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Questions & Answers About Arthritis and Rheumatoid Arthritis

This fact sheet answers basic questions about arthritis and rheumatic diseases. The National Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse (NAMSIC) has other fact sheets that provide more information about specific forms of arthritis and rheumatic diseases. NAMSIC also has information about exercise and arthritis and diet and arthritis.

If you have further questions after reading this fact sheet, you may wish to discuss them with your doctor.

• What Are Rheumatic Diseases and What Is Arthritis?
• What Causes Rheumatic Disease?
• Who Is Affected by Arthritis and Rheumatic Conditions?
• What Are the Symptoms of Arthritis?
• How Are Rheumatic Diseases Diagnosed?
• What Are the Treatments?
• What Can Be Done To Help?
• What Is Some of the Current Research Being Done on Arthritis?
• Where Can People Find More Information About Arthritis?
• Acknowledgments

What Are Rheumatic Diseases and What Is Arthritis?

There are more than 100 rheumatic diseases. These diseases may cause pain, stiffness, and swelling in joints and other supporting structures of the body such as muscles, tendons, ligaments, and bones. Some rheumatic diseases can also affect other parts of the body, including various internal organs.

Many people use the word “arthritis” to refer to all rheumatic diseases. However, the word literally means joint inflammation; that is, swelling, redness, heat, and pain caused by tissue injury or disease in the joint. The many different kinds of arthritis comprise just a portion of the rheumatic diseases. Some rheumatic diseases are described as connective tissue diseases because they affect the body’s connective tissue—the supporting framework of the body and its internal organs. Others are known as autoimmune diseases because they are caused by a problem in which the immune system harms the body’s own healthy tissues. Examples of some rheumatic diseases are provided on the next page.

Examples of Rheumatic Diseases

• Osteoarthritis—Also known as degenerative joint disease, osteoarthritis is the most common type of arthritis, affecting an estimated 20.7 million adults in the United States. Osteoarthritis primarily affects cartilage, which is the tissue that cushions the ends of bones within the joint. Osteoarthritis occurs when cartilage begins to fray, wear, and decay. In extreme cases, the cartilage may wear away entirely, leaving a bone-on-bone joint. Bony spurs (pointy bulges of bone) may form at the edges of the joint. Osteoarthritis can cause joint pain, reduced joint motion, loss of function, and disability. Disability results most often when the disease affects the spine and the weight-bearing joints (the knees and hips).
• Rheumatoid arthritis—Rheumatoid arthritis is an inflammatory disease of the synovium, or lining of the joint, that results in pain, stiffness, swelling, deformity, and loss of function in the joints. Inflammation most often affects joints of the hands and feet and tends to be symmetrical (occurring equally on both sides of the body). This symmetry helps distinguish rheumatoid arthritis from other types of arthritis. About 1 percent of the U.S. population (about 2.1 million people) has rheumatoid arthritis.
• Fibromyalgia—Fibromyalgia is a chronic disorder that causes pain and stiffness throughout the tissues that support and move the bones and joints. Pain and localized tender points occur in the muscles and tendons, particularly those of the neck, spine, shoulders, and hips. Patients may experience widespread pain, fatigue, and sleep disturbances.
• Systemic lupus erythematosus—Systemic lupus erythematosus (also known as lupus and SLE) is an autoimmune disease in which the immune system harms the body’s own healthy cells and tissues. In SLE, this can result in inflammation of and damage to the joints, skin, kidneys, heart, lungs, blood vessels, and brain.
• Scleroderma—Also known as systemic sclerosis, the word scleroderma means “hard skin.” It refers to several diseases that almost always affect the skin, blood vessels, and joints. A more serious form also affects internal organs such as the lungs and kidneys. In scleroderma, there is an abnormal and excessive production of collagen (a fiber-like protein) in the skin or internal organs.
• Juvenile rheumatoid arthritis—This is the most common form of arthritis in childhood, causing pain, stiffness, swelling, and loss of function in the joints. The arthritis may be associated with rashes or fevers, or may affect other parts of the body.
• Ankylosing spondylitis—This type of arthritis primarily affects the spine, but may also cause arthritis in the hips, shoulders, and knees. The tendons and ligaments around the bones and joints in the spine become inflamed, resulting in pain and stiffness, especially in the lower back. Ankylosing spondylitis tends to affect people in late adolescence or early adulthood.
• Gout—This type of arthritis results from deposits of needle-like crystals of uric acid in the connective tissue, joint spaces, or both. Uric acid is a normal breakdown product of purines, which are present in body tissues and in many foods. Usually, uric acid passes through the kidney into urine and is eliminated. If the concentration of uric acid in the blood rises above normal levels, sodium urate crystals may form in the tendons, ligaments, and cartilage of the joints. These needle-like crystals cause inflammation, swelling, and pain in the affected joint. The joint most commonly affected is the big toe.
• Infectious arthritis—This is a general term used to describe forms of arthritis that are caused by infectious agents, such as bacteria or viruses. Parvovirus arthritis, gonococcal arthritis, and Lyme disease are examples of infectious arthritis. In those cases caused by bacteria, early diagnosis and treatment with antibiotics relieve the arthritis symptoms and cure the disease.
• Reactive arthritis—This form of arthritis develops after an infection involving the lower urinary tract, bowel, or other organs. It is commonly associated with eye problems, skin rashes, and mouth sores. Reiter’s syndrome is an example of reactive arthritis.
• Psoriatic arthritis—This form of arthritis occurs in some patients with psoriasis, a common scaling skin disorder. Psoriatic arthritis often affects the joints at the ends of the fingers and is accompanied by changes in the fingernails and toenails. Some people also have spinal involvement.
• Bursitis—This condition involves inflammation of the bursae, small, fluid-filled sacs that help reduce friction between bones and other moving structures in the joints. The inflammation may result from arthritis in the joint or injury or infection of the bursae. Bursitis produces pain and tenderness and may limit the movement of nearby joints.
• Tendinitis (Tendonitis)—This refers to inflammation of tendons (tough cords of tissue that connect muscle to bone) caused by overuse, injury, or related rheumatic conditions. Tendinitis produces pain and tenderness and may restrict movement of nearby joints.

