WHAT IS MULTIPLE SCLEROSIS
often called MS, is a disease of the nervous system. It is characterized by repeated attacks of nervous system damage, followed by recovery. The time and severity of attacks are unpredictable. The illness can cause serious disabilities, including paralysis of the legs and partial loss of vision. MS afflicts more women than men. Most patients begin to have symptoms of MS when they are from 20 to 25 years old. MS is the most common cause of disability for people under the age of 45 in the United States.
MS is characterized by scattered areas of inflammation and by destruction of myelin in the white matter of the brain and spinal cord. Myelin is a fatty substance that surrounds and protects certain nerve fibers. Many small, hard, platelike areas of scar called plaques appear throughout the myelin and interfere with the normal function of nerve pathways. The word sclerosis comes from a Greek term that means hard and refers to the plaques. Some studies suggest that MS may kill nerve cells in addition to damaging myelin.
The symptoms of MS depend on which areas of the brain and spinal cord are affected. Therefore, the symptoms differ with each attack. In time, more and more plaques develop in the victim's myelin, causing new symptoms. Physicians diagnose MS chiefly from the symptoms. A technique called magnetic resonance imaging (MRI) can aid in diagnosis. MRI produces highly detailed images of the brain that can rule out other diseases or reveal the telltale plaques.
The first symptoms may appear suddenly, but they may also start slowly and gradually worsen. Difficulty walking is commonly the first problem. Loss of vision, double vision, loss of balance, and weakness in an arm or leg may also occur. Numbness or tingling may occur in the fingers or elsewhere, and problems of coordination are also common. After several days to several weeks, these symptoms decrease and may disappear entirely. New attacks appear unpredictably after periods of recovery lasting months to years. In a small number of patients, symptoms are progressive with no apparent recovery between attacks. About a third of MS patients become seriously disabled, but few die from MS.
Physicians do not know the cause of MS. Many experts think that the disease may involve malfunctions in the body's immune system. Normally, the immune system defends the body against disease by attacking bacteria, viruses, and other invaders. Immune defenses include substances called antibodies and white blood cells. In MS, a defect in the immune system may allow antibodies or white blood cells to attack myelin.
Certain genes that control the body's immune system are associated with MS. Many scientists think the immune system, under the control of genes, may react with an unidentified environmental factor_possibly a virus_to produce a condition that can lead to MS.
There is no cure for MS. Many patients receive drugs called corticosteroids as treatment for attacks. Certain other drugs, such as interferons and glatiramer acetate, can slow the progression of the disease and reduce the frequency of attacks for some patients.
WHAT IS RHEUMATOID ARTHRITIS
More than one in seven Americans experience the nagging pains and physical limitations of the more than 100 forms of arthritis. Rheumatoid arthritis is among the most debilitating of them all, causing joints to ache and throb and eventually become deformed. Sometimes these symptoms make even the simplest things _ like opening a jar or taking a walk _ difficult to manage.
Unlike osteoarthritis, which results from normal wear and tear on the joints, rheumatoid arthritis is an inflammatory condition. The exact cause is unknown. But it's believed to be caused by the body's immune system attacking the synovium _ the tissue that lines the joints.
Rheumatoid arthritis affects about 2.5 million Americans. It's three times more common in women than in men and generally strikes between the ages of 20 and 50. But rheumatoid arthritis also can appear in very young children and adults older than age 50.
There's no cure for rheumatoid arthritis. But with proper treatment, a strategy for joint protection and changes in lifestyle, you can live a long, productive life with the condition.
Signs & Symptoms
The signs and symptoms of rheumatoid arthritis may come and go over time. They include:
Pain and swelling in the smaller joints of your hands and feet
Overall aching or stiffness of the joints and muscles, especially after sleep or after periods of rest
Loss of motion of the affected joints
Loss of strength in muscles attached to the affected joints
Fatigue, which can be severe during a flare_up
Low_grade fever
Deformity of the joints as time goes on
Rheumatoid arthritis usually causes problems in many joints at the same time. Joints in the wrists, hands, feet and ankles are the ones most often affected. The disease also can involve your elbows, shoulders, hips, knees, neck and jaw. It generally affects both sides of the body at the same time. The knuckles of both hands might be one example.
Small lumps, called rheumatoid nodules, may form under the skin of your elbow, your hands, the back of your scalp, over your knee or on your feet and heels. These nodules can range in size _ appearing as small as a pea to as large as a walnut. Usually the lumps aren't painful.
