arthroplasty or joint replacement surgery, in which natural joints are replaced with synthetic ones to restore function in the affected area. Joint fusions also may be needed to take care of pain that doesn't respond to medications. Surgery also may relieve pain, increase movement, or improve the physical appearance of the affected area.

Living With Psoriatic Arthritis

There is no cure for psoriatic arthritis. However, by understanding the disorder and knowing what to expect, you can learn new ways to perform daily tasks or plan activities during the times and days you are least bothered by the effects of the disease. Once you understand and learn to predict the ways in which your body responds to psoriatic arthritis, you can use exercise and therapy to alleviate discomfort and reduce stress and fatigue.

Pseudogout

Pseudogout is a form of arthritis that causes pain, stiffness, tenderness, redness, warmth and swelling in some joints. It usually affects one joint at a time, but sometimes may affect several joints at once.

Pseudogout commonly affects the knee or wrist. Less often, it can involve the hips, shoulders, elbows, knuckles, toes or ankles.

What Causes Pseudogout?

Pseudogout results from the abnormal formation of calcium pyrophosphate (CPP) crystals in the cartilage (cushioning material between the bones), which is later followed by the release of crystals into the joint fluid. When CPP crystals are released into the joint, they can cause a sudden attack of arthritis, similar to gout.

The cause of abnormal deposits of CPP crystals in cartilage is unknown. They may form due to abnormal cells in the cartilage, or they may be produced as the result of another disease that damages cartilage. CPP crystals may be released from cartilage during a sudden illness, joint injury or surgery. The abnormal formation of CPP crystals also may be a hereditary trait.

What Are the Symptoms of Pseudogout?

The symptoms of pseudogout are similar to symptoms of several other diseases, especially gout (which is why this form of arthritis is called pseudogout). Some symptoms of pseudogout are similar to those of rheumatoid arthritis or osteoarthritis. Symptoms of pseudogout include:

• Sudden, intense joint pain.
• Swollen joint that's warm to the touch.
• Red or purple skin around the joint.
• Severe tenderness around the joint (even the slightest touch or pressure may bring extreme pain).

Less often, pseudogout may cause persistent swelling, warmth and pain in several joints, and can even mimic rheumatoid arthritis.

Most symptoms of pseudogout go away within five to 12 days, even without treatment.

Who Gets Pseudogout?

Pseudogout affects both men and women. Like gout, pseudogout occurs more frequently in people as they age, commonly affecting people over age 60.

People who have a thyroid condition, kidney failure, or disorders that affect calcium, phosphate or iron metabolism have an increased risk for pseudogout.

It also is commonly seen in people who have osteoarthritis, and "attacks" of osteoarthritis associated with pain, swelling and redness of the joint may in fact be due to pseudogout.

It is unusual for young people to develop pseudogout.

How Frequently Do Pseudogout Attacks Occur?

Like gout, pseudogout attacks can recur from time to time in the same joint or in different joints. The initial attack may last five to 12 days unless it is treated. Unlike gout, attacks are not linked to certain foods in your diet.

Over time, pseudogout attacks may increase, involve more joints, cause more severe symptoms and last longer. Frequency of attacks is variable. Attacks may occur from once every few weeks to less than once a year. Frequent, repeated attacks can damage the affected joints.

How Is Pseudogout Diagnosed?

Pseudogout cannot be diagnosed simply from a blood test. An X-ray of the joint can be taken to look for the presence of calcium containing crystals. To diagnose the condition, fluid is removed from the inflamed joint and analyzed under a microscope. The presence of CPP crystals indicates pseudogout.

Fluid is removed through a needle from the inflamed joint in a procedure called "arthrocentesis." Removing the fluid also may help reduce the pressure within the joint and thereby reduce pain.

How Is Pseudogout Treated?