What Causes Rheumatic Disease?

The causes of rheumatic diseases vary depending on the type of disease. Researchers have pinpointed the cause or causes of some rheumatic diseases, such as infectious arthritis and gout.

The causes of most rheumatic diseases are still under investigation. In osteoarthritis, excessive stress on the joint, from repeated injury or inherited cartilage weakness, may play a role. In lupus, rheumatoid arthritis, and scleroderma, the combination of genetic factors that determine susceptibility, the influence of certain hormones, and environmental triggers are believed to be important.

Scientists are also studying the risk factors that determine why some people develop rheumatic diseases and others do not. For example, being overweight increases the likelihood that a person will develop osteoarthritis. The chance of developing osteoarthritis also increases with age. Genes and family history play a role in many rheumatic diseases including gout, rheumatoid arthritis, lupus, ankylosing spondylitis, scleroderma, and some others.

Certain rheumatic conditions, such as lupus, rheumatoid arthritis, scleroderma, and fibromyalgia, are more common among women (see below for details). This indicates that hormones or other male-female differences play a role in the development of these conditions.

Who Is Affected by Arthritis and Rheumatic Conditions?

An estimated 40 million people in the United States have arthritis or other rheumatic conditions. By the year 2020, this number is expected to reach 59 million. Rheumatic diseases are the leading cause of disability among adults age 65 and older.

Rheumatic diseases affect people of all races and ages. Some rheumatic conditions are more common among certain populations. For example:

• Rheumatoid arthritis occurs two to three times more often in women than in men.
• Scleroderma is more common in women than in men.
• Nine out of 10 people who have lupus are women.
• Nine out of 10 people who have fibromyalgia are women.
• Gout is more common in men than in women.
• Lupus is three times more common in African-American women than in Caucasian women.
• Ankylosing spondylitis is more common in men than in women.

Common Symptoms of Arthritis

• Swelling in one or more joints
• Stiffness around the joints that lasts for at least 1 hour in the early morning
• Constant or recurring pain or tenderness in a joint
• Difficulty using or moving a joint normally
• Warmth and redness in a joint

What Are the Symptoms of Arthritis?

Different types of arthritis have different symptoms. In general, people who have arthritis have pain and stiffness in the joints. Some of the more common symptoms are listed in the box on this page. Early diagnosis and treatment help decrease further joint damage and help control symptoms of arthritis and many other rheumatic diseases.

How Are Rheumatic Diseases Diagnosed?

Diagnosing rheumatic diseases can be difficult because some symptoms and signs are common to many different diseases. A general practitioner or family doctor may be able to evaluate a patient or refer him or her to a rheumatologist: a doctor who specializes in treating arthritis and other rheumatic diseases.

