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April 2012

Questions and Answers about

Arthritis and Rheumatic

Diseases

This booklet answers basic questions about

arthritis and rheumatic diseases. The National

Institute of Arthritis and Musculoskeletal and

Skin Diseases (NIAMS) has other fact sheets

and booklets that provide more information

about specific forms of arthritis and rheumatic

diseases. If you have further questions after

reading this information, you may wish to

discuss them with your doctor.

What Is Arthritis and What Are

Rheumatic Diseases?

Arthritis literally means joint inflammation.

Although joint inflammation describes a

symptom or sign rather than a specific

diagnosis, the term “arthritis” is often used to

refer to any disorder that affects the joints.

These disorders fall within the broader

category of rheumatic diseases. These are

diseases characterized by inflammation (signs

include redness or heat, swelling, and

symptoms such as pain) and loss of function of

one or more connecting or supporting

structures of the body. These diseases

especially affect joints, tendons, ligaments,

bones, and muscles. Common signs and

symptoms are pain, swelling, and stiffness.

Some rheumatic diseases also can involve

internal organs.

There are more than 100 rheumatic diseases.

Some are described as connective tissue

diseases because they affect the supporting

framework of the body and its internal organs.

Others are known as autoimmune diseases

because they occur when the immune system,

which normally protects the body from infection

and disease, harms the body’s own healthy

tissues. Throughout this booklet, the terms

“arthritis” and “rheumatic diseases” are used

interchangeably.

The burden of arthritis in the United States is

enormous. More than 46 million people in the

United States have arthritis or other rheumatic

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conditions.

What Are Some Examples of

Rheumatic Diseases?

What Causes Rheumatic Diseases?

Who Is Affected by Rheumatic

Diseases?

What Are the Signs and Symptoms of

Arthritis and Rheumatic Diseases?

How Are Rheumatic Diseases

Diagnosed?

What Are the Treatments?

Myths About Treating Arthritis

Work With Your Doctor to Limit Your

Pain

What Can Be Done to Help?

What Research Is Being Done on

Arthritis and Rheumatic Diseases?

The Health Partnership Program: A

Local Diversity Outreach Initiative for

Treating Rheumatic Diseases

Where Can People Find More

Information About Arthritis and

Rheumatic Diseases?

Acknowledgments

Information Box

Common Signs and Symptoms of

Arthritis

What Are Some Examples of

Rheumatic Diseases?

Osteoarthritis. This is the most common type

of arthritis, affecting an estimated 27 million

adults in the United States. Osteoarthritis

affects both the cartilage, which is the tissue

that cushions the ends of bones within the

joint, as well as the underlying bone. In

osteoarthritis, there is damage to the cartilage,

which begins to fray and may wear away

entirely. There is also damage to the bond

stock of the joint. Osteoarthritis can cause joint

pain and stiffness. Disability results most often

when the disease affects the spine and the

weight-bearing joints (the knees and hips).

Rheumatoid arthritis. This inflammatory

disease of the immune system targets first the

synovium, or lining of the joint, resulting in

pain, stiffness, swelling, joint damage, and loss

of function of the joints. Inflammation most

often affects joints of the hands and feet and

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tends to be symmetrical (occurring equally on

both sides of the body). This symmetry helps

distinguish rheumatoid arthritis from other

forms of the disease. About 0.6 percent of the

U.S. population (about 1.3 million people) has

rheumatoid arthritis.

Juvenile arthritis. This disease is the most

common form of arthritis in childhood, causing

pain, stiffness, swelling, and loss of function of

the joints. This condition may be associated

with rashes or fevers and may affect various

parts of the body. Prevalence statistics for

juvenile arthritis vary, but about 294,000

children age 0 to 17 are affected with arthritis

or other rheumatic conditions.

Fibromyalgia. Fibromyalgia is a chronic

disorder that causes pain throughout the

tissues that support and move the bones and

joints. Pain, stiffness, and localized tender

points occur in the muscles and tendons,

particularly those of the neck, spine,

shoulders, and hips. Patients also may

experience fatigue and sleep disturbances.