The type of treatment prescribed will depend on several factors, including the person's age, other medications he or she is taking, overall health, medical history and the severity of the attack. Medications to treat pseudogout include:

• Anti-inflammatory painkiller drugs also called (NSAIDs) generally are prescribed to treat sudden and severe pseudogout attacks. NSAIDs -- such as ibuprofen and naproxen -- usually reduce inflammation and pain within hours.
• Corticosteroids (also called steroids) may be prescribed for people who cannot take NSAIDs. Steroids also work by decreasing inflammation, and can be injected into the affected joint or given as pills.
• Colchicine, a gout drug, is sometimes used in low doses for a longer period of time to reduce the risk of recurrent attacks of pseudogout.

Anti-inflammatory medications are usually continued until the pseudogout attack completely resolves. Symptoms are often relieved within 24 hours after treatment has begun.

If side effects occur, the medication may be changed. Not everyone will develop side effects from these medications. How often any side effect occurs varies from person to person. The occurrence depends on the dose, type of medication, length of treatment, other illnesses and other medications the person may be taking.

Arthritis:Rheumatoid Arthritis Basics

Arthritis is a general term that describes inflammation in joints. That inflammation is characterized by redness, warmth, swelling and pain.

Rheumatoid arthritis is a type of chronic arthritis that occurs in joints on both sides of the body (such as hands, wrists or knees). This symmetry helps distinguish rheumatoid arthritis from other types of arthritis.

In addition to affecting the joints, rheumatoid arthritis may occasionally affect the skin, eyes, lungs, heart, blood, nerves or kidneys.

What Are the Symptoms of Rheumatoid Arthritis?

Symptoms of rheumatoid arthritis include:

• Joint pain and swelling
• Stiffness, especially in the morning or after sitting for long periods
• Fatigue

Rheumatoid arthritis affects everyone differently. In most people, joint symptoms develop gradually over several years. But in some, rheumatoid arthritis may progress rapidly and yet other people may have rheumatoid arthritis for a limited period of time and then enter a period of remission.

Who Gets Rheumatoid Arthritis?

Rheumatoid arthritis affects about 1% of the U.S. population. While it is two to three times more common in women than in men, men tend to be more severely affected when they get it. It usually occurs in middle age, however, young children and the elderly also can develop rheumatoid arthritis.

What Causes Rheumatoid Arthritis?

The exact cause of rheumatoid arthritis is unknown, but it is thought to be due to a combination of genetic, environmental and hormonal factors. With rheumatoid arthritis, something seems to trigger the immune system to attack the joints and sometimes other organs. Some theories suggest that a virus or bacteria may alter the immune system, causing it to attack the joints.

Research hasn't been able to determine exactly what role genetics plays in rheumatoid arthritis. However, some people do seem to have a genetic or inherited factor that increases their chance of developing rheumatoid arthritis.

How Does Rheumatoid Arthritis Affect the Body?

Once the immune system is triggered, immune cells migrate from the blood into the joints and produce substances that cause inflammation. The increased number of cells and inflammatory substances within the joint cause irritation, wearing down cartilage (cushioning material at the end of bones), swelling the joint lining (synovium) and causing the joint lining to produce fluid.

As the cartilage wears down, the space between the bones narrows. If the condition worsens, the bones could rub against each other.

As the joint lining expands, it may invade into or erode the bone, resulting in irreversible damage to the bone. All of these factors cause the joint to become very painful, swollen and warm to the touch.

How Is Rheumatoid Arthritis Diagnosed?

The diagnosis of rheumatoid arthritis is based on a combination of factors, including:

• The specific location and symmetry of painful joints.
• The presence of joint stiffness in the morning.
• Presence of bumps and nodules under the skin (rheumatoid nodules).
• Results of X-ray tests that suggest rheumatoid arthritis.
• Positive results of a blood test called the rheumatoid factor.

Most, but not all, people with rheumatoid arthritis have the rheumatoid-factor antibody in their blood. The rheumatoid factor may be present in people who do not have rheumatoid arthritis. Other diseases also can cause the rheumatoid factor to be produced in the blood. Therefore, the diagnosis of rheumatoid arthritis is based on a combination of several factors and not just the presence of the rheumatoid factor in the blood.

People with RA may have a mild anemia. Blood tests may also reveal an elevated erythrocyte sedimentation rate (ESR) a marker of inflammation.

A few people with RA may also have a positive antinuclear antibody test (ANA). This test is positive in people with lupus.