The doctor will review the patient’s medical history, conduct a physical examination, and obtain laboratory tests and X rays or other imaging tests. The doctor may need to see the patient more than once to make an accurate diagnosis.

Medical History

It is vital for people with joint pain to give the doctor a complete medical history. Answers to the following questions will help the doctor make an accurate diagnosis:

• Is the pain in one or more joints?
• When does the pain occur?
• How long does the pain last?
• When did you first notice the pain?
• What were you doing when you first noticed the pain?
• Does activity make the pain better or worse?
• Have you had any illnesses or accidents that may account for the pain?
• Is there a family history of any arthritis or rheumatic diseases?
• What medicine(s) are you taking?

It may be helpful for people to keep a daily journal that describes the pain. Patients should write down what the affected joint looks like, how it feels, how long the pain lasts, and what they were doing when the pain started.

Physical Examination and Laboratory Tests

The doctor will examine all of the patient’s joints for redness, warmth, deformity, ease of movement, and tenderness. Because some forms of arthritis, such as lupus, may affect other organs, a complete physical examination including the heart, lungs, abdomen, nervous system, and eyes, ears, and throat may be necessary. The doctor may order some laboratory tests to help confirm a diagnosis. Samples of blood, urine, or synovial

Common Laboratory Tests

• Antinuclear antibody (ANA)—This test checks blood levels of antibodies that are often present in people who have connective tissue diseases or other autoimmune disorders, such as lupus. Since the antibodies react with material in the cell’s nucleus (control center), they are referred to as antinuclear antibodies. There are also tests for individual types of ANA’s that may be more specific to people with certain autoimmune disorders. ANA’s are also sometimes found in healthy people. Therefore, having ANA’s in the blood does not necessarily mean that a person has a disease.
• Arthrocentesis—Arthrocentesis or joint aspiration is done to obtain a sample of synovial fluid. The doctor injects a local anesthetic, inserts a thin, hollow needle into the joint, and removes the synovial fluid into a syringe. The test provides important diagnostic information. For example, the test allows the doctor to see whether crystals (found in patients with gout or other types of crystal-induced arthritis) or bacteria or viruses (found in patients with infectious arthritis) are present in the joint.
• Complement—This test measures the level of complement, a group of proteins in the blood. Complement helps destroy foreign substances, such as germs, that enter the body. A low blood level of complement is common in people who have active lupus.
• Complete blood count (CBC)—This test determines the number of white blood cells, red blood cells, and platelets present in a sample of blood. Some rheumatic conditions or drugs used to treat arthritis are associated with a low white blood count (leukopenia), low red blood count (anemia), or low platelet count (thrombocytopenia). When doctors prescribe medications that affect the CBC, they periodically test the patient’s blood.
• Creatinine—This blood test is commonly ordered in patients who have rheumatic diseases to monitor for underlying kidney disease.
• Erythrocyte sedimentation rate (sed rate)—This blood test is used to detect inflammation in the body. Higher sed rates indicate the presence of inflammation and are typical of many forms of arthritis, such as rheumatoid arthritis and ankylosing spondylitis, and many of the connective tissue diseases.
• Hematocrit (PCV, packed cell volume)—This test and the test for hemoglobin (a substance in the red blood cells that carries oxygen through the body) measure the number of red blood cells present in a sample of blood. A decrease in the number of red blood cells (anemia) is common in people with inflammatory arthritis and rheumatic diseases.
• Rheumatoid factor—This test determines whether rheumatoid factor is present in the blood. Rheumatoid factor is an antibody found in the blood of most (but not all) people who have rheumatoid arthritis. Rheumatoid factor may be found in many other diseases besides rheumatoid arthritis, and sometimes in normal, healthy people.
• Urinalysis—In this test, a urine sample is studied for protein, red blood cells, white blood cells, or casts. These abnormalities indicate kidney disease, which may be seen in several rheumatic diseases such as lupus or vasculitis. Some medications used to treat arthritis can also cause abnormal findings on urinalysis.
• White blood cell count (WBC)—This test determines the number of white blood cells present in a sample of blood. The number may increase as a result of infection or decrease in response to certain medications, or with certain diseases, such as lupus. Low numbers of white blood cells increase a person’s risk of infections.

Work With Your Doctor To Limit Your Pain

The role you play in developing your treatment plan is very important. It is vital for you to have a good relationship with your doctor so that you can work together. You should not be afraid to ask questions about your condition or treatment. You must understand the treatment plan and tell the doctor whether or not it is helping you. Studies have shown that patients who are well informed and participate actively in their own care experience less pain and make fewer visits to the doctor than other patients do.

