Health

Non-pharmacologic
These interventions give people with rheumatoid arthritis a sense of control over their illness.

Education and Counseling: This is very important for persons with rheumatoid arthritis to have the information they need to help manage their disease over a lifetime. This helps improve outcome, outlook, and coping with chronic medical problems.

Biofeedback and Cognitive behavioral therapy:  These interventions have been shown to improve self esteem and decrease pain, depression, and sense of disability.

Rest and relative rest: The most important aspect is balancing activity and rest. Both are very important for a person with rheumatoid arthritis. This can be taking a nap to counter fatigue, a common symptom of rheumatoid arthritis. It can also be relative rest of an inflamed joint, like using a wrist splint. Bed rest may be needed during an acute flare involving many joints. You also need to make sure you get plenty of sleep and prioritize daily activities to conserve energy.

Exercise: Studies have shown that regular aerobic exercise can improve strength, mobility, physical function, aerobic capacity, and depression in persons with rheumatoid arthritis. It can also help prevent bone loss associated with steroid use. Exercise can be beneficial without worsening arthritis.

Nutrition and Diet: A well-balanced diet is recommended for all persons with rheumatoid arthritis. There is no proven nutritional supplement that cures rheumatoid arthritis. Some of the products like fish oils have helped some people with rheumatoid arthritis.

Sleep: It is very important for a person with rheumatoid arthritis to have good sleep hygiene. This means a nightly routine that includes relaxation, a regular bedtime, and at least 8-10 hours of sleep.

Prayer and Spirituality: Research suggests that interaction between mind, body, and spirit have effects on our health. Prayer is cited as a commonly used alternative treatment for arthritis.

Medications
Many factors affect the recommended pharmacologic treatment of persons with rheumatoid arthritis including disease activity, severity, and stage of the disease. With a variety of medications to treat rheumatoid arthritis and all with different mechanisms of action, you will probably be on combination drug therapy. As with all medications, you and your doctor must weigh the potential benefits and risks on an individual basis.

Simple analgesics: Medications like Tylenol are the first line treatment for pain relief, but they have no effect on inflammation.

Narcotic analgesics: Stronger pain relievers like Darvocet, Vicodin, and Tylenol with codeine may be used for pain relief. Since rheumatoid arthritis needs treatment over a lifetime, these medications have limited use due to the risk for abuse and dependence.

Nonsteroidal anti-inflammatory drugs: NSAIDs relieve both pain and inflammation but do not alter the course of the disease. There are many choices in this group and you may need to try many before you find one that works for you. Examples of this group include over-the-counter medications like ibuprofen, Advil, Aleve, Motrin, and prescription Daypro, Relafen, Indocin, Arthrotec, and Mobic, among many more. It also includes COX-2 inhibitors like celecoxib (Celebrex).

Steroids: Medications like prednisone and prednisolone have powerful anti-inflammatory properties. These medications are helpful for treating acute flares and may be used as a low maintenance dose to reduce inflammation and slow joint damage. They are available in intravenous, oral, inhalation, and topical preparations.

Disease-modifying antirheumatic drugs:  DMARDs can reduce or prevent joint damage, preserve joint structure, and preserve function. They are the standard for aggressively treating rheumatoid arthritis, especially methotrexate (Rheumatrex). Other examples include hydroxychloroquine (Plaquenil), gold salts (Ridaura, Solganal), cyclosporine (Sandimmune, Neoral), azathioprine (Imuran), leflunomide (Arava), D-penicillamine (Depen, Cuprimine), and sulfasalazine (Azulfidine).

Biologic response modifiers: These drugs directly modify the immune system by inhibiting cytokines, which are biological proteins that cause inflammation. Examples include etanercept, infliximab, adaliumuab, and anakinra.

Joint injection
Steroid: Local injection of steroid into a symptomatic joint may offer pain relief. Due to long-term consequence of steroid use, these types of injections are limited to several times per year in a given joint.

Artificial joint fluid (viscosupplementation): Local injection of a gel-like substance (hyaluronates) into a joint to supplement the viscous property of synovial fluid. This can offer pain relief for months. This type of therapy is usually given for knee pain and comes in a series of several injections. This group includes Hyalgan, Orthovisc, Supartz, Synvisc, and Euflexxa.
 