How Is Rheumatoid Arthritis Treated?

There are many different ways to treat rheumatoid arthritis. Treatments include medications, rest and exercise, and surgery to correct damage to the joint.

The type of treatment will depend on several factors including the person's age, overall health, medical history and severity of the arthritis.

Medications

There are many medications available to decrease joint pain, swelling and inflammation, and possibly prevent or minimize the progression of the disease.

Medications that offer relief of arthritis symptoms (joint pain, stiffness and swelling) include:

• Anti-inflammatory painkiller drugs, such as aspirin, ibuprofen or naproxen
• Topical (applied directly to the skin) pain relievers
• Corticosteroids, such as prednisone
• Narcotic pain relievers

There are also many strong medications called disease-modifying antirheumatic drugs (DMARDs) that are used to treat RA. These medicines usually work by interfering with or suppressing the immune system attack on the joints. They include:

• Arava
• Anti-malaria medications, such as Plaquenil
• Chemotherapy drugs such as methotrexate, Imuran, Cytoxan, and Rituxan
• Organ rejection drugs, such as cyclosporine
• Biologic treatments, including Enbrel, Humira, Kineret, Orencia, Remicade, and Rituxan
• Miscellaneous drugs, such as Azulfidine and gold

Another medication, Orencia, was approved in December 2005 for the treatment of moderate to severe rheumatoid arthritis. It is the first in a new class of drugs that also focuses on the immune system. Orencia is approved to reduce the symptoms of RA in patients not helped by other RA drugs.

In February 2006, the U.S. Food and Drug Administration (FDA) approved another new medication, Rituxan, in combination with methotrexate, for the treatment of moderate to severe RA. Rituxan is a biological agent that targets a different immune cell, the B-cell, and is specifically geared towards people with RA who have not improved with other biological agents, such as Remicade and Enbrel.

Some of these medications are traditionally used to treat other conditions such as cancer or inflammatory bowel disease, or to reduce the risk of rejection of a transplanted organ. However, when chemotherapy medications are used to treat rheumatoid arthritis, the doses are significantly lower and the risks of side effects tend to be considerably less than when prescribed in higher doses for cancer treatment.

People who do not responded to the DMARDs may consider another relatively new treatment called apheresis with Prosorba.

Apheresis is a treatment that removes antibodies from the blood. A special catheter, like that used for kidney dialysis, is placed in a large vein and blood travels out of the body, into a special machine containing the Prosorba column, and then circulates back to the body. When the blood passes through the Prosorba column, antibodies are retained in the column and removed from the blood.

The treatments take about two hours each. For rheumatoid arthritis, the treatments are performed once a week for 12 weeks.

Research studies have shown that some patients with rheumatoid arthritis improve after Prosorba treatments. Possible complications include anemia, infection, clotting of the vein or the catheter, and low blood pressure.

Why Is Rest and Exercise Important?

A balance of rest and exercise is important in treating rheumatoid arthritis. During flare-ups (worsening of joint inflammation), it is best to rest the joints that are inflamed. This may be accomplished by the temporary use of a cane or joint splints.

When joint inflammation is decreased, guided exercise programs are necessary to maintain flexibility of the joints and to strengthen the muscles that surround the joints. Range-of-motion exercises should be done regularly to maintain joint mobility.

When Is Surgery Necessary?

When joint damage from the arthritis has become severe or pain is not controlled with medications, surgery may be an option to help restore function to a damaged joint.

Can Rheumatoid Arthritis Be Cured?

Although there is not yet a cure for rheumatoid arthritis, early, aggressive treatment has been shown to help prevent disability. There are many different methods available for reducing the pain and inflammation. Research is in progress to determine the cause of rheumatoid arthritis and the best treatment for it.

Reiter's Syndrome

Reiter's syndrome, also called "reactive arthritis," is a form of arthritis that, in addition to joints, also affects many other areas of the body including the eyes, urethra (the tube that carries urine from the bladder to the outside of the body) and skin.

The disease is recognized by a number of symptoms in different organs of the body that may or may not appear at the same time. It may come on quickly and severely or more slowly, with sudden remissions or recurrences.