In contrast to osteoarthritis, which affects only your bones and joints, rheumatoid arthritis can cause inflammation of tear glands, salivary glands, the lining of your heart and lungs, the lungs themselves and, in rare cases, your blood vessels.
Although rheumatoid arthritis is often a chronic disease, it tends to vary in severity and may even come and go. Periods of increased disease activity _ called flare_ups or flares _ alternate with periods of relative remission, during which the swelling, pain, difficulty in sleeping and weakness fade or disappear.
Swelling or deformity may limit the flexibility of your joints. But even if you have a severe form of rheumatoid arthritis, you'll probably retain flexibility in many joints. You also may have less pain than the appearance of deformed joints suggests.
Causes
As with other forms of arthritis, rheumatoid arthritis involves inflammation of the joints. A membrane called the synovium lines each of your joints. When you have rheumatoid arthritis, white blood cells _ whose normal job is to attack unwanted invaders such as bacteria and viruses _ move from your bloodstream into your synovium. There, these blood cells appear to play an important role in causing the synovial membrane to become inflamed.
This inflammation results in the release of proteins that, over months or years, cause thickening of the synovium. These proteins also can damage cartilage, bone, tendons and ligaments. Gradually, the joint loses its shape and alignment. Eventually, it may be destroyed.
Some researchers suspect that rheumatoid arthritis is triggered by an infection _ possibly a virus or bacterium _ in people with an inherited susceptibility. Although the disease itself isn't inherited, certain genes that create a susceptibility are. People who have inherited these genes won't necessarily develop rheumatoid arthritis. But they may have more of a tendency to do so than others. The severity of their disease also may depend on the genes inherited
Screening & Diagnosis
If you have symptoms of rheumatoid arthritis, your doctor will likely conduct a physical examination and order laboratory tests to determine if you have this form of arthritis. A blood test that measures your erythrocyte sedimentation rate (or "sed" rate) can indicate the presence of an inflammatory process in your body. People with rheumatoid arthritis tend to have abnormally high sed rates. The sed rates in those with osteoarthritis tend to be normal.
Another blood test looks for an antibody called rheumatoid factor. Four out of five persons with rheumatoid arthritis eventually have this abnormal antibody, although it may be absent early on in the disease. It's also possible to have the rheumatoid factor in your blood and not have rheumatoid arthritis.
Doctors may take X_rays of your joints to differentiate between osteoarthritis and rheumatoid arthritis. A sequence of X_rays obtained over time can show the progression of arthritis.
Complications
Rheumatoid arthritis causes pain and also may cause fatigue and stiffness. It can lead to difficulty with everyday tasks, such as turning a doorknob or holding a pen. Dealing with the pain and unpredictability of rheumatoid arthritis also can cause depression.
In the past, people with rheumatoid arthritis may have ended up confined to a wheelchair because damage to joints made it difficult or impossible to walk. That's not as likely today because of better treatments and self_care methods.
Treatment
See your doctor if you have persistent discomfort and swelling in multiple joints on both sides of your body. Your doctor can work with you to develop a pain management and treatment plan. Treatments for arthritis have improved in recent years. Most involve medications. But in some cases, surgical procedures may be necessary.
Medications
Medications for rheumatoid arthritis can relieve its symptoms and slow or halt its progression. They include:
Nonsteroidal anti_inflammatory drugs (NSAIDs). This group of medications, which includes aspirin, helps relieve both pain and inflammation if taken regularly. Prescription NSAIDs can provide higher dosages and more potency than over_the_counter NSAIDs. Yet taking NSAIDs can lead to such side effects as indigestion and stomach bleeding. Other potential side effects may include damage to the liver and kidneys, ringing in the ears (tinnitus), fluid retention and high blood pressure.
COX_2 inhibitors. This class of NSAIDs may be less damaging to your stomach. Like other NSAIDs, COX_2 inhibitors suppress an enzyme called cyclooxygenase (COX) that triggers joint inflammation and pain. Researchers believe that NSAIDs work against two versions of COX that are present in your body (COX_1 and COX_2). However, there is evidence that by suppressing COX_1, NSAIDs may cause stomach and other problems because COX_1 is the enzyme that protects your stomach lining. COX_2 inhibitors suppress only COX_2, the enzyme involved in inflammation.