Scientists estimate that fibromyalgia affects 5

million Americans age 18 or older.

Systemic lupus erythematosus. Systemic

lupus erythematosus (also known as lupus or

SLE) is an autoimmune disease in which the

immune system harms the body’s own healthy

cells and tissues. 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, scleroderma means literally “hard

skin.” The disease affects the skin, blood

vessels, and joints. It may also affect 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 and internal organs.

Spondyloarthropathies. This group of

rheumatic diseases principally affects the

spine. One common form—ankylosing

spondylitis—also may affect the hips,

shoulders, and knees. The tendons and

ligaments around the bones and joints become

inflamed, resulting in pain and stiffness.

Ankylosing spondylitis tends to affect people in

late adolescence or early adulthood. Reactive

arthritis is another spondyloarthropathy. It

develops after an infection involving the lower

urinary tract, bowel, or other organ. It is

commonly associated with eye problems, skin

rashes, and mouth sores.

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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 and gonococcal

arthritis are examples of infectious arthritis.

Arthritis symptoms also may occur in Lyme

disease, which is caused by a bacterial

infection following the bite of certain ticks. In

those cases of arthritis caused by bacteria,

early diagnosis and treatment with antibiotics

are crucial to removing the infection and

minimizing damage to the joints.

Gout. This type of arthritis results from

deposits of needle-like crystals of uric acid in

the joints. The crystals cause episodic

inflammation, swelling, and pain in the affected

joint, which is often the big toe. Scientists

estimate that 6 million adults age 20 and older

report having had gout at some time in their

lives.

Polymyalgia rheumatica. Because this

disease involves tendons, muscles, ligaments,

and tissues around the joint, symptoms often

include pain, aching, and morning stiffness in

the shoulders, hips, neck, and lower back. It is

sometimes the first sign of giant cell arteritis, a

disease of the arteries characterized by

headaches, inflammation, weakness, weight

loss, and fever.

Polymyositis. This rheumatic disease causes

inflammation and weakness in the muscles.

The disease may affect the whole body and

cause disability.

Psoriatic arthritis. This form of arthritis

occurs in some patients with psoriasis, a

scaling skin disorder. Psoriatic arthritis often

affects the joints at the ends of the fingers and

toes and is accompanied by changes in the

fingernails and toenails. Back pain may occur if

the spine is involved.

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 condition refers

to inflammation of tendons (tough cords of

tissue that connect muscle to bone) caused by

overuse, injury, or a rheumatic condition.

Tendinitis produces pain and tenderness and

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may restrict movement of nearby joints.

What Causes Rheumatic Diseases?

Rheumatic diseases are generally believed to

be caused by a combination of genetic and

environmental factors. In other words, you may

be born with a susceptibility to a disease, but it

may take something in your environment to get

the disease started.

Some of these factors have been identified.

For example, in osteoarthritis, inherited

cartilage weakness or excessive stress on the

joint from repeated injury may play a role. In

rheumatoid arthritis, juvenile arthritis, and

lupus, patients may have a variation in a gene

that codes for an enzyme called protein

tyrosine phosphatase nonreceptor 22

(PTPN22).

Certain viruses may trigger disease in

genetically susceptible people. For example,

scientists have found a connection between

Epstein-Barr virus and lupus. There are likely

many genes and combinations of genes that

predispose people to rheumatic diseases, and

many different environmental factors that

trigger them.

Gender is another factor in some rheumatic

diseases. Lupus, rheumatoid arthritis,

scleroderma, and fibromyalgia are more

common among women. (See next section for

details.) This indicates that hormones or other

male-female differences may play a role in the

development of these conditions.

Who Is Affected by Rheumatic

Diseases?

An estimated 46 million people in the United

States have arthritis or other rheumatic

conditions.

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.

Between 80 and 90 percent of those

diagnosed with fibromyalgia are

women.

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Gout is more common in men than in

women. After menopause, the

incidence of gout for women begins to

rise.

Systemic lupus erythematosus is more

common in women than in men, and it

occurs more often in African Americans

and Hispanics than in Caucasians.