Reiter's syndrome primarily affects sexually active males between the ages of 20 and 40. Those with HIV (human immunodeficiency virus) are at a particularly high risk.

What Causes Reiter's Syndrome?

The cause of Reiter's syndrome is still unknown, but research suggests the disease is caused by a combination of genetic predisposition and various other factors.

Approximately 75% of those with the condition have a positive blood test for the genetic marker HLA-B27, which suggests that the disease has a genetic component. In sexually active males, most cases of Reiter's syndrome follow infection with Chlamydia trachomatis or Ureaplasma urealyticum (both are common sexually transmitted diseases). In other cases, people develop the symptoms following an intestinal infection with Shigella, Salmonella, Yersinia or Campylobacter bacteria that cause food poisoning.

With the exception of using condoms during sexual activity, there is no known preventative measure for Reiter's syndrome.

What Are the Symptoms of Reiter's Syndrome?

The first symptoms of Reiter's syndrome are painful urination and a discharge from the penis if there is inflammation of the urethra. More rarely diarrhea occurs if the intestines are affected. This is then followed by arthritis 4 to 28 days later. The arthritis usually affects the fingers, toes, ankles, hips and knee joints. Other symptoms include:

• Mouth ulcers
• Inflammation of the eye
• Keratoderma blennorrhagica (patches of scaly skin on the palms, soles, trunk, or scalp)

How Is Reiter's Syndrome Diagnosed?

Diagnosis of Reiter's syndrome can be complicated by the fact that symptoms often occur several weeks apart. A doctor may diagnose Reiter's syndrome when the patient's arthritis occurs together with or shortly following inflammation of the eye and the urinary tract and lasts a month or longer.

There is no specific test for diagnosing Reiter's syndrome, but the doctor may have the urethral discharge tested to check for sexually transmitted diseases. Stool samples may also be tested for signs of infection. Blood tests of Reiter's syndrome patients are typically positive for the HLA-B27 genetic marker, with an elevated white blood cell count and an increased erythrocyte sedimentation rate (ESR) -- both signs of inflammation. The patient may also be mildly anemic (having too few red blood cells in the bloodstream, leading to inadequate oxygen in the organs and tissues).

X-rays do not usually reveal any abnormalities unless the patient has had recurrent episodes of the disease. On an X-ray, joints that have been repeatedly inflamed may show areas of bone loss, signs of osteoporosis, or bony spurs.

How Is Reiter's Syndrome Treated?

Bacterial infections, such as Chlamydia, will need to be treated with antibiotics. Joint inflammation is usually treated with nonsteroidal anti-inflammatory drugs (NSAIDs). Skin eruptions and eye inflammation can be treated with steroids.

Those with chronic disease may be prescribed other medications including methotrexate. Patients with chronic arthritis also may be referred to a physical therapist and may be advised to exercise regularly.

What Is the Outlook For People With Reiter's Syndrome?

The prognosis for Reiter's syndrome varies. Most people recover in 3 to 4 months, but about half have recurrences for several years. Some people develop complications that may include inflammation of the heart muscle, inflammation with stiffening of the spine, glaucoma, progressive blindness, feet abnormalities or accumulation of fluid in the lungs.

Osteoarthritis Basics

Arthritis is a general term that means inflammation in joints. Osteoarthritis, also called degenerative joint disease, is the most common type of arthritis. It is associated with a breakdown of cartilage in joints and can occur in almost any joint in the body. It most commonly occurs in the weight bearing joints of the hips, knees and spine. It can also affect the fingers, neck and large toe. It rarely affects other joints unless prior injury or excessive stress is involved.

Cartilage is a firm, rubbery material that covers the ends of bones in normal joints. Its main function is to reduce friction in the joints and serve as a "shock absorber." The shock-absorbing quality of normal cartilage comes from its ability to change shape when compressed (flattened or pressed together).

Osteoarthritis causes the cartilage in a joint to become stiff and lose its elasticity, making it more susceptible to damage. Over time, the cartilage may wear away in some areas, greatly decreasing its ability to act as a shock absorber. As the cartilage deteriorates, tendons and ligaments stretch, causing pain. If the condition worsens, the bones could rub against each other.