X Rays and Other Imaging Procedures

To see what the joint looks like inside, the doctor may order X rays or other imaging procedures. X rays provide an image of the bones, but they do not show the cartilage, muscles, and ligaments. Other noninvasive imaging methods such as computed tomography (CT or CAT), magnetic resonance imaging (MRI), and arthrography (joint X ray) show the whole joint. The doctor may also use an arthroscope (a small, flexible tube that transmits the image of the inside of a joint to a video screen) to examine damage to a joint. The arthroscope is inserted into the affected joint through a very small incision in the skin. This procedure, called arthroscopy, allows the doctor to see inside the joint. Doctors also use arthroscopy to perform surgery for some types of joint injury.

What Are the Treatments?

Treatments for arthritis include rest and relaxation, exercise, proper diet, medication, and instruction about the proper use of joints and ways to conserve energy. Other treatments include the use of pain relief methods and assistive devices, such as splints or braces. In severe cases, surgery may be necessary. The doctor and the patient work together to develop a treatment plan that helps the patient maintain or improve his or her lifestyle. Treatment plans usually combine several types of treatment and vary depending on the rheumatic condition and the patient.

Rest, Exercise, and Diet

People who have a rheumatic disease should develop a comfortable balance between rest and activity. One sign of many rheumatic conditions is fatigue. Patients must pay attention to signals from their bodies. For example, when experiencing pain or fatigue, it is important to take a break and rest. Too much rest, however, may cause muscles and joints to become stiff.

Physical exercise can reduce joint pain and stiffness and increase flexibility, muscle strength, and endurance. It also helps with weight reduction and contributes to an improved sense of well-being. Before starting any exercise program, people with arthritis should talk with their doctor. People with arthritis can participate in a variety of sports and exercise programs. Exercises that doctors often recommend include

• Range-of-motion exercises to help maintain normal joint movement, maintain or increase flexibility, and relieve stiffness.
• Strengthening exercises to maintain or increase muscle strength. Strong muscles help support and protect joints affected by arthritis.
• Aerobic or endurance exercises to improve cardiovascular fitness, help control weight, and improve overall well-being. Studies show that aerobic exercise can also reduce inflammation in some joints.

Another important part of a treatment program is a well-balanced diet. Along with exercise, a well-balanced diet helps people manage their body weight and stay healthy. Weight control is important to people who have arthritis because extra weight puts extra pressure on some joints and can aggravate many types of arthritis. Diet is especially important for people who have gout. People with gout should avoid alcohol and foods that are high in purines, such as organ meats (liver, kidney), sardines, anchovies, and gravy.

Medications

A variety of medications are used to treat rheumatic diseases. The type of medication depends on the rheumatic disease and on the individual patient. At this time, the medications used to treat most rheumatic diseases do not provide a cure, but rather limit the symptoms of the disease. The one exception is treatments for infectious arthritis. If caught early enough, arthritis associated with an infection (such as Lyme disease) can usually be cured with antibiotics.

Medications commonly used to treat rheumatic diseases provide relief from pain and inflammation. In some cases, the medication may slow the course of the disease and prevent further damage to joints or other parts of the body. This fact sheet describes the medications most commonly used to treat pain and inflammation.

The doctor may delay using medications until a definite diagnosis is made, because medications can hide important symptoms (such as fever and swelling) and thereby interfere with diagnosis. Patients taking any medication, either prescription or over-the-counter, should always follow the doctor’s instructions. The doctor should be notified immediately if the medicine is making the symptoms worse or causing other problems, such as an upset stomach, nausea, or headache. The doctor may be able to change the dosage or medicine to reduce these side effects.

Analgesics (pain relievers) such as aspirin; other nonsteroidal anti-inflammatory drugs (NSAID’s) such as ibuprofen (Motrin,þ Advil, Nuprin); and acetaminophen (Tylenol) are used to reduce the pain caused by many rheumatic conditions. Aspirin and NSAID’s have the added benefit of decreasing the inflammation associated with arthritis. Certain analgesics, such as aspirin and NSAID’s, can have side effects, such as stomach irritation, that can be reduced by changing the dosage or the medication. The dosage will vary depending on the particular illness and the overall health of the patient. The doctor and patient must work together to determine which analgesic to use and the appropriate amount. If analgesics do not ease the pain, the doctor may use other medications, depending on the diagnosis.