What Are the Signs and Symptoms

of Arthritis and Rheumatic

Diseases?

Different types of arthritis and rheumatic

diseases have different signs and symptoms.

In general, people who have arthritis feel pain

and stiffness in the joints. Some of the more

common symptoms are listed in the box below.

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).

Common Signs and

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

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

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patient more than once and possibly a number

of times 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?

Are you experiencing any other

symptoms besides pain?

Is there a family history of arthritis or

other rheumatic disease?

What medicine(s) are you taking?

Have you had any recent infections?

Because rheumatic diseases are so diverse

and sometimes involve several parts of the

body, the doctor may ask many other

questions.

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 the patient’s joints for

redness, warmth, damage, ease of movement,

and tenderness. Because some forms of

arthritis, such as lupus, may affect internal

organs, a complete physical examination that

includes the heart, lungs, abdomen, nervous

system, eyes,

ears, mouth, and throat may be necessary.

The doctor may order some laboratory tests to

help confirm a diagnosis. Samples of blood,

urine, or synovial fluid (lubricating fluid found in

the joint) may be needed for the tests. Many of

these same tests may be useful later for

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monitoring the disease or the effectiveness of

treatments.

Common laboratory tests and procedures

include the following:

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. Because 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

ANAs that may be more specific to people with

certain autoimmune disorders. ANAs are also

sometimes found in people who do not have

an autoimmune disorder. (In such cases, the

result is referred to as a “false positive.”)

Therefore, having ANAs in the blood does not

necessarily mean that a person has a disease.

CCP (or anti-CCP). This test checks blood

levels of antibodies to citrulline, a protein that

can be detected in up to 70 percent of people

in the early stages of rheumatoid arthritis.

Because the presence of anti-CCPs is

associated with more aggressive disease, the

test can also be useful in helping doctors plan

treatment.

C-reactive protein test. This nonspecific test

is used to detect generalized inflammation.

Levels of the protein are often increased in

patients with active disease such as

rheumatoid arthritis or any other disease that

causes inflammation.

Complement. This test measures the level of

complement, a group of proteins in the blood.

Complement helps destroy germs and other

foreign substances 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).

Creatinine. This blood test measures the level

of creatinine, a breakdown product of creatine,

which is an important component of muscle.

Creatinine is excreted from the body entirely by

the kidneys, and the level remains constant

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and normal when kidney function is normal.

This test is commonly used to diagnose and

monitor kidney disease in patients who have a

rheumatic condition such as lupus.

Erythrocyte sedimentation rate (sed rate

or ESR). This blood test is used to detect

inflammation in the body. Higher sed rates,

indicating the presence of inflammation, are

typical of many forms of arthritis, such as

rheumatoid arthritis and ankylosing spondylitis.

Higher sed rates are also typical of many of

the immunologic connective tissue diseases,

such as lupus and scleroderma.

Hematocrit (PCV or packed cell volume).

This test and the test for hemoglobin (a

substance in the red blood cells that carries

oxygen throughout 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 who

have inflammatory arthritis or another

rheumatic disease.

Rheumatoid factor. This test detects the

presence of rheumatoid factor, an antibody

found in the blood of most (but not all) people

who have rheumatoid arthritis. In rheumatoid

arthritis, it is associated with more aggressive

disease. Rheumatoid factor may be found in

many diseases besides rheumatoid arthritis

and sometimes in people without health

problems. (In the latter case, the result is

referred to as a “false positive.”)

Synovial fluid examination. Synovial fluid

may be examined for white blood cells (found

in patients with rheumatoid arthritis and

infections), bacteria or viruses (found in

patients with infectious arthritis), or crystals in

the joint (found in patients with gout or other

types of crystal-induced arthritis). To obtain a

specimen, the doctor injects a local anesthetic,

then inserts a needle into the joint to withdraw

the synovial fluid into a syringe. The procedure

is called arthrocentesis or joint aspiration.

Urinalysis. In this test, a urine sample is

studied for protein, red blood cells, white blood

cells, and bacteria. These abnormalities may

indicate kidney disease, which may be seen in

lupus as well as several rheumatic conditions.