Corticosteroids. These medications reduce inflammation and slow joint damage. In the short term, corticosteroids can make you feel dramatically better. But when used for many months or years, they may become less effective and cause serious side effects. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a round face, diabetes and high blood pressure. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication.
Disease_modifying antirheumatic drugs (DMARDs). Doctors have begun to prescribe DMARDs to limit the amount of joint damage that occurs in rheumatoid arthritis. Taking these drugs at early stages of rheumatoid arthritis helps slow the disease and save the joints and other tissue from permanent damage. Because many of them act slowly (it may be weeks to months before you notice any benefit), DMARDs typically are used with a NSAID or a corticosteroid. While the NSAID or corticosteroid handles immediate symptoms and limits inflammation, the DMARD works on the disease itself. Commonly used DMARDs include hydroxychloroquine sulfate (Plaquenil), gold compounds (Ridaura, Solganal), sulfasalazine (Azulfidine) and minocycline (Minocin). Other forms of DMARDs include immunosuppressants and tumor necrosis factor (TNF) blockers. Immunosuppressant medications act to "tame" the immune system. In addition, some of these drugs attack and eliminate cells that are associated with the disease. Some of the commonly used immunosuppressants include methotrexate (Rheumatrex), leflunomide (Arava), azathioprine (Imuran), cyclosporine (Sandimmune, Neoral), and cyclophosphamide (Cytoxan). These medications can have potentially serious side effects such as increased susceptibility to infection and disease.
TNF blockers. These are a new class of DMARD for treatment of rheumatoid arthritis. TNF is a cytokine, or cell protein, that acts as an inflammatory agent in rheumatoid arthritis. TNF blockers, or "anti_TNF" medications, target or block this cytokine and can help reduce pain, morning stiffness and tender or swollen joints _ usually within 1 or 2 weeks after treatment begins. These medications often are taken with the immunosuppressant methotrexate. Two TNF blockers approved for treatment of rheumatoid arthritis are etanercept (Enbrel) and infliximab (Remicade). If you have an active infection, you shouldn't take these medications.
Antidepressant drugs. Living with arthritis can produce depression in some people. Studies of people with chronic diseases, including arthritis, have found that about one in five reports feelings of depression. If your arthritis has caused feelings of depression, your doctor may prescribe one of these tricyclic antidepressants: amitriptyline (Elavil or Endep), desipramine (Norpramin), imipramine (Tofranil) or nortriptyline (Pamelor or Aventyl). Many other antidepressants may be prescribed, including trazodone (Desyrel), maprotiline (Ludiomil), fluoxetine (Prozac) and sertraline (Zoloft).
Surgical or other procedures
Although a combination of medication and self_care is the first course of action for rheumatoid arthritis, other methods are available for severe cases.
Prosorba column. This is a blood_filtering technique that has been approved as a new therapy for the treatment of rheumatoid arthritis. The technique removes certain antibodies that contribute to pain and inflammation in your joints and muscles and is usually given once a week for 12 weeks as an outpatient procedure. Some of the side effects include fatigue and a short increase in joint pain and swelling for the first few days after the treatment. The Prosorba column treatment is not recommended if you are taking angiotensin converting enzyme (ACE) inhibitors or if you have heart problems, high blood pressure or blood clotting problems.
Joint replacement surgery. For about one_third of people with rheumatoid arthritis, medicines and therapies can't prevent joint destruction. When joints are severely damaged, joint replacement surgery can often help restore joint function, reduce joint pain or correct a deformity. You may need to have an entire joint replaced with a metal or plastic prosthesis. Surgery also may involve tightening tendons that are too loose, loosening tendons that are too tight, fusing bones to reduce pain, or removing part of a diseased bone to improve mobility.
Complementary and alternative medicine
Many complementary medicine methods have not been studied extensively by researchers using scientific methods. As a result, it's difficult for the scientific community to evaluate their effectiveness or safety. And with much of today's research funding coming from the pharmaceutical industry, some "low_tech," nontraditional approaches to managing diseases such as arthritis may not get as much attention from the research community as they deserve. For these reasons, many Western physicians just don't know enough about these methods to endorse them. Nonetheless, a growing body of evidence indicates that complementary medicine practices could have a role in treating and managing some diseases.