þ Brand names included in this fact sheet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean that the product is unsatisfactory.

Corticosteroids, such as prednisone, cortisone, solumedrol, and hydrocortisone, are used to treat many rheumatic conditions because they decrease inflammation and suppress the immune system. The dosage of these medications will vary depending on the diagnosis and the patient; again, the patient and doctor must work together to determine what dose is best for the patient.

Corticosteroids can be given by mouth, in creams applied to the skin, or by injection. Short-term side effects of corticosteroids include swelling, increased appetite, weight gain, and emotional ups and downs. These side effects generally stop when the drug is stopped. It can be dangerous to stop taking corticosteroids suddenly, so it is very important that the doctor and patient work together when changing the corticosteroid dose. Side effects that may occur after long-term use of corticosteroids include stretch marks, excessive hair growth, osteoporosis, high blood pressure, damage to the arteries, high blood sugar, infections, and cataracts.

Although some rheumatic diseases respond to analgesics and corticosteroids, others may not. Rheumatoid arthritis, gout, lupus, scleroderma, and fibromyalgia are some of the rheumatic diseases that routinely require other medications; these are prescribed to slow the course of the disease or to treat disease-specific symptoms.

Heat and Cold Therapies

Heat and cold can both be used to reduce the pain and inflammation of arthritis. Both therapies come in different forms, and the patient and doctor can determine which form works best. Studies have shown heat and cold therapies to be equally effective in reducing pain, although they are usually avoided in acute gout.

Heat therapy increases blood flow, tolerance for pain, and flexibility. Heat therapy can involve treatment with paraffin wax, microwaves, ultrasound, or moist heat. Physical therapists are needed to apply paraffin wax, or use microwave or ultrasound therapy, but patients can apply moist heat themselves. Some ways to apply moist heat include placing warm towels or hot packs on the inflamed joint or taking a warm bath or shower.

Cold therapy numbs the nerves around the joint (which reduces pain) and relieves inflammation and muscle spasms. Cold therapy can involve cold packs, ice massage, soaking in cold water, or over-the-counter sprays and ointments that cool the skin and joints.

Hydrotherapy, Mobilization Therapy, and Relaxation Therapy

Hydrotherapy involves exercising or relaxing in warm water, which helps relax tense muscles and relieve pain. Exercising in a large pool is easier because water takes some weight off painful joints. This type of exercise improves muscle strength and joint movement.

Mobilization therapies include traction (gentle, steady pulling), massage, and manipulation (using the hands to restore normal movement to stiff joints). When done by a trained professional, these methods can help control pain, increase joint motion, and improve muscle and tendon flexibility.

Relaxation therapy helps reduce pain by teaching people various ways to release muscle tension throughout the body. In one method of relaxation therapy, known as progressive relaxation, the patient tightens a muscle group and then slowly releases the tension. Doctors and physical therapists can teach patients progressive relaxation and other relaxation techniques.

Assistive Devices

The most common assistive devices for treating arthritis pain are splints and braces, which are used to support weakened joints or allow them to rest. Some of these devices prevent the joint from moving; others allow some movement. A splint or brace should be used only when recommended by a doctor or therapist, who will show the patient the correct way to put the device on, ensure that it fits properly, and explain when and for how long it should be worn. The incorrect use of a splint or brace can cause joint damage, stiffness, and pain.

A person with arthritis can use other kinds of devices to ease the pain. For example, the use of a cane when walking can reduce some of the weight placed on an arthritic knee or hip. A shoe insert (orthotic) can ease the pain of walking caused by arthritis of the foot or knee.

Arthritis Surgery

Surgery may be required to repair damage to a joint after trauma (a torn meniscus, for example) or to restore function or relieve pain in a joint damaged by arthritis. The doctor may recommend arthroscopic surgery, bone fusion (surgery in which bones in the joint are fused or joined together), or arthroplasty (also known as total joint replacement, in which the damaged joint is removed and replaced with an artificial one).

Myths About Treating Arthritis

At this time, the only type of arthritis that can be cured is that caused by infections. Although symptoms of other types of arthritis can be effectively managed with rest, exercise, and medication, there are no cures. Some people claim to have been cured by treatment with herbs, oils, chemicals, special diets, radiation, or other products. However, there is no scientific evidence that such treatments are helpful in patients with arthritis and, moreover, they may actually cause harm with the development of side effects. Patients should talk to their doctor before using any therapy that has not been prescribed or recommended by the health care team caring for the patient.

What Can Be Done To Help?