Some medications used to treat arthritis also

can cause abnormal findings on urinalysis.

X Rays and Other Imaging Procedures

To see what the joint looks like inside, the

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doctor may order x rays or other imaging

procedures. X rays provide an image of the

bones, but they do not show cartilage,

muscles, and ligaments. Other noninvasive

imaging methods such as computed

tomography (CT or CAT scan), magnetic

resonance imaging (MRI), and arthrography

show the whole joint. The doctor also may look

for damage to a joint by using an arthroscope,

a small, flexible tube that is inserted through a

small incision at the joint. The arthroscope

transmits the image from inside the joint to a

video screen.

What Are the Treatments?

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.

Range-of-motion exercises (e.g.,

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stretching, dance) help maintain normal

joint movement, maintain or increase

flexibility, and relieve stiffness.

Strengthening exercises (e.g., weight

lifting) maintain or increase muscle

strength. Strong muscles help support

and protect joints affected by arthritis.

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

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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.

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.

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.

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.

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.

All NSAIDs work similarly by blocking

substances called prostaglandins that

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contribute to inflammation and pain. However,

each NSAID is a different chemical, and each

has a slightly different effect on the body.2

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.

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.

Biologic response modifiers.

Biologic response modifiers, or

biologics, are a new family of

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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.

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.

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.

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

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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

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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:

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.

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

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unit.

Osteotomy. A surgery in which a

section of bone is removed to improve

the positioning of a joint.

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.

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 cure

arthritis. Moreover, some may lead to serious

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side effects. Patients should talk to their doctor

before using any therapy that has not been

prescribed or recommended by their health

care team.

Work With Your Doctor to Limit Your

Pain

The role you play in planning your treatment is

very important. It is vital for you to have a good

relationship with your doctor in order to 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.

Research has shown that well-informed

patients who participate actively in their own

care experience less pain and make fewer

visits to the doctor.

What Can Be Done to Help?

Many people find that having arthritis or

another rheumatic disease limits their

activities. When people can no longer

participate in some of their favorite activities,

their overall well-being can be affected. Even

when arthritis impairs only one joint, a person

may have to change many daily activities to

reduce pain and protect that joint from further

damage. When a condition affects the entire

body, as it often does with rheumatoid arthritis,

lupus, 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 hands affected by

arthritis to make meal preparation easier. An

occupational therapist can help people who

have rheumatic conditions to identify and make

adjustments in their homes to create a safer,

more comfortable, and more efficient

environment.

Friends and family members 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

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people who have the same disease, can make

it easier to cope.

What Research Is Being Done on

Arthritis and Rheumatic Diseases?

The NIAMS, 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.

Both clinical studies (involving patients) and

basic (laboratory) research result in a better

understanding of what causes these conditions

and how best to treat and prevent them.

The NIAMS currently supports three types of

research centers that study arthritis, rheumatic

diseases, and other musculoskeletal

conditions: Centers of Research Translation

(CORTs), Multidisciplinary Clinical Research

Centers (MCRCs), and Research Core

Centers (RCCs). A list of these centers and

their locations can be obtained from the NIAMS

(See “Where Can People Find More

Information About Arthritis and Rheumatic

Diseases?”)

CORTs are designed to bring together

basic and clinical research in a way

that helps translate basic discoveries

into new drugs, treatments, and

diagnostics. Currently there are four

CORTs, including one focusing on

lupus and another focusing on

scleroderma.

MCRCs focus on clinical research

designed to assess and improve

outcomes for patients affected by

arthritis and other rheumatic diseases,

musculoskeletal disorders (including

bone and muscle diseases), and skin

diseases. Each center studies one or

more of the diseases within the NIAMS

mission and provides resources for

developing clinical projects using more

than one approach.

RCCs promote interdisciplinary,

collaborative efforts among scientists

doing high-quality research related to a

common theme. By providing funding

for facilities, pilot and feasibility studies,

and program enrichment activities at

RCCs, the Institute reinforces

investigations already under way in

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NIAMS program areas. Current centers

include Rheumatic Diseases Research

Core Centers, Skin Disease Research

Core Centers, and Core Centers for

Musculoskeletal Disorders.