Who Gets Osteoarthritis?

Osteoarthritis affects nearly 21 million Americans. The chance of developing the disease increases with age. Most people over age 60 have osteoarthritis to some degree, but its severity varies. Even people in their 20's and 30's can get osteoarthritis.

What Are the Symptoms of Osteoarthritis?

Symptoms of osteoarthritis most often develop gradually and include:

• Joint aching and soreness, especially with movement.
• Pain after overuse or after long periods of inactivity.
• Bony enlargements in the middle and end joints of the fingers (which may or may not be painful).
• Joint swelling.

What Causes Osteoarthritis?

There are several factors that increase a person's chances of developing osteoarthritis. These include:

• Heredity. Some people have an inherited defect in one of the genes responsible for making cartilage. This causes defective cartilage, which leads to more rapid deterioration of joints. People born with joint abnormalities are more likely to develop osteoarthritis, and those born with an abnormality of the spine (such as scoliosis or curvature of the spine) are more likely to develop osteoarthritis of the spine.

• Obesity. Obesity increases the risk for osteoarthritis of the knee and hip. Maintaining ideal weight or losing excess weight may help prevent osteoarthritis of the knee and hip or decrease the rate of progression once osteoarthritis is established.

• Injury. Injuries contribute to the development of osteoarthritis. For example, athletes who have knee-related injuries may be at higher risk of developing osteoarthritis of the knee. In addition, people who have had a severe back injury may be predisposed to develop osteoarthritis of the spine. People who have had a broken bone near a joint are prone to develop osteoarthritis in that joint.

• Joint Overuse. Overuse of certain joints increases the risk of developing osteoarthritis. For example, people in jobs requiring repeated bending of the knee are at increased risk for developing osteoarthritis of the knee.

How Is Osteoarthritis Diagnosed?

The diagnosis of osteoarthritis is based on a combination of the following factors:

• Your description of symptoms.
• The location and pattern of pain.
• Certain findings on physical examination, when necessary.

Your doctor may use X-rays to help confirm the diagnosis and make sure you don't have another type of arthritis. X-rays show how much joint damage has occurred.

Sometimes blood tests will be given to determine if you have a different type of arthritis.

If fluid has accumulated in the joints, your doctor may remove some of the fluid (called joint aspiration) and examine it under a microscope to rule out other diseases.

How Is Osteoarthritis Treated?

Osteoarthritis usually is treated by medications, exercise, hot and cold compresses to the painful joint, use of supportive devices such as crutches or canes, and weight control. Surgery may be helpful to relieve pain when other treatment options have not been effective.

The type of treatment prescribed will depend on several factors including your age, activities and occupation, overall health, medical history, location of your osteoarthritis, and severity of the condition.

What Medications Are Used to Treat Osteoarthritis?

For some people with persistent pain despite these pills or creams, steroids can be injected directly into the joint for pain relief. These injections are typically limited since prolonged use can lead to bone and cartilage deterioration and weakness.

Medications may be prescribed to reduce pain caused by osteoarthritis. Pain-relieving medications include acetaminophen (for example, Tylenol) and anti-inflammatory drugs (often called NSAIDs), such as aspirin, ibuprofen or Celebrex. Some medications in the form of creams, rubs or sprays may be applied over the skin of affected areas to relieve pain. For some people with persistent pain despite these pills or creams, steroids can be injected directly into the joint for pain relief. These injections are typically limited since prolonged use can lead to bone and cartilage deterioration and weakness.

Synvisc, Supartz, Euflexxa, Orthovisc and Hyalgan are medications given as a series of 3 to 5 weekly joint injections that can relieve pain in some people with osteoarthritis.

When osteoarthritis pain is severe and other treatments are not working, some doctors will give stronger pain pills, such as narcotics.

Unfortunately, none of these will reverse or slow the progression of joint damage caused by osteoarthritis.

How Does Weight and Exercise Impact Osteoarthritis?

