Treatments for rheumatic diseases 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 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 to become weak and joints to become stiff.
People with a rheumatic disease such as arthritis can participate in a variety of sports and exercise programs. Physical exercise can reduce joint pain and stiffness and increase flexibility, muscle strength, and endurance. Exercise also can result in weight loss, which in turn reduces stress on painful joints and contributes to an improved sense of well-being. Before starting any exercise program, people with arthritis should talk with their doctor.
Doctors often recommend getting exercise in each of these three categories. The benefits listed below often reinforce each other.
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Range-of-motion exercises (e.g., stretching, dance) help maintain normal joint movement, maintain or increase flexibility, and relieve stiffness.
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Strengthening exercises (e.g., weight lifting) maintain or increase muscle strength. Strong muscles help support and protect joints affected by arthritis.
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Aerobic or endurance exercises (e.g., walking, bicycle riding, swimming) improve cardiovascular fitness, help control weight, improve strength, 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. 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. The medications used to treat most rheumatic diseases do not provide a cure, but rather limit the symptoms of the disease. One exception is infectious arthritis, which can be cured if medications are used properly. Another exception is Lyme disease, which is spread by the bite of certain ticks: if the infection is caught early and treated with antibiotics, symptoms of arthritis may be prevented or may disappear.
Medications commonly used to treat rheumatic diseases provide relief from pain and inflammation. In some cases, especially when a person has rheumatoid arthritis or another type of inflammatory arthritis, the medication may slow the course of the disease and prevent further damage to joints or other parts of the body.
The doctor may delay using medications until a definite diagnosis is made because medications can hide important symptoms or signs (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 upset stomach, nausea, or headache. The doctor may be able to change the dosage or medicine to reduce these side effects.
Following are some of the types of medications commonly used in the treatment of rheumatic diseases.
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Oral analgesics. Analgesics (pain relievers) such as acetaminophen (Tylenol1) are often used to reduce the pain caused by many rheumatic conditions. For severe pain or pain following surgery or a fracture, doctors may prescribe stronger prescription or narcotic analgesics.
1 Brand names included in this booklet 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 or imply that the product is unsatisfactory.
All NSAIDs work similarly by blocking substances called prostaglandins that contribute to inflammation and pain. However, each NSAID is a different chemical, and each has a slightly different effect on the body.2
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Topical analgesics. People who cannot take oral pain relievers or who continue to have some pain after taking them may find topical analgesics helpful. These creams or ointments are rubbed into the skin over sore muscles or joints and relieve pain through one or more active ingredients.
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Counterirritants. Counterirritants are applied topically to the skin as a cream or spray. They stimulate the nerve endings in the skin to provide feelings of warmth or cold and dull the sensation of pain.
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Nonsteroidal anti-inflammatory drugs (NSAIDS). A large class of medications useful against both pain and inflammation, NSAIDs are staples in arthritis treatment. A number of NSAIDs, such as ibuprofen (Advil, Motrin), naproxen sodium (Aleve), and ketoprofen (Orudis, Oruvail) are available over the counter. More than two dozen others, including a subclass of NSAIDs called COX-2 inhibitors, are available only with a prescription.
2 Warning: NSAIDs can cause stomach irritation or, less often, they can affect kidney function. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs because NSAIDs alter the way the body uses or eliminates these other drugs. Check with your health care provider or pharmacist before you take NSAIDs. Also, NSAIDs sometimes are associated with serious gastrointestinal problems, including ulcers, bleeding, and perforation of the stomach or intestine. People age 65 and older, as well as those with any history of ulcers or gastrointestinal bleeding, should use NSAIDs with caution.
The Food and Drug Administration has warned that long-term use of NSAIDs, or use by people who have heart disease, may increase the chance of a heart attack or stroke. So it’s important to work with your doctor to choose the one that’s safest and most effective for you. Side effects also may include stomach upset and stomach ulcers, heartburn, diarrhea, fluid retention, hypertension, and kidney damage. For unknown reasons, some people seem to respond better to one NSAID than another.
Corticosteroids can be given by mouth, in creams applied to the skin, intravenously, or by injection directly into the affected joint(s). 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 glucose, infections, and cataracts.
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Disease-modifying antirheumatic drugs (DMARDs). A family of medicines that are used to treat inflammatory arthritis like rheumatoid arthritis and ankylosing spondylitis, DMARDs may be able to slow or stop the immune system from attacking the joints. This in turn decreases pain and swelling. DMARDs typically require regular blood tests to monitor side effects, which may include increased risk of infection. In addition to relieving signs and symptoms, DMARDs may help to retard or even stop joint damage from progressing. However, DMARDs cannot fix joint damage that has already occurred. Some of the most commonly prescribed DMARDs are methotrexate, hydroxychloroquine, sulfasalazine, and leflunomide.