Research registries provide a means for

collecting clinical, demographic, and laboratory

information from patients, and sometimes from

their relatives. These registries facilitate

studies that could ultimately lead to improved

diagnosis, treatment, and prevention. The

NIAMS currently supports research registries

for rheumatic diseases such as rheumatoid

arthritis, fibromyalgia, antiphospholipid

syndrome (an autoimmune disorder),

ankylosing spondylitis, lupus and neonatal

lupus, scleroderma, juvenile idiopathic arthritis,

and juvenile dermatomyositis.

Some current NIAMS research efforts that

pertain to rheumatic diseases are outlined

below.

Biomarkers

Recent scientific breakthroughs in basic

research have provided new information about

what happens to the body’s cells and other

structures as rheumatic diseases progress.

Biomarkers (laboratory and imaging signposts

that detect disease) help researchers

determine both the likelihood that a person will

develop a specific disease as well as its

possible severity and outcome. Biomarkers

have the potential to lead to novel and more

effective ways of predicting and monitoring

both disease activity and responses to

treatment. NIAMS supports research on

biomarkers for rheumatic and skin diseases,

including initiatives to identify and validate

biomarkers for osteoarthritis and lupus.

PROMIS

NIAMS has responsibility for managing an

NIH-wide initiative known as PROMIS (PatientReported Outcomes Measurement Information

System). The goal of this initiative is to

develop ways to measure patient-reported

symptoms such as pain and fatigue as well as

other aspects of health-related quality-of-life

across a wide variety of chronic diseases and

conditions. Arthritis and many other diseases

that compromise daily life involve pain, fatigue,

and other quality-of-life outcomes that are hard

to measure. A means of measuring changes in

these symptoms could enhance clinical

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research and practice, providing a significant

benefit to patients and their health care

providers.

Studies on specific rheumatic diseases are

described as follow.

Fibromyalgia. In recent years, the

NIAMS has supported an increasing

amount of research into this condition,

which is not well understood. Scientists

are using imaging studies of the central

nervous system to better understand

the overresponsiveness to painful

stimuli in people with this disorder.

They are studying the role of sex

hormones, stress, and other factors on

fibromyalgia. They are also examining

the effectiveness of behavior therapy,

exercise, medications, micronutrients,

acupuncture, and other alternative

approaches for dealing with pain,

fatigue, and loss of sleep.

Osteoarthritis. The NIAMS has

embarked on several innovative efforts

to understand the causes and identify

effective treatment and prevention

methods for osteoarthritis. Through a

public/private partnership, researchers

are identifying biomarkers for

osteoarthritis that will help develop and

test new drugs. Imaging studies

designed to better identify joint

disorders and assess their progression

are taking place as well.

The NIH’s National Center for

Complementary and Alternative

Medicine and the NIAMS funded a

major, 16-center study on the

usefulness of the dietary supplements

glucosamine and chondroitin sulfate,

which previous studies have suggested

may be useful for osteoarthritis. (See

“Nutritional Supplements” for more

details about this trial.)

Some genetic and behavioral studies

are focusing on factors that may cause

osteoarthritis to develop. Among

behavioral risk factors, excessive

weight and lack of exercise have been

identified as contributing to knee and

hip disability.

Researchers are working to

understand the role certain enzymes

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play in the breakdown of joint cartilage

in osteoarthritis. They also are testing

drugs that block the action of these

enzymes and looking at new ways to

administer drugs.

Studies show that young adults who

have had a previous joint injury are

more likely to develop osteoarthritis.

These studies underscore the need for

increased education about joint injury

prevention and use of proper sports

equipment. They are also prompting

scientists to look for ways to prevent

joint cartilage breakdown after injury.

Rheumatoid arthritis. Researchers

are trying to identify the cause of

rheumatoid arthritis so they can

develop better and more specific

treatments. They are examining the

roles 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 spark 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,

genetic therapies, and biologic agents

that selectively block certain immune

system activities associated with

inflammation. In recent years, several

biologic agents have been approved.

