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Rheumatoid arthritis

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of rheumatoid arthritis.

Alternative Names

Arthritis - rheumatoid

Lifestyle Changes

It is important to maintain a balance between rest (which will reduce inflammation) and exercise (which will relieve stiffness and weakness). Studies have suggested that even as little as 3 hours of physical therapy over 6 weeks will help people with RA, and that these benefits are sustained.

The goal of exercise is to:

• Maintain a wide range of motion
• Increase strength, endurance, and mobility
• Improve general health
• Promote well-being

In general, doctors recommend the following approaches:

• Start with the easiest exercises, stretching and tensing of the joints without movement.
• Next attempt mild strength training. (One study found that people with RA who exercised with machines that use compressed air for gentle resistance experienced less pain and increased muscle tone.)
• Aerobic exercises may then be tried. These include walking, dancing, or swimming, particularly in heated pools. Avoid heavy impact exercises such as running, downhill skiing, and jumping.
• Tai chi, which uses graceful slow sweeping movements, is an excellent method for combining stretching and range-of-motion exercises with relaxation techniques. It is of particularly value for elderly RA patients who report significantly less pain after practicing this technique.

While traditional guidelines have restricted RA patients to only gentle exercise, recent research suggests that more intense exercise may not only be safe, but may actually produce greater muscle strength and overall functioning. Common sense is the best guide:

• If exercise is causing sharp pain, stop immediately.
• If lesser aches and pains continue for more than 2 hours afterwards, then a lighter exercise program should be tried for a while.
• Using large joints instead of small ones for ordinary tasks can help relieve pressure, for instance, closing a door with the hip or pushing buttons with the palm of the hand.

Diet

Fad diets for RA are common:

• Some people claim that foods from the nightshade family (tomatoes, potatoes, green peppers, and eggplant) can worsen arthritis.
• The Dong Diet eliminates all additives, preservatives, fruits, red meat, herbs, alcohol, and dairy.
• A few studies have reported that vegetarian diets may be helpful for some patients. In one study, 40% of patients who were on a vegetarian diet and avoided foods containing gluten (found in wheat, barley, and rye) reported improved scores.
• In another study high total caloric intake correlated with worse symptoms.

Little scientific evidence of benefits for RA exists for any of these diets, and some may result in deficiencies of important nutrients. On the other hand, one study found that 10 out of 17 people benefited from any diet recommended by their doctor.

Mediterranean Diet. Perhaps the best recommendation is for the Mediterranean Diet. A 2003 study reported that RA patients who followed it experienced reduced inflammatory activity, improved physical function and improved vitality compared to those on a standard Western diet. The Mediterranean diet is also rich in heart-healthy fiber and nutrients, omega-3 fatty acids, and antioxidants. The diet recommends:

• A relatively high fat intake (about 35 - 45% of daily calories), but mostly from monounsaturated and polyunsaturated oils. The Mediterranean diet is known specifically for its use of olive oil. Some evidence suggests that high intake of olive oil and cooked vegetables reduces the risk of RA.
• Daily glass or two of wine
• Protein source with this diet is primarily fish, which might be specifically helpful for RA patients. Fish (particularly -- but not only -- oily fish) has anti-inflammatory effects. Protein is lost during the inflammatory process, and high amounts of protein may be protective. Either fish or soy should be the primary sources of protein. Some evidence also suggests that fish oil supplements might be helpful.
• Carbohydrate choices emphasize fresh fruits, vegetables, nuts, legumes, beans, and whole grains.
• Foods are seasoned with garlic, onions, and herbs.

Coffee and Tea. A 2002 study reported an association between RA and decaffeinated coffee but not regular coffee. Furthermore, drinking tea was associated with a lower risk.

Vitamins. Certain vitamin supplements may be beneficial. For example, certain drugs used for RA deplete folic acid, a critical vitamin B. Some patients take antioxidant supplements, such as vitamins C and E and selenium, although there is no strong evidence supporting their benefits. (Some studies have reported some possible benefits with vitamin E or other antioxidant combinations when used with standard medications.) Patients should check with their doctors about the need for supplements.

Miscellaneous Supportive Treatments

Various ointments, including Ben Gay and capsaicin (a cream that use the active ingredient in chilies) may help soothe painful joints.

Orthotic devices are specialized braces and splints that support and help align joints. Many such devices made from a variety of light materials are available and can be very helpful when worn properly.

A number of specially designed appliances and devices are available to ease daily activities.

Managing Psychological and Emotional Conditions

Although the influence of stress or emotions on the progression of RA is not fully known, having a history of major depression that persists or reoccurs seems to increase the pain, disability, and fatigue. Stress management alone cannot reduce pain, but it may be very helpful in helping people deal with their condition.

One study found that people with RA reported significant clinical improvement after writing about their pain, stress, or other traumatic experiences. Writing for 20 minutes, just a few days a week, resulted in improvement that lasted for months. A 2001 study found that spirituality (defined as "a belief in a power outside oneself and one's own existence," as opposed to the practice of any specific religion) is associated with better health, happiness and well-being among RA patients. (Spiritual healing does not appear to offer any advantages.)

Alternative and Integrative Medicine

People often turn to alternative therapies or nontraditional remedies to relieve the pain of rheumatoid arthritis. Some alternative procedures, such as acupuncture, massage, relaxation techniques, biofeedback, and hypnosis, are not harmful and may be a useful adjunct to standard treatments.

• In a small 2001 study, acupuncture reduced pain by a third in 73% of patients, and more than half reported at least a 50% improvement in pain. Patients also reduced their use of pain medications. Research presented at the 2006 American College of Rheumatology annual meeting suggested that both electroacupuncture and traditional acupuncture may help reduce joint tenderness.
• Balneotherapy, also known as hydrotherapy or spa therapy, is an ancient form of therapy that involves mineral baths to soothe pain, and some patients have reported relief using such baths.
• The NIH is conducting clinical trials to examine whether relaxation response, tai chi, stress management, and cognitive-behavioral therapy can help patients with RA feel better.

Herbal Remedies

Herbal remedies used for RA include boswellia, equisetum arvense (horsetail), devil's claw, borage seed oil, and many others. To date, no evidence supports their efficacy.

Researchers are currently conducting studies in animals to determine if supplements extracted from the turmeric spice can help prevent joint inflammation. The U.S. National Institutes of Health is also conducting a clinical trial to compare the clinical effects of the Chinese herb Tripterygium wilfordi Hook F (TwHF) with the pharmaceutical drug sulfasalazine. TwHF is traditionally used in Chinese medicine for its anti-inflammatory properties.

Herbs and Supplements Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

• Review Date: 1/16/2007
• Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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