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Biologic response modifiers. Biologic response modifiers, or biologics, are a new family of genetically engineered drugs that block specific molecular pathways of the immune system that are involved in the inflammatory process. They are often prescribed in combination with DMARDs such as methotrexate. Because biologics work by suppressing the immune system, they could be problematic for patients who are prone to frequent infection. They are typically administered by injection at home or by intravenous infusion at a clinic. Some commonly prescribed biologics include etanercept, adalimumab, infliximab, abatacept, and rituximab.
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Corticosteroids. 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 as well as their method of administration will vary depending on the diagnosis and the patient. Again, the patient and doctor must work together to determine the right amount of medication.
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Hyaluronic acid substitutes. Hyaluronic acid products, such as Hyalgan and Synvisc, mimic a naturally occurring body substance that serves to lubricate joints and is believed to be deficient in joints with osteoarthritis. Depending on the particular product, patients receive a series of three to five injections, which are administered directly into the affected knee(s) or hip(s) to help provide temporary relief of pain and flexible joint movement.
Medical Devices
A number of devices may be used to treat some rheumatic diseases. For example, transcutaneous electrical nerve stimulation (TENS) has been found effective in modifying pain perception. TENS blocks pain messages to the brain with a small device that directs mild electric pulses to nerve endings that lie beneath the painful area of the skin.
Some health care facilities use a blood-filtering device called the Prosorba Column to filter out harmful antibodies in people with severe rheumatoid arthritis.
Heat and Cold Therapies
Heat and cold can both be used to reduce the pain and inflammation of arthritis. The patient and doctor can determine which one works best.
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 for some of these therapies, such as 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 may relieve 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. The water takes some weight off painful joints, making it easier to exercise. It helps relax tense muscles and relieve pain.
Mobilization therapies include traction (gentle, steady pulling), massage, and manipulation. (Someone other than the patient moves stiff joints through their normal range of motion.) 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 a variety of relaxation techniques.
Splints and Braces
Splints and braces are used to support weakened joints or allow them to rest. Some 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 explain to the patient when and for how long the device should be worn. The doctor or therapist also will demonstrate the correct way to put it on and will ensure that it fits properly. The incorrect use of a splint or brace can cause joint damage, stiffness, and pain.
Assistive Devices
A person with arthritis can use many kinds of devices to ease the pain. For example, using a cane when walking can reduce some of the weight placed on a knee or hip affected by arthritis. A shoe insert (orthotic) can ease the pain of walking caused by arthritis of the foot or knee. Other devices can help with activities such as opening jars, closing zippers, and holding pencils.
Surgery
Surgery may be required to repair damage to a joint after injury or to restore function or relieve pain in a joint damaged by arthritis. Many types of surgery are performed for arthritis. These include:
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Anthroscopic surgery. Surgery to view the joint using a thin, lighted scope inserted through a small incision over the joint. If repair is needed, tools may be inserted through additional small incisions.
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Bone fusion. Surgery in which joint surfaces are removed from the ends of two bones that form a joint. The bones are then held together with screws until they grow together forming one rigid unit.
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Osteotomy. A surgery in which a section of bone is removed to improve the positioning of a joint.
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Arthroplasty. Also known as total joint replacement. This procedure removes and replaces the damaged joint with an artificial one.
Nutritional Supplements
Nutritional supplements are sometimes used in treating rheumatic diseases. These include products such dehydroepiandrosterone (DHEA) for lupus, and glucosamine and chondroitin sulfate for osteoarthritis.
The Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT), the results of which were published in 2006, assessed the effectiveness and safety of glucosamine and chondroitin sulfate when taken together or separately. The 24-week trial was cosponsored by the National Center for Complementary and Alternative Medicine and the NIAMS. The trial found that the combination of glucosamine and chondroitin sulfate did not provide significant relief from osteoarthritis pain among all participants. However, a smaller subgroup of study participants with moderate to severe pain received significant relief from the combined supplements. A 2-year GAIT study revealed that subjects who took the supplements (alone or in combination) had outcomes similar to those experienced by patients who took an NSAID or a placebo pill.
Generally speaking, reports on the safety and effectiveness of any nutritional supplement should be viewed with caution because the Food and Drug Administration does not regulate supplements the way it monitors medications, and many have not been proven helpful in formal studies.