These include etanercept (Enbrel) and

infliximab (Remicade), which block a

cytokine, or chemical messenger,

called tumor necrosis factor (TNF);

anakinra (Kineret), which blocks the

cytokine interleukin-1 (IL-1); and

abatacept (Orencia), which interferes

with function of some cells such as

T-lymphocytes. These cells are

important in rheumatoid arthritis.

Followup studies of biologics have

shown that they not only relieve signs

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and symptoms of rheumatoid arthritis,

but also block the joint destruction it

causes. Studies for additional new

drugs targeting other cytokines and

inflammation pathways continue.

Recently, scientists discovered that the

presence of proteins called

anticitrulline antibodies can help

identify people with early rheumatoid

arthritis who are likely to have

aggressive disease. This enables

doctors to begin aggressive treatment

early and help prevent damage.

Researchers continue to search for

biomarkers that identify people at risk

of aggressive disease as well as those

most likely to respond to a particular

treatment.

Researchers are also studying

nonmedication treatments for

rheumatoid arthritis, such as green tea,

fish oil, borage seed oil, and relaxation

techniques.

Scleroderma. Current studies on

scleroderma are focusing on

overproduction of collagen, blood

vessel injury, and abnormal immune

system activity. Researchers hope to

discover how these three elements

interact to cause and promote

scleroderma. In a number of studies,

researchers have found evidence of

fetal cells within the blood and skin

lesions of women who had been

pregnant years before developing

scleroderma. These studies suggest

that fetal cells may somehow play a

role in scleroderma.

Scientists are continuing to study the

implications of this finding.

Scientists are also trying to better

understand the organ complications

that can occur in people with

scleroderma and to find factors that

predict who is at greatest risk for these

complications.

Treatment studies are under way as

well. One study in particular has looked

at the effectiveness of ultraviolet light in

softening the thickened skin of people

with scleroderma, and others have

shown that drugs affecting the

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circulation can improve symptoms of

scleroderma.

Spondyloarthropathies. Researchers

are working to understand the genetic

and environmental causes of

spondyloarthropathies, which include

ankylosing spondylitis, psoriatic

arthritis, reactive arthritis, and arthritis

associated with inflammatory bowel

disease. They are also looking at

genetic determinants of disease

severity, the development of associated

eye problems, and potential new

treatments for the diseases and their

complications.

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 or more severe in certain

populations, and they have made

progress in identifying the genes that

may be responsible for lupus.

Researchers also continue to study the

cellular and molecular basis of

autoimmune disorders such as lupus.

Promising areas of research on

treatment include biologic agents;

newer, more selective drugs that

suppress the immune system; and

bone marrow transplants to correct

immune abnormalities. Contrary to the

widely held belief that estrogens can

make the disease worse, a major

NIAMS-supported study has shown

that it may be safe to use estrogens for

hormone replacement therapy and birth

control in women with lupus.

More information on research is available from

the following websites:

ClinicalTrials.gov offers up-to-date

information for locating federally and

privately supported clinical trials for a

wide range of diseases and conditions.

NIH Clinical Research Trials and

You was designed to help people learn

more about clinical trials, why they

matter, and how to participate. Visitors

to the website will find information

about the basics of participating in a

clinical trial, first-hand stories from

actual clinical trial volunteers,

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explanations from researchers, and

links to how to search for a trial or

enroll in a research-matching program.

NIH RePORTER is an electronic tool

that allows users to search a repository

of both intramural and extramural

NIH-funded research projects from the

past 25 years and access publications

(since 1985) and patents resulting from

NIH funding.

PubMed is a free service of the U.S.

National Library of Medicine that lets

you search millions of journal citations

and abstracts in the fields of medicine,

nursing, dentistry, veterinary medicine,

the health care system, and preclinical

sciences.