Studies show that an estimated 18 percent of Americans who have arthritis or other rheumatic conditions believe that their condition limits their activities. People with arthritis may find that they can no longer participate in some of their favorite activities, which can affect their overall well-being. Even when arthritis impairs only one joint, a person may have to change many daily activities to protect that joint from further damage and reduce pain. When arthritis affects the entire body, as it does in people with rheumatoid arthritis or fibromyalgia, many daily activities have to be changed to deal with pain, fatigue, and other symptoms.

Changes in the home may help a person with chronic arthritis continue to live safely, productively, and with less pain. People with arthritis may become weak, lose their balance, or fall in the bathroom. Installing grab bars in the tub or shower and by the toilet, placing a secure seat in the tub, and raising the height of the toilet seat can help. Special kitchen utensils can accommodate arthritic hands to make meal preparation easier. An occupational therapist can help people who have rheumatic conditions identify and make adjustments in their homes to create a safer, less painful, and more efficient environment.

Friends and family can help a patient with a rheumatic condition by learning about that condition and understanding how it affects the patient’s life. Friends and family can provide emotional and physical assistance. Their support, as well as support from other people who have the same disease, can make it easier to cope. The Arthritis Foundation (see the list of resources at the end of this fact sheet) has a wealth of information to help people with arthritis.

What Is Some of the Current Research Being Done on Arthritis?

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the National Institutes of Health (NIH), leads the Federal medical research effort in arthritis and rheumatic diseases. The NIAMS sponsors research and research training on the NIH campus in Bethesda, Maryland, and at universities and medical centers throughout the United States.

The NIAMS supports three types of centers: Multipurpose Arthritis and Musculoskeletal Diseases Centers (MAMDC’s), Specialized Centers of Research (SCOR’s), and Core Centers.

The MAMDC’s foster a multidisciplinary approach to the many problems of arthritis and musculoskeletal diseases and develop new capabilities for research into other diseases. Centers develop and carry out research in basic or laboratory and clinical science, professional and patient education, and epidemiology and health services.

Each SCOR focuses on a single disease: currently, rheumatoid arthritis, systemic lupus erythematosus, osteoarthritis, osteoporosis, and scleroderma. By doing laboratory and clinical studies under one roof, these centers aim to speed up basic research on the causes of these diseases and to hasten transfer of advances from the laboratory to the bedside and improve patient care.

Core Centers promote interdisciplinary collaborative efforts among scientists engaged in high-quality research related to a common theme. By providing funding for facilities, pilot and feasibility studies, and program enrichment activities at the Core Center, the Institute reinforces and amplifies investigations already ongoing in NIAMS program areas. Core Centers are currently targeted for skin diseases (Skin Disease Research Core Centers) and for musculoskeletal disorders (Core Centers for Musculoskeletal Disorders).

Some current NIAMS research efforts in rheumatoid arthritis, osteoarthritis, lupus, and scleroderma are outlined below.

Rheumatoid Arthritis

Researchers are trying to identify the causes of rheumatoid arthritis in the hope that understanding the cause will lead to new treatments. They are examining the role that the endocrine (hormonal), nervous, and immune systems play, and the ways in which these systems interact with environmental and genetic factors in the development of rheumatoid arthritis. Some scientists are trying to determine whether an infectious agent triggers rheumatoid arthritis. Others are studying the role of certain enzymes (specialized proteins in the body that carry out biochemical reactions) in breaking down cartilage. Researchers are also trying to identify the genetic factors that place some people at higher risk than others for developing rheumatoid arthritis.

Moreover, scientists are looking at new ways to treat rheumatoid arthritis. They are experimenting with new drugs and “biologic agents” that selectively block certain immune system activities associated with inflammation. Recent studies suggest that these represent promising approaches to treatment. Other investigators have shown that minocycline and doxycycline, two antibiotic medications in the tetracycline family, have a modest benefit for people with rheumatoid arthritis.

Osteoarthritis

Researchers are working to understand what role certain enzymes play in the breakdown of joint cartilage in osteoarthritis and are testing drugs that block the action of these enzymes. In addition, a gene that may be linked to an inherited form of osteoarthritis has recently been discovered.

