The doctor informed me that not only did my son have activity-induced asthma, but a heavy coat of smog was intensifying it. I was advised to keep my son from running around in 90-plus-degree temperatures, from playing outside when the smog was visibly heavy and to make sure that he took his medicine 20 minutes before going out to play.

To be truthful, I never knew the severity asthma had on one’s life until last year. I took my daughter to the doctor and I saw a grown, 240-pound man crying. He was having trouble breathing. His airway had swollen so badly that the machine they had him on didn’t seem to be doing its job.

Then about six months ago, my mother’s asthma nearly took her life. Her asthma became so severe that she was literally suffocating to death. The strain of trying to breath caused her heart to shift and caused a heart attack.

Needless to say, finding out my son had asthma was not something I wanted to hear.

According to the Asthma Channel, asthma affects an estimated 14 million people in the United States and kills an estimated 5,000 people each year.

The Childhood Asthma Foundation defines asthma this way: “Asthma is a disease that causes the muscles surrounding the bronchial tubes in the lungs to contract more than they should, narrowing the air passages. The lining of the air passages becomes inflamed and swollen. Increased mucus production begins to block the passage of air into the lungs.”

Knowing this, I wondered if asthma was curable. The answer I found was that although asthma is not curable, people can either outgrow it or find it gets worse with age. The good news, according to the Pulmonology Channel, is that out of all the children who develop asthma between the ages of two and 10, half will outgrow their asthma.

There are many things that can trigger an asthmatic episode; such as strenuous exercise, allergies, smoking, fumes from cleaning products as well as car exhausts, pollens, dust mites, pet dander, smog (air pollution), medications, and yes, even cockroaches. While some people seem to have no effect to the cold, others will have bad asthma attacks during cold weather.

With proper medications and awareness, asthma can become manageable, resulting in a long and otherwise healthy life. The key to managing asthma is to learn what triggers the episodes and follow that up with preventative measures.

For instance:

Dust mites can be controlled with special pillow coverings. Removing all carpeting and replacing with tile or wood floors can also control them. And by dusting and vacuuming on a daily (or near daily) basis, washing bed dressings on a weekly basis, and getting rid of any and all stuffed animals can help the problem.

Pet dander is not as easily managed, so it may be best to find a new home for pets. If this is not an option, consider keeping pets outdoors.

Mold also plays a key role in triggering asthma attacks, so it’s important to bleach the bathrooms on a weekly basis. If mold is growing on the outside walls, it can seep through the walls causing problems for the asthmatic person living inside. The best prevention would be to pour bleach on the mold.

From perfumes to pollen to food, Allergies can also trigger asthma attacks. For instance, my mother cannot eat pixy sticks because there is something in that particular candy that causes her asthma to kick in.

I used to think that the greatest tragedy of my life was that I was born two decades too late. I should have been a child of the Sixties. I would have grown my hair, followed the Dead, gone to every sit in, walk in, be in, every demonstration there was. Instead, I was a frustrated radical during the Reagan era, as dull and complacent as the Eisenhower administration. I compensated by being an Alabama punk rocker (“Anarchy, y’all!”), by driving around with a “Warning: I break for anti-nuclear activists” bumpersticker in a town virtually cowering in the shadow of Browns Ferry Nuclear Plant and by covering the walls in my bedroom with pictures of Abbie Hoffman and Jerry Rubin.

As soon as I became of age, I moved away so fast, I left tread marks.

Motherhood came—unplanned and too soon—and so I remained a frustrated radical. And then I moved to Richmond, where every third person is an artist. In a town like that, you have to be damned strange before you’re even considered “eccentric”.

I was home.

I am Hippie, Hear me Bore

While too cynical to become a full-fledged flower child (once a Punk, always a Punk) , I did become quite the New Ager. I was especially interested in the New Age philosophy on health. I quit smoking, worked out and became an ardent vegetarian. In this day and age, I believed, no one should be sick. Cancer, heart disease, diabetes—and yes, rheumatoid arthritis (my grandmother had RA and I believed it my mission to “cure her”)—could be prevented and even cured with the proper—i.e. meatless—diet. For seven wonderful years, I was almost preternaturally healthy, which only confirmed my beliefs. I moved to San Diego, continued living a meat-free existence and settled into my own arrogance.

Fast-forward: seven years, three thousand miles and another child later.

Bad Karma, Man

One morning, I woke up and could barely walk. My hands, my knees and my feet felt as if they were full of ground glass: one wrong move (and they were all wrong) and you get cut. Because of my grandmother, I knew exactly what it was. I wasn’t worried, though. I had studied holistic health for years, was a competent amateur herbalist, had a complete library of books, all promoting natural healing. It was just a matter of figuring out what I did “wrong” and correcting it.

