Once the immune system is triggered, cells migrate from the blood into the joints and produce substances that cause inflammation.

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1 HealthExchange Points For Your Joints An Arthritis Talk Howard Epstein, MD Orthopaedic & Rheumatologic Institute Rheumatic & Immunologic Disease Cleveland Clinic Beachwood Family Health & Surgery Center Appointments: Rheumatoid Arthritis Arthritis is a general term that describes inflammation in joints. Inflammation is characterized by redness, warmth, swelling and pain. Rheumatoid arthritis is a type of chronic (ongoing) arthritis that occurs in joints on both sides of the body (such as both 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? Joint pain Joint swelling Stiffness especially in the morning or after sitting for long periods Fatigue best defined as tiredness and excessive sleepiness How does rheumatoid arthritis affect people? Rheumatoid arthritis affects everyone differently. In most people, joint symptoms may develop

2 may alter the immune system, causing it to attack the joints. Some people have a genetic or inherited factor that makes them more likely to develop rheumatoid arthritis. What are the results of joint inflammation? Once the immune system is triggered, 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: gradually over several years. In other people, rheumatoid arthritis may progress rapidly. Other people may have rheumatoid arthritis for a limited period of time and then enter a remission (a time with no symptoms). Who is affected by rheumatoid arthritis? Rheumatoid arthritis affects more than 1% of the United States population. It is three times more common in women than men. It usually occurs in people between the ages of 20 to 50; however, young children and the elderly can also develop rheumatoid arthritis. What causes rheumatoid arthritis? The exact cause of rheumatoid arthritis is unknown. However, it is believed to be caused by a combination of genetic, environmental and hormonal factors. Normally, the immune system protects the body from infection. In rheumatoid arthritis, something triggers the immune system to attack the joints and sometimes other organs. Some theories suggest that a virus or bacteria Irritation Wearing down of cartilage (cushions at the end of bones) Swelling of the joint lining (synovium) Production of fluid in the joint lining 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 grows, it may invade or erode into the bone, resulting in irreversible damage to the bone. All of these factors cause the joint to become very painful, swollen and warm to 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/nodules under the skin (rheumatoid nodules) Results of x-ray tests that suggest

3 rheumatoid arthritis Positive results of a blood test called the rheumatoid factor* *Many, 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 can also cause the rheumatoid factor to be produced in the blood. A new test called CCP antibody can sometimes help to determine whether the rheumatoid factor antibody is due to rheumatoid arthritis or some other disease. That is why 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. 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 prescribed 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 hopefully prevent or minimize the progression of the disease. These medications include: Non-steroidal anti-inflammatory drugs (NSAIDs such as aspirin, ibuprofen or naproxen) Corticosteroids (such as prednisone) Anti-malarial medications (such as hydroxychloroquine) Other medications* including gold, methotrexate, sulfasalazine, penicillamine, cyclophosphamide, cyclosporin and minocycline New biologic agents that block a specific inflammation factor (cytokine) called tumor necrosis factor (such as infliximab, etanercept or adalimumab) or that block another inflammation factor called interleukin 1 (such as anakinra) might also be used *Some of these medications are traditionally used to treat other conditions such as cancer, inflammatory bowel disease, infections or organ transplants. When chemotherapy is used to treat rheumatoid arthritis, the doses are significantly lower and the risks of side effects tend to be considerably less than when chemotherapy is used to treat cancer. When you are prescribed any medication, it is important to meet with your physician regularly so he or she can detect the development of any side effects. Rest and exercise 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-ofmotion exercises should be done regularly to maintain joint mobility. Surgery When bone damage from the arthritis has

4 become severe or pain is not controlled with medications, surgery is an option to restore function to a damaged joint. Is there hope for people with rheumatoid arthritis? Yes. Although there is not yet a cure for rheumatoid arthritis, there are many different methods available for decreasing the pain and inflammation. Early diagnosis and effective treatment is of great importance. Research is in progress to determine the cause of rheumatoid arthritis and the best treatment for it. A physical therapist or fitness instructor (preferably one with experience working with arthritis patients) can provide you with instruction on how to correctly and effectively perform isometric and isotonic exercises. Hydrotherapy or aquatherapy (water therapy), is a program of exercises performed in a pool. Aquatherapy may be easier on painful joints because the water takes some of the weight off of the affected areas while providing resistance training. Endurance exercise The foundation of endurance training is aerobic exercise, which includes any activity that uses large muscle groups, can be maintained continuously for a long period of time and is rhythmic in nature. Aerobic activity conditions the heart, lungs and cardiovascular system to: Use oxygen more efficiently Supply the entire body with larger amounts of oxygen-rich blood Build stronger muscle tissue When paired with a healthy diet, aerobic activity also is fundamental for weight control (which reduces excess pressure on affected joints) and improving overall general health. People with arthritis should perform about 15 minutes of aerobic activity (called the duration of the exercise) at least three times a week (called the frequency of the exercise) at first, then gradually build up to 30 minutes daily. The activity also should include at least 5 to 10 minutes of warm up plus 5 to 10 minutes of cool down. While peak benefits are achieved when an aerobic activity is performed continuously for at least 30 minutes, aerobic exercise can be spread out in smaller segments of time throughout the day to suit your comfort level, without overexerting yourself. Aerobic exercise should be performed at a comfortable, steady pace that allows you to talk normally and easily during the activity. Ask your therapist what intensity of exercise is appropriate for your fitness level. Intensity is how hard you are exercising. During exercise, your heart's "training range" or training heart rate should be closely monitored. To improve your body's aerobic condition, you need to exercise at an intensity between 60 and 80 percent of your maximum heart rate. Examples of aerobic activities include walking, swimming, low-impact aerobic dance, and biking, and may even include such daily activities as mowing the lawn, raking leaves or playing golf. Walking is one of the easiest aerobic exercise programs to begin because it requires no special skills or equipment other than a good pair of supportive walking shoes, and it's less stressful on joints than running or jogging. Biking also may be more beneficial to people

5 with arthritis than other aerobic activities because it places less stress on knee, foot and ankle joints. Appropriate recreational exercise, including sports, can be helpful to most people with arthritis, but only if it is preceded by a program of range-of-motion, strength and aerobic exercise to reduce the chance of injury. Beginning a new exercise program Regardless of your condition, discuss exercise options with a physician before beginning any new exercise program. Also, begin new exercise programs under the supervision of a physical or occupational therapist, preferably one with experience working with arthritis patients. People with arthritis who are beginning a new exercise program should spend some time conditioning using a program that consists only of range-of-motion and strengthening exercises, depending on their physical and athletic condition. Endurance exercises should be added gradually, and only after you feel comfortable with your current fitness level. As with any change in lifestyle, your body will have to take time to adapt to your new program. During the first few weeks, you may notice changes in the way your muscles feel, changes in your sleep patterns or different energy levels. These changes are to be expected with increased activity levels. However, improper exercise levels or programs may be harmful, making symptoms of arthritis worse. Consult your physician or therapist and adjust your program if you experience any of the following: Unusual or persistent fatigue Sharp or increased pain Increased weakness Decreased range of motion Increased joint swelling Continuing pain (lasting greater than 24 hours) Effective treatment of arthritis should include a comfortable balance of range-of motion, strengthening and endurance exercises. But regardless of the exercise program you select, it's important to begin slowly and choose a program you enjoy so that you maintain it. Make exercise part of your weekly routine so that it becomes a lifetime commitment. This information is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition Euclid Avenue Cleveland, Ohio CCF.CARE Produced by The Center for Consumer Health Information Copyright The Cleveland Clinic Foundation. All rights reserved.

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