Surgery
When more conservative measure fail to manage rheumatoid arthritis adequately, suregery may be necessary to repair or replace a joint. 

Osteotomy: This procedure involves resection of part of the bone around the joint to realign or reposition the weight-bearing surfaces of the joint.

Synovectomy: This involves the removal of inflamed joint lining (synovium).

Tendon repair: This involves repair of damaged tendons like rotator cuff surgery.

Tendon lengthening: This procedure is performed to treat contractures or tissue shortening that result in limitation of joint movement.

Arthroscopic surgery: This procedure involves inserting a small scope with a camera to clean out the joint space and repair tissue.

Partial or total joint replacement: Joint replacement surgery is indicated for advanced joint destruction that leads to pain and deformity. The surgery involves removal of the joint, resurfacing and replacement of the joint with artificial parts. Joint replacements can last 10-20 years and then you would need a revision joint replacement. Replacement of only part of the knee (medial or lateral) is called unicondylar knee replacement.

Fusion of joint (arthrodesis): This procedure involves fusing two bones together to eliminate motion and treat pain and instability of a joint.

Cervical spine stabilization: This procedure involves surgical treatment of the neck or cervical spine. The top two cervical vertebra are designated C1 (atlas) and C2 (axis) form a synovial joint and can be affected by rheumatoid arthritis. This is called atlantoaxial subluxation and can lead to spinal cord compression. Symptoms of spinal cord compression can include difficulty walking, weakness in arms or legs, numbness or pain in arms or legs, and change in bowel or bladder control. Atlantoaxial subluxation can occur in up to 70% of persons with rheumatoid arthritis.

Rehabilitation Treatment
Basic Principles
Rehabilitation refers to the process of helping a person return to as much normal function as possible. There are many ways to help improve function. Some of the rehabilitation treatment is focused on regaining what is lost and other treatment focuses on compensating for lost function. Most patients with rheumatoid arthritis will benefit from both.

Rehabilitation Professionals
Rehabilitation is provided by many different professionals depending on your symptoms or problems. Often, these professionals work as a team to help coordinate the care they provide.

Physical Medicine and Rehabilitation (PMR) physician or Physiatrist: A doctor who focuses on overall function and symptom complex to suggest treatment and make appropriate referrals for therapy.

Physical therapist (PT): A therapist who focuses on mobility and adaptive equipment used for mobility like canes, walkers, wheelchairs; exercise and modalities to treat pain and improve or maintain function.

Occupational therapist (OT): A therapist who focuses on activities of daily living (ADLs) or ability to perform certain tasks like dressing, cooking, bathing; energy conservation; and adaptive equipment.

Certified hand therapist (CHT): have specialized training in elbow, wrist, and hands and splinting.
  
Orthotist: A professional who makes splints and braces.

Therapy Program
An individualized therapy program is very important for persons with rheumatoid arthritis. Therapy programs are divided into skilled therapy treatment and maintenance home exercise program. Therapy is available in various settings including in the hospital, rehabilitation unit, outpatient clinic, or at home with home health services. A course of therapy with a skilled therapist can improve mobility and ability to perform activities of daily living. Your doctor will need to write a prescription and refer you for therapy. It is usually covered by your health insurance. A therapy program seems also to give patients a greater sense of control, which is helpful in dealing with the psychological effects and provides a sense of well-being. Education is a big part of the treatment plan. Patients should be referred for evaluation at all stages of the disease process and should have periodic reevaluation as their clinical course progresses. Inactivity results in deconditioning; therapy and exercise can reverse the weakness associated with lack of use. It is important to find the right balance between rest and activity.

Exercise
A general exercise program is beneficial for a person with rheumatoid arthritis. A complete program should include aerobic, strengthening, and stretching exercises. Exercise is important for maintaining and even improving mobility, flexibility, balance, and range of motion. It can also help with depression. An exercise program addresses the problems of decreased flexibility, muscle atrophy, decreased strength, difficulty using hands, and aerobic deconditioning. It is important that a person with rheumatoid arthritis use proper technique and joint protection during exercise to avoid additional injury to the joints and surrounding tissue. Certain exercises like swimming, walking, low-impact aerobics, yoga, Pilates, and Tai-chi may help reduce joint pain and stiffness.