Common forms of complementary and alternative medicine for treatment of arthritis include:
Acupuncture
Copper jewelry
Nutritional supplements, including glucosamine and chondroitin sulfate
Homeopathy, the use of highly diluted preparations of natural substances, typically plants and minerals, to relieve symptoms
Magnets
Be careful when considering alternative therapies. Many are expensive and some may be harmful. Before taking any complementary medications or dietary supplements, talk with your doctor to learn about potential dangers, particularly if you're taking other medications.
Self-Care
Treating rheumatoid arthritis typically involves using a combination of medical treatment and self_care strategies. The following self_care procedures are important elements for managing the disease.
Exercise regularly. Different types of exercise achieve different goals. Check with your doctor or physical therapist first and then begin a regular exercise program for your specific needs. If you can walk, walking is a good starter exercise. If you can't walk, try a stationary bicycle with no resistance or do hand or arm exercise. A chair exercise program may be helpful. Aquatic exercise is another option, and many health clubs with pools offer such classes.
Move each joint daily. It's good to move each joint in its full range of motion every day. As you move, maintain a slow, steady rhythm. Don't jerk or bounce. Also, remember to breathe. Holding your breath can temporarily deprive your muscles of oxygen and tire them. It's also important to maintain good posture while you exercise. Avoid exercising tender, injured or severely inflamed joints. If you feel new joint pain, stop. New pain that lasts more than 2 hours after you exercise probably means you've overdone it. If pain persists for more than a few days, call your doctor.
Control your weight. Excess weight puts added stress on joints in your neck, hips, knees and feet _ places where arthritis pain is commonly felt. Excess weight also can make joint surgery more difficult and risky.
Eat a healthy diet. A healthy diet emphasizing fruit, vegetables and whole grains can help you control your weight and maintain your overall health, allowing you to deal better with your arthritis. However, there's no special diet that can be used to treat arthritis. It hasn't been proven that eating any particular food will make your joint pain or inflammation better or worse.
Apply heat. Heat will help ease your pain, relax tense, painful muscles and increase the regional flow of blood. One of the easiest and most effective ways to apply heat is to take a hot shower or bath for 15 minutes. Other options include using a hot pack, an electric heat pad (set on its lowest setting) or a radiant heat lamp with a 250_watt reflector heat bulb to warm specific muscles and joints. If your skin has poor sensation or if you have poor circulation, don't use heat treatment.
Apply cold for occasional flare_ups. Cold may dull the sensation of pain. Cold also has a numbing effect and decreases muscle spasms. Don't use cold treatments if you have poor circulation or numbness.
Practice relaxation techniques. Hypnosis, guided imagery, deep breathing and muscle relaxation all can be used to control pain.
Take your medications as recommended. By taking medications regularly instead of waiting for pain to build, you will lessen the overall intensity of your discomfort.
Coping strategies
The degree to which rheumatoid arthritis affects your daily activities depends in part on how well you cope with the disease. Physical and occupational therapists can help you devise strategies to cope with specific limitations you experience as the result of weakness or pain. These suggestions may help you cope:
Keep a positive attitude. With your doctor, make a plan for managing your arthritis. This will help you feel in charge of your disease. Studies show that people who take control of their treatment and actively manage their arthritis experience less pain and have less difficulty functioning.
Use assistive devices. A painful knee may need a brace for support. You also might want to use a cane to take weight off the joint as you walk. The cane should be used in the hand opposite the affected joint. If your hands are affected, various helpful tools and gadgets are available to help you maintain an active lifestyle. Contact your pharmacy or health care provider for information on ordering items that may help you the most.
Know your limits. Rest when you're tired. Arthritis can make you prone to fatigue and muscle weakness _ a deep exhaustion that makes everything you do a great effort. A rest or short nap that doesn't interfere with nighttime sleep may help.
Avoid grasping actions that strain your finger joints. Instead of using a clutch purse, for example, select one with a shoulder strap. Use hot water to loosen a jar lid and pressure from your palm to open it, or use a jar opener. Don't twist or use your joints forcefully.
Spread the weight of an object over several joints. For instance, use both hands to lift a heavy pan.
Take a break periodically to relax and stretch. Stretching lengthens muscle tissue, making muscles less tight, and increases your flexibility.
Maintain good posture. Poor posture causes uneven weight distribution and may strain ligaments and muscles. The easiest way to improve your posture is by walking. Some people find that swimming also helps improve their posture.
Use your strongest muscles and favor large joints. Don't push open a heavy glass door. Lean into it. To pick up an object, bend your knees and squat while keeping your back straight.