Staying at your recommended weight helps prevent osteoarthritis of the knees, reduces the stress on weight-bearing joints and reduces pain in affected joints. Once you have osteoarthritis, losing weight also can relieve the stress and pain in your knees.

Exercise is important to improve joint movement and to strengthen the muscles that surround the joints. Gentle exercises, such as swimming or walking on flat surfaces, are recommended because they are less stressful on your joints. Avoid activities that increase joint pain, such as jogging or high impact aerobics.

Are There Alternative Treatments for Osteoarthritis?

Some medical research has shown that the supplements glucosamine and chondroitin can relieve pain in some people with osteoarthritis -- especially in the knee. There is also evidence that glucosamine can help rebuild cartilage.

Some people also use methylsulfonylmethane (MSM) and S-adenosylmethionine (SAM-e) for arthritis but there is less medical evidence showing their benefits. MSM is a naturally occurring sulfur that is taken as a dietary supplement. SAM-e helps our bodies to produce hormones and other chemicals and is taken as a dietary supplement.

Acupuncture and bioelectric therapy also may be useful at relieving pain.

What Supportive Devices Are Available to Help With Osteoarthritis?

Supportive or assistive devices may be helpful to decrease pressure on the joints. Knee supports may be helpful for some people to stabilize the ligaments and tendons and decrease pain. Canes or crutches may be helpful to take pressure off certain joints.

When Is Surgery Necessary?

When osteoarthritis pain is not controlled with medications and the other mentioned treatments, or when the pain prevents you from participating in your normal activities, you may want to consider surgery.

There are several surgical procedures that could be used. They include:

• Arthroscopy to clean out the damaged cartilage.
• Joint replacement surgery to replace the damaged joint with an artificial one. Even under the best of circumstances, surgery cannot return the joint to its normal state (artificial joints do not have all of the motion of a normal joint). However, an artificial joint will very likely diminish pain. The two joints most often replaced are the hip joint and the knee joint. Artificial joints are now also available to replace shoulders, fingers, elbows and back joints to treat severe pain that has not responded to other treatments.
• Joint fusion removes the damaged joint and fuses the two bones on each side of the joint. This is done more often in areas in which joint replacement is not effective, such as the ankle. However, an artificial joint will very likely diminish pain. The two joints most often replaced are the hip joint and the knee joint. Artificial joints are now also available to replace shoulders, fingers, elbows and back joints to treat severe pain that has not responded to other treatments.

Talk to your doctor to determine if any of these treatment options are right for you.

Inflammation and Arthritis

What Is Inflammation?

Inflammation is a process in which the body's white blood cells and chemicals help protect us from infection and foreign substances such as bacteria and viruses.

In some diseases, however, the body's defense system (immune system) triggers an inflammatory response when there are no foreign substances to fight off. In these diseases, called autoimmune diseases, the body's normally protective immune system causes damage to its own tissues. The body responds as if normal tissues are infected or somehow abnormal.

What Diseases Are Associated With Inflammation?

Some, but not all types of arthritis, are the result of misdirected inflammation. Arthritis is a general term that describes inflammation in joints. Some types of arthritis associated with inflammation include:

• Rheumatoid arthritis
• Tendonitis or bursitis
• Gouty arthritis
• Polymyalgia rheumatica

The most common form of arthritis called osteoarthritis (also known as degenerative arthritis) is a bit of a misnomer. It is not believed that inflammation plays much or any role in osteoarthritis. Other painful conditions of the joints and musculoskeletal system that are not associated with inflammation include fibromyalgia, muscular low back pain and muscular neck pain.

What Are the Symptoms of Inflammation?

Inflammation is characterized by:

• Redness
• Swollen joint that's warm to touch
• Joint pain
• Joint stiffness
• Loss of joint function

Often, only a few of these symptoms are present.

Inflammation may also be associated with general "flu"-like symptoms including:

• Fever
• Chills
• Fatigue/loss of energy
• Headaches
• Loss of appetite
• Muscle stiffness

What Causes the Symptoms of Inflammation?