The Health Partnership Program: A

Local Diversity Outreach Initiative for

Treating Rheumatic Diseases

In the winter of 2000, the NIAMS launched the

Health Partnership Program (HPP), a local

model of research and service that addresses

disparities in preventing and treating rheumatic

diseases in multicultural communities. The

initiative focuses on four key areas: (1) public

health education, (2) patient care, (3) access

to clinical investigations, and (4) recruitment

for research careers. The partnership includes

community leaders and organizations

representing the populations being served.

They promote awareness of the program and

its services and advise the Institute on

community outreach activities.

One component of the HPP is the NIAMS

Community Health Center, located in Silver

Spring, Maryland. The health center provides

a platform for conducting health disparities

research by implementing the four key areas of

the HPP. The health center offers patients

quality health care and health information in a

community clinic setting. Patients also have

the opportunity to participate in clinical studies.

More information about the HPP is available at

http://www.niams.nih.gov/About_Us

/Mission_and_Purpose/Community_Outreach

/Health_Partnership/default.asp.

Where Can People Find More

Information About Arthritis and

Rheumatic Diseases?

You can get additional information through the

following organizations:

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National Institute of Arthritis and

Musculoskeletal and Skin Diseases

(NIAMS)

Information Clearinghouse

National Institutes of Health

1 AMS Circle

Bethesda, MD 20892-0001

Phone: 301-495-4484

Toll Free: 877-22-NIAMS (877-226-4267)

TTY: 301-565-2966

Fax: 301-718-6366

Email: NIAMSinfo@mail.nih.gov

Website: http://www.niams.nih.gov

Other Resources

American Academy of Orthopaedic

Surgeons (AAOS)

Website: http://www.aaos.org

American College of Rheumatology

Website: http://www.rheumatology.org

For additional contact information, visit the

NIAMS website or call the NIAMS Information

Clearinghouse.

Acknowledgments

The NIAMS gratefully acknowledges the

assistance of the following individuals in the

preparation and review of the original version

of this booklet: Barri Fessler, M.D., Cleveland

Clinic Foundation, Cleveland, OH; John H.

Klippel, M.D., Arthritis Foundation, Atlanta,

GA; Reva Lawrence, M.P.H., NIAMS, NIH;

Eric Matteson, M.D., Mayo Clinic, Rochester,

MN; and Barbara Mittleman, M.D., NIAMS,

NIH.

The mission of the National Institute of Arthritis

and Musculoskeletal and Skin Diseases

(NIAMS), a part of the U.S. Department of

Health and Human Services’ National Institutes

of Health (NIH), 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. The National Institute of Arthritis and

Musculoskeletal and Skin Diseases

Information Clearinghouse is a public service

sponsored by the NIAMS that provides health

information and information sources. Additional

information can be found on the NIAMS

website at www.niams.nih.gov.

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For Your Information

This publication contains information about

medications used to treat the health condition

discussed here. When this publication was

developed, we included the most up-to-date

(accurate) information available. Occasionally,

new information on medication is released.

For updates and for any questions about any

medications you are taking, please contact

U.S. Food and Drug Administration

Toll Free: 888–INFO–FDA

(888–463–6332)

Website: http://www.fda.gov

For additional information on specific

medications, visit Drugs@FDA at

www.accessdata.fda.gov/scripts

/cder/drugsatfda. Drugs@FDA is a

searchable catalog of FDA-approved

drug products.

For updates and questions about statistics,

please contact

Centers for Disease Control and

Prevention’s National Center for

Health Statistics

Website: http://www.cdc.gov/nchs

This publication is not copyrighted. Readers

are encouraged to duplicate and distribute as

many copies as needed.

Additional copies of this publication are

available from:

National Institute of Arthritis and

Musculoskeletal and Skin Diseases

(NIAMS)

Information Clearinghouse

National Institutes of Health

1 AMS Circle

Bethesda, MD 20892-0001

Phone: 301-495-4484

Toll Free: 877-22-NIAMS

(877-226-4267)

TTY: 301-565-2966

Fax: 301-718-6366

Email: NIAMSinfo@mail.nih.gov

Website: http://www.niams.nih.gov

NIH Publication No. 12-4999

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available in print. Would you like to

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