In the meantime, after “firing” my first rheumatologist I settled with my present rheumatologist, reluctantly taking Naproxen and Plaquenil, secretly wondering if I was further poisoning my body with all of those “toxins”. To make up for it, I gave up eggs and dairy products and became a Vegan. When it became apparent that the Plaquenil wasn’t working, I refused to take my doctor’s advice to take anything stronger. I upped the ante on my diet by cutting out fats. I took ginger, turmeric, evening primrose oil, took massive doses of vitamin C. I did yoga, daily. I meditated.

And I worsened. Within one month, the middle finger on my left hand developed a deformity (and yes, I have been struck by that little irony). On top of everything else, I felt terrible guilt. Obviously, I had brought this on myself somehow. Should I cut out the Nightshade vegetables? Dare I eat fish and go on a macrobiotic diet? Was it my own cynicism? Was I a horrible brute in some past life?

Faithfully, I read every book, every magazine that promoted holistic living. Two years after I was first diagnosed, I eagerly opened my monthly vegetarian magazine. On the cover was “Guaranteed Cures for Arthritis!” I found the article…which listed its “cures” as ginger…turmeric…evening primrose oil…vitamin C…and, of course, vegetarianism.

Rebel Without a Clue, Redux

Immediately, I cancelled my subscription. I called my rheumatologist and finally agreed to take Prednisone. On the way to the pharmacy, I turned into the first drive-through I could find, and—in between puffs of a filtered Camel—ordered a double cheeseburger. Diet meant nothing, I thought. Herbs, attitude…what a lot of crap. It all boiled down to having a bum gene.

I stopping haranguing my doctor about every “cure” I read about, and as soon as I could afford it, went on methotrexate. I ate whatever I wanted, exercised only because I hated my thighs, smoked half a pack a day and sneered at every well-meaning hippie nai”ve enough to offer advice. For the first time in my life, I began catching the flu like everyone else…but unlike everyone else, it would take me a month to get well. Colds lingered for weeks. Cuts didn’t heal properly. In my earlier life, I would have blamed the drugs, but now I knew that the drugs were the only things keeping me going.

A Kinder, Gentler Michael

Most of you out there are smart enough to know what took me five years to figure out: moderation is the key. After five attempts, I finally quit smoking. I’m no vegetarian, but I do try to eat lean meats, whole grains and five fruits and vegetables a day; I use the right kind of oils, eat fish at least twice a week, keep my caffeine intake to less than nine espressos a day (some mornings are rougher than others…). I take a multi-vitamin and extra calcium when I’m on Prednisone, which is almost always. I exercise daily—for my health, not my thighs. While I don’t believe that I “caused” my RA, I have noticed that stress and depression seem to exacerbate the symptoms, so I try my best to stay positive.

All advice I could have gotten from the Arthritis Foundation, from the hundreds of books and websites on RA, or from my patient, long-suffering rheumatologist, Garry Bayliss, M.D.

Alternative Lifestyles

So is all that holistic philosophy nonsense? Maybe not. There are over 100 forms of synovitis (that’s RA, in doctorese), ranging from barely noticeable to crippling. Perhaps a mild form of RA could benefit from a vegetarian diet—perhaps it could even bring about remission (I won’t go as far as to say “cure”). Even the stolid Arthritis Foundation won’t completely reject the idea of a “food allergy”, although they don’t support the idea either. My philosophy (which is untrained, undereducated and has no clinical data to back it up—please always ask your rheumatologist before changing any aspect of your diet, medication, etc) is—as long as you are taking the proper medication and following your doctor’s advice—if you’re interested in trying some alternative form of healing, go ahead…as long as it isn’t harmful (e.g. sitting in abandoned Uranium mines).

For example, taking fish oil may have beneficial effects, but even if it doesn’t help your arthritis, it’s not going to hurt you and may provide some other benefits, like protecting your heart. Make sure you do your research, though. I was taking ginger (for my stomach, not for RA…I already learned that lesson), even though I knew that it shouldn’t be taken in conjunction with blood thinners. Ginger is an effective blood thinner…as is about three other drugs that I’m taking. It wasn’t until my six-week blood work up, when my vein suddenly became a geyser that I realized that maybe ginger wasn’t such a good idea.

Whatever you decide, try to be patient with those who offer unsolicited advice. They mean well and they really believe in whatever “cure” they’re espousing. Just treat them as you would a religious fanatic—gingerly but firmly. Tell them that you’ll take their advice under consideration and change the subject. And later, when they inevitably face their own illnesses/surgeries/injuries, be sympathetic, patient and—no matter how tempting—resist the urge to say, “I told you so!”

The premise of the study was that children who are exposed to more children early in life-a measure of exposure to infection, are less likely to develop asthma and allergies later in childhood, than children with less exposure 1.

Dr. Thomas Ball and colleagues, at the University of Arizona, College of Medicine, in Tucson studied 1246 children followed since birth for up to 13 years. 1035 parents completed at least one questionnaire about their child’s respiratory status, in the previous year, at years 6, 8, 11 and 13 and 996 parents provided information on daycare attendance. Additional 585 children were tested with allergens at years 6 and 11.