Systemic Lupus Erythematosus

Researchers are looking at how genetic, environmental, and hormonal factors influence the development of systemic lupus erythematosus. They are trying to find out why lupus is more common in certain populations. There has been very promising progress in identifying the genes that may be responsible for lupus. Promising areas of treatment research include biologic agents; newer, more selective drugs that suppress the immune system; and efforts to correct immune abnormalities with bone marrow transplantation. Clinical studies are underway to determine the safety of estrogens for hormone replacement therapy and birth control in women with lupus. Contrary to the widely held belief that estrogens can make the disease worse, recent data suggest that these drugs may be safe for some women with lupus.

Scleroderma

Current studies on scleroderma are focusing on three areas of the disease: overproduction of collagen, blood vessel injury, and abnormal immune system activity. Researchers hope to discover how these three elements interact with each other to cause and promote scleroderma. In one recent study, researchers found evidence of fetal cells within the blood and skin lesions of women who had been pregnant years before developing scleroderma. The study suggests that fetal cells may play a role in scleroderma by maturing immune cells that promote the overproduction of collagen. Scientists are continuing to study the implications of this finding.

Where Can People Find More Information About Arthritis and Rheumatic Diseases?

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484 or
877-22-NIAMS (226-4267) (free of charge)
TTY: 301-565-2966
Fax: 301-718-6366
E-mail: niamsinfo@mail.nih.gov
www.niams.nih.gov
NIAMS provides information about various forms of arthritis and rheumatic diseases and bone, muscle, joint, and skin diseases. It distributes patient and professional education materials and refers people to other sources of information. Additional information and updates can be found on the NIAMS Web site. Listings of clinical trials recruiting patients who have or are at risk of developing a rheumatic disease can be found at www.ClinicalTrials.gov.

American Academy of Orthopaedic Surgeons
P.O. Box 2058
Des Plaines, IL 60017
Phone: 800-824-BONE (2663) (free of charge)
www.aaos.org
The academy provides education and practice management services for orthopaedic surgeons and allied health professionals. It also serves as an advocate for improved patient care and informs the public about the science of orthopaedics. The orthopaedist's scope of practice includes disorders of the body's bones, joints, ligaments, muscles, and tendons. For a single copy of an AAOS brochure, send a self-addressed stamped envelope to the address above or visit the AAOS Web site.

American College of Rheumatology/Association of Rheumatology Health Professionals
1800 Century Place, Suite 250
Atlanta, GA 30345-4300
Phone: 404-633-3777
Fax: 404-633-1870
www.rheumatology.org
This association provides referrals to rheumatologists and physical and occupational therapists who have experience working with people who have rheumatic diseases. The organization also provides educational materials and guidelines about many different rheumatic diseases.

Arthritis Foundation
1330 West Peachtree Street, Suite 100
Atlanta, GA 30309
Phone: 404-872-7100 or 800-568-4045 (free of charge)
or call your local chapter (listed in the telephone directory)
www.arthritis.org
This is the main voluntary organization devoted to arthritis. The foundation publishes free pamphlets on many types of arthritis and a monthly magazine for members that provides up-to-date information on arthritis. The foundation can provide physician and clinic referrals. The American Juvenile Arthritis Organization (AJAO) is under the umbrella of the Arthritis Foundation. It shares the same address, phone numbers, and Web site.

Acknowledgments

The NIAMS gratefully acknowledges the assistance of Barri Fessler, M.D., Cleveland Clinic Foundation, OH; John H. Klippel, M.D., Arthritis Foundation, Washington, DC; Reva Lawrence, M.P.H., NIAMS, NIH; Eric Matteson, M.D., Mayo Clinic, Rochester, MN; and Barbara Mittleman, M.D., NIAMS, NIH in the preparation and review of the current and earlier versions of this fact sheet.

Acupuncture Relieves Pain and Improves Function in Knee Osteoarthritis

By the National Center for Complementary and Alternative Medicine and National Institute of Arthritis and Musculoskeletal and Skin Diseases

Acupuncture provides pain relief and improves function for people with osteoarthritis of the knee and serves as an effective complement to standard care. This landmark study was funded by the National Center for Complementary and Alternative Medicine (NCCAM) and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), both components of the National Institutes of Health. The findings of the study-the longest and largest randomized, controlled phase III clinical trial of acupuncture ever conducted-were published in the December 21, 2004, issue of the Annals of Internal Medicine (I).

The Study

The multi-site study team, including rheumatologists and licensed acupuncturists, enrolled 570 patients, aged 50 or older with osteoarthritis of the knee. Participants had significant pain in their knee the month before joining the study, but had never experienced acupuncture, had not had knee surgery in the previous 6 months, and had not used steroid or similar injections. Participants were randomly assigned to receive one of three treatments: acupuncture, sham acupuncture, or participation in a control group that followed the Arthritis Foundation's self-help course for managing their condition. Patients continued to receive standard medical care from their primary physicians, including anti-inflammatory medications, such as COX-2 selective inhibitors, non-steroidal anti-inflammatory drugs, and opioid pain relievers.