When inflammation occurs, chemicals from the body are released into the blood or affected tissues. This release of chemicals increases the blood flow to the area of injury or infection and may result in redness and warmth. Some of the chemicals cause a leak of fluid into the tissues, resulting in swelling. This process may stimulate nerves and cause pain.

What Are the Results of Joint Inflammation?

The increased number of cells and inflammatory substances within the joint can cause irritation, wearing down of cartilage (cushions at the end of bones) and swelling of the joint lining.

How Are Inflammatory Diseases Diagnosed?

Diagnosis of inflammatory diseases consists of all or some of the following:

• Complete medical history and physical exam.
• The location of painful joints.
• Presence of joint stiffness in the morning.
• Evaluation of other symptoms.
• Results of X-rays and other tests.

Can Inflammation Affect Internal Organs?

Yes. Inflammation can affect organs as part of an autoimmune disorder. The type of symptoms depends on which organs are affected. For example:

• Inflammation of the heart (myocarditis) may cause vague chest pain or fluid retention.
• Inflammation of the small tubes that transport air to the lungs (bronchiolitis) may cause shortness of breath similar to an asthma attack.
• Inflammation of the kidneys (nephritis) may cause high blood pressure or kidney failure.
• Inflammation of the large intestine (colitis) may cause cramps and diarrhea.

Pain may not be a main symptom since many organs do not have many pain-sensitive nerves. Treatment of organ inflammation is directed at the cause of inflammation whenever possible.

How Are Inflammatory Joint Diseases Treated?

There are a number of treatment options for inflammatory diseases including medications, rest and exercise, and surgery to correct joint damage. The type of treatment prescribed will depend on several factors including the type of disease, the person's age, type of medications he or she is taking, overall health, medical history and severity of symptoms.

The goals of treatment are to:

• Avoid or modify activities that aggravate pain
• Relieve pain through pain-relieving medications and anti-inflammatory medications
• Maintain joint movement and muscle strength through physical therapy and exercise
• Decrease stress on the joints by using braces, splints or canes as needed

What Medications Are Used to Treat Inflammatory Diseases?

There are many medications available to decrease joint pain, swelling and inflammation and hopefully prevent or minimize the progression of the inflammatory disease. The medications include:

• Anti-inflammatory pain reliever drugs (NSAIDs - such as aspirin, ibuprofen or Celebrex).
• Corticosteroids (such as prednisone).
• Other medications* include chemotherapy drugs, disease modifying treatments, biologic therapy, or narcotic pain relievers.

*Some of these medications are traditionally used to treat other conditions such as cancer and inflammatory bowel disease or to prevent organ rejection after transplants. However, when "chemotherapy" types of medications are used to treat inflammatory diseases, the doses are significantly lower and the risks of side effects tend to be considerably less than when prescribed in higher doses for cancer.

When you are prescribed any medication, it is important to meet with your doctor regularly so he or she can check its effectiveness and detect the development of any side effects.

Arthritis Basics

What Is Arthritis?

Arthritis is a general term for a group of more than 100 diseases. The word "arthritis" means "joint inflammation." Inflammation is one of the body's natural reactions to disease or injury, and includes swelling, pain and stiffness. Inflammation that lasts for a very long time or recurs, as in arthritis, can lead to tissue damage.

A joint is where two or more bones come together, such as the hip or knee.

The bones of a joint are covered with a smooth, spongy material called cartilage, which cushions the bones and allows the joint to move without pain. The joint is enclosed in a fibrous casing called the synovium. The synovium's lining produces a slippery fluid -- called synovial fluid -- that nourishes the joint and helps limit friction within. Strong bands of tissue, called ligaments, connect the bones and help keep the joint stable. Muscles and tendons also support the joints and enable you to move.

With arthritis, an area in or around a joint becomes inflamed, causing pain, stiffness and, sometimes, difficulty moving. Some types of arthritis also affect other parts of the body, such as the skin and internal organs.