Stretching
Stretching is critical to maintaining flexibility and range of joint motion. Loss of joint range of motion or tightness in the muscles can aggravate the underlying symptoms of rheumatoid arthritis and worsen walking and ability to perform tasks. Acutely inflamed joints should be rested.

Massage
Massage may offer temporary relief of muscle pain and spasm. Massage may have the secondary benefit of offering stress relief.

Aquatic Therapy
A therapeutic exercise program can be based on land, in the water or both. An aquatic program may be the best solution for many patients with rheumatoid arthritis because it allows joints to be unloaded during weight-bearing activities. The warm water also helps joint pain and stiffness.

Weight Reduction
It is very important for person with rheumatoid arthritis to maintain ideal body weight. Excessive weight can lead to pain and further destruction of weight-bearing joints like hips and knees.

Support Groups
For many people, supports groups can be very helpful. They provide education, support, and advice for living with the disease and opportunities to meet others who have similar experiences. These groups can be a source of practical information for living better with rheumatoid arthritis.

Orthotics
The use of a splint or brace to rest and protect inflamed joints will be needed intermittently. These can be over-the-counter or custom-made. It is important to receive proper instruction in use of splints because use of splints over a long time can weaken the muscles and contribute to loss of joint motion. There are many options for custom shoes and orthotics to manage foot pain and deformity. A consultation with an occupational therapist may be very helpful in receiving recommendations and getting fitted with braces or splints.

Assistive Devices
These improve walking or mobility and a consultation with a physical therapist will help you select the most appropriate mobility aid for you including manual and power wheelchairs. Power wheelchairs may be very helpful in maintaining independent mobility and minimizing pain and fatigue. There are many gadgets to improve activities of daily living (reacher, sock aid, button hook, jar opener, book holder) and a consultation with an occupational therapist with help you with individual needs.

Modalities
Hot and cold modalities have been used for many centuries (if you have poor circulation, consult your doctor before using cold or heat). In acutely inflamed joints, cold is preferred to reduce pain and inflammation by causing vasoconstriction or decreased blood flow to the area. In contrast, heat will cause vasodilatation and cause more fluid to move into the area, worsening swelling. In chronic conditions, both are very helpful and usually patient preference determines which modality to use. These should be used carefully to avoid injury or burns. Most applications should be limited to 20 minutes at a time but can be applied multiple times in a day.

Cryotherapy
Cold treatment with ice, cold water, and biofreeze.

Hot treatment
1. Moist: bath or shower
2. Dry: heating pad
3. Superficial: paraffin, whirlpool, hot packs
4. Deep: ultrasound, diathermy.

Iontophoresis: Combines modalities with medication to deliver medication like steroids to local tissues. This is done with a skilled therapist or doctor.
   
Transcutaneous electrical nerve stimulation (TENS): This device is used to treat pain. A therapist can provide a trial of a TENS unit for a patient, and if beneficial, instruct the patient in use of the device at home. A doctor’s prescription is required.

Acupuncture: Performed by a licensed acupuncture therapist. This may be beneficial for some patients for treatment of their pain. The number of treatments and frequency of treatment are variable.

Medical Specialists
There are many different medical specialists that need to be involved in your care to maximize symptom management and improve quality of life. 

Physical Medicine and Rehabilitation (Physiatrist)
A physician who specializes in treatment of conditions that affect mobility, self care, and interfere with the ability to perform given roles at home, work, and in the community.

Rheumatologist
A physician who specializes in diseases of the musculoskeletal system. They diagnose and treat arthritis. They are the experts in medications to treat rheumatoid arthritis.

Orthopedic Surgeon
A physician who specializes in the surgical treatment of conditions that affect the spine and nervous system.

Internist
A physician that provides general health care to adults.

Psychiatrist
A physician who specializes in the treatment of conditions that affect emotional well-being and cognitive disturbances. They are experts in treating depression and are very knowledgeable in medication and medication side effects. They can be helpful for persons experiencing chronic pain.

Podiatrist
A specialist in problems with the feet. They are knowledgeable about shoe orthotics and specialized shoes.