The Result

"For the first time, a clinical trial with sufficient rigor, size, and duration has shown that acupuncture reduces the pain and functional impairment of osteoarthritis of the knee," said Stephen E. Straus, M.D., NCCAM Director. "These results also indicate that acupuncture can serve as an effective addition to a standard regimen of care and improve quality of life for knee osteoarthritis sufferers. NCCAM has been building a portfolio of basic and clinical research that is now revealing the power and promise of applying stringent research methods to ancient practices like acupuncture."

The Scope of Osteoarthritis

"More than 20 million Americans have osteoarthritis. This disease is one of the most frequent causes of physical disability among adults," said Stephen I. Katz, M.D., Ph.D., NIAMS Director. "Thus, seeking an effective means of decreasing osteoarthritis pain and increasing function is of critical importance."

Effectiveness of Acupuncture as Adjunctive Therapy in Osteoarthritis of the Knee

During the course of the study, led by Brian M. Berman, M.D., Director of the Center for Integrative Medicine and Professor of Family Medicine at the University of Maryland School of Medicine, Baltimore, Maryland, 190 patients received true acupuncture and 191 patients received sham acupuncture for 24 treatment sessions over 26 weeks. Sham acupuncture is a procedure designed to prevent patients from being able to detect if needles are actually inserted at treatment points. In both the sham and true acupuncture procedures, a screen prevented patients from seeing the knee treatment area and learning which treatment they received. In the education control group, 189 participants attended six, 2-hour group sessions over 12 weeks based on the Arthritis Foundation's Arthritis Self-Help Course-a proven, effective model.

On joining the study, patients' pain and knee function were assessed using standard arthritis research survey instruments and measurement tools, such as the Western Ontario McMasters Osteoarthritis Index (WOMAC). Patients' progress was assessed at 4, 8, 14, and 26 weeks. By week 8, participants receiving acupuncture were showing a significant increase in function and by week 14 a significant decrease in pain, compared with the sham and control groups. These results, shown by declining scores on the WOMAC index, held through week 26. Overall, those who received acupuncture had a 40 percent decrease in pain and a nearly 40 percent improvement in function compared to baseline assessments.

"This trial, which builds upon our previous NCCAM-funded research, establishes that acupuncture is an effective complement to conventional arthritis treatment and can be successfully employed as part of a multidisciplinary approach to treating the symptoms of osteoarthritis," said Dr. Berman.

Acupuncture's Progress

Acupuncture-the practice of inserting thin needles into specific body points to improve health and well-being-originated in China more than 2,000 years ago. In 2002, acupuncture was used by an estimated 2.1 million U.S. adults, according to the Centers for Disease Control and Prevention's 2002 National Health Interview Survey (II). The acupuncture technique that has been most studied scientifically involves penetrating the skin with thin, solid, metallic needles that are manipulated by the hands or by electrical stimulation. In recent years, scientific inquiry has begun to shed more light on acupuncture's possible mechanisms and potential benefits, especially in treating painful conditions such as arthritis.

The Web site for the Center for Integrative Medicine at the University of Maryland School of Medicine is www.compmed.umm.edu.

The National Center for Complementary and Alternative Medicine (NCCAM) is dedicated to exploring complementary and alternative medical (CAM) practices in the context of rigorous science, training CAM researchers, and disseminating authoritative information to the public and professionals. For additional information, call NCCAM's Clearinghouse toll free at 1-888-644-6226, or visit the NCCAM Web site at www.nccam.nih.gov.

The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases, the training of basic and clinical scientists to carry out this research, and the dissemination of information on research progress in these diseases. For additional information, call NIAMS's Clearinghouse toll free at 1-877-22-NIAMS, or visit the NIAMS Web site at www.niams.nih.gov.

I Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AMK, Hochberg MC. Effectiveness of Acupuncture as Adjunctive Therapy in Osteoarthritis of the Knee: A Randomized, Controlled Trial. Annals of Internal Medicine. 2004; 141(12):901-910.

II Barnes P, Powell-Griner E, McFann K, Nahin R. CDC Advance Data Report #343. Complementary and Alternative Medicine Use Among Adults: United States, 2002. May 27, 2004.

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