Types of Arthritis

There are more than 100 different types of arthritis. Some of the more common types include:

• Osteoarthritis. This is the most common type of arthritis. It occurs when the cartilage covering the end of the bones gradually wears away. Without the protection of the cartilage, the bones begin to rub against each other and the resulting friction leads to pain and swelling. Osteoarthritis can occur in any joint, but most often affects the hands and weight-bearing joints such as the knee, hip and facet joints (in the spine). Osteoarthritis often occurs as the cartilage breaks down, or degenerates, with age. For this reason, osteoarthritis is sometimes called degenerative joint disease.

• Rheumatoid arthritis. Rheumatoid arthritis is a long-lasting disease that can affect joints in any part of the body but most commonly the hands, wrists, and knees. With rheumatoid arthritis, the immune system -- the body's defense system against disease -- mistakenly attacks itself and causes the joint lining to swell. The inflammation then spreads to the surrounding tissues, and can eventually damage cartilage and bone. In more severe cases, rheumatoid arthritis can affect other areas of the body, such as the skin, eyes, and nerves.

• Gout. Gout is a painful condition that occurs when the body cannot eliminate a natural substance called uric acid. The excess uric acid forms needle-like crystals in the joints that cause swelling and severe pain. Gout most often affects the big toe, knee and wrist joints.

What Are the Symptoms of Arthritis?

Different types of arthritis have different symptoms and the symptoms vary in severity from person to person. Osteoarthritis does not generally cause any symptoms outside the joint. Symptoms of other types of arthritis may include fatigue, fever, a rash and the signs of joint inflammation, including:

• Pain
• Swelling
• Stiffness
• Tenderness
• Redness
• Warmth

What Causes Arthritis?

There are many different types of arthritis and the cause of most types is not known. It's likely that there are many different causes. Researchers are examining the role of genetics (heredity) and lifestyle behaviors in the development of arthritis.

Although the exact cause of arthritis may not be known, there are several risk factors for arthritis. (A risk factor is a trait or behavior that increases a person's chance of developing a disease or predisposes a person to a certain condition.) Risk factors for arthritis include:

• Age. The risk of developing arthritis, especially osteoarthritis, increases with age.
• Gender. In general, arthritis occurs more frequently in women than in men.
• Obesity. Being overweight puts extra stress on weight-bearing joints, increasing wear and tear, and increasing the risk of arthritis, especially osteoarthritis.
• Work factors. Some jobs that require repetitive movements or heavy lifting can stress the joints and/or cause an injury, which can lead to arthritis, particularly osteoarthritis.

How Common Is Arthritis?

Arthritis is very common. It has been estimated that as many as 70 million Americans -- or about one in three -- have some form of arthritis or joint pain. It is a major cause of lost work time and serious disability for many people. Osteoarthritis, the most common form, affects more than 20 million Americans. Arthritis affects people of all ages, but is more common in older adults.

How Is Arthritis Diagnosed?

Osteoarthritis is typically diagnosed with a complete medical history, including a description of your symptoms, and physical examination. Imaging techniques—such as X-rays or magnetic resonance imaging (MRI)—are sometimes used to show the condition of the joints. If other types of arthritis are suspected, laboratory tests on blood, urine and/or joint fluid may be helpful in determining the type of arthritis. These tests also can help rule out other diseases as the cause of your symptoms.

How Is Arthritis Treated?

The goal of treatment is to provide pain relief and increase joint mobility and strength. Treatment options include medication, exercise, heat/cold compresses, use of joint protection and surgery. Your treatment plan may involve more than one of these options.

What Is the Outlook for People With Arthritis?

With early diagnosis, most types of arthritis can be managed and the pain and disability minimized. In addition, early diagnosis and treatment may be able to prevent tissue damage caused by arthritis. Early, aggressive treatment is particularly important for rheumatoid arthritis in order to help prevent further damage and disability down the road.

Can Arthritis Be Prevented?

Although it may not be possible to prevent arthritis, there are steps to take to reduce your risk of developing the disease and to slow or prevent permanent joint damage. These include:

• Maintaining a healthy weight. Excess weight puts strain on your joints.
• Exercising. Keeping your muscles strong can help protect and support your joints.
• Using joint-protecting devices and techniques at work. Proper lifting and posture can help protect your muscles and joints.
• Eating a healthy diet. A well balanced, nutritious diet can help strengthen your bones and muscles.