Children with a lower incidence of asthma and wheezing also had a low prevalence of high IgE concentrations and skin reactivity to allergens. These children were more likely to have started daycare before 6-months of age and have 2 or more siblings at home, than children who started daycare after 1 year of age and have fewer than 2 siblings at home. However, those children who did not develop asthma were more likely to experience more wheezing, signaling infection, at year 2 than those children who later developed asthma.

Dr. Sandra Christiansen 2, Scripps Research Institute, suggests that, “the relation between asthma an exposures in early life probably reflects the effect of these exposures on the developing immune system.” The immune system an infant is born with changes in response to exposure to environmental factors, including bacteria. These environmental factors teach the immune system effective responses to fight infection. But without exposure, the immune system does not learn how to fight germs and build tolerance, and instead relies on the original incompetent immune response. This learning period is time sensitive, for asthma anyway, it must take place within the first 6-month of life.

Asthma Facts

More than 5000 deaths a year are caused by Asthma, with children under the age of 18 making up 4.8 million of the 14.6 million who suffer from this chronic respiratory disease. Symptoms of asthma include cough, wheezing, and tightness of the chest and shortness of breath. Although there is no genetic basis for asthma, there is an inherited predisposition-asthma runs in families. The exact cause of asthma is unknown.

Several variables are know to trigger an asthma attack including: allergies to pets, dust-mites, pollens, fungus and some foods; pollutants like cigarette smoke and car exhaust; exercise especially in cold temperatures; a virus or infection; emotional reactions like fear and anger and some medications like aspirin and anti-inflammatory medication.

Asthma can be effectively managed and children and adults can lead relatively normal, active lives. Quality medical education and the development of behaviors that support recognition of asthma symptoms and their treatment are essential to breathing well. Ask your doctor about Asthma Management Programs. Most health care providers offer medical education about asthma.

Lately, I’ve been selling on eBay (which can be a terrific part-time job for arthritic folk…) and I’ve become addicted. In this house, anything that doesn’t move is in danger of being sold. Mementos, schmementos, is my motto…I want cash. On my latest closet raid, however, I was struck by a pang of sentimentality. There, in the corner—dust-covered and much ignored—was my old fencing equipment. It’s lunacy not to sell it—special-ordered foil with a pistol-handled grip, very nice fencing jacket, top-of-line mask, even the Valkyrie breast plates, all zipped up in a practically new carrying case. I could get a hundred bucks for it, easy…sold separately, maybe as much as $200.

And yet, I can’t bring myself to do it. Yes, I know that my fencing days are behind me—the quick, flicking motions of the wrist alone would kill me, not to mention the lunges—and yet, I have this irrational belief that if I sell my equipment, I’ll be jinxing myself. I can’t help feeling that if I give up on the idea of fencing, then I’ll never fence again…which leads to a whole Pandora’s box of fears that I’m really not up to facing.

Holding on to a fantasy isn’t always counter-productive, though. In this case, my admitted superstition about my fencing equipment is silly, illogical and maybe even childish, but it does serve a purpose. It gives me incentive to try to stay in shape (okay, sorta) on the off chance that medical technology catches up me. It’s not something I dwell upon, it doesn’t hurt anyone else and it gives me hope.

But some fantasies are harmful. Living with rheumatoid arthritis does, unfortunately, mean sacrifice. I doubt that there is anyone with RA who hasn’t had to give up something—and at times, it feels as if we’ve given up almost everything. Many of us lose our livelihoods, some of us lose important relationships and nearly all of us lose some measure of security, independence, and happiness. And, as devastating as it is to let go of something you love, holding on to an elusive dream can impede your progress towards acceptance…and without acceptance, you can never truly “live” with arthritis.

The Hobby
There are some truly inspiring arthritic folk out there. In Arthritis Today, I’ve read about mountain climbers, dancers, skiers, even runners—all people with rheumatoid arthritis. True, severity of symptoms varies wildly among us, and some people luck out on the right drug combination, but still…you can’t help but admire their determination.

And that kind of determination might make a difference in your abilities, as well. I will not be the one to tell you to give up football, hockey, rugby, ballet, or any other arthritis-unfriendly activity. Only you know what you can and can’t do. But sometimes pursuing an old hobby not only can lead to a serious (and possibly permanent) injury, it also leads to self-blame and anger…which can be just as harmful.

And letting go doesn’t have to mean giving up entirely…it just means modification. Suppose you used to love playing football on the weekends. Is it possible that you could play touch football? Or how about volunteering to coach a kid’s team? Maybe you can develop your writing abilities and submit an article to your favorite sports magazine. Become an entrepreneur and sell sports equipment, specializing in football. Be an avid booster for the local high school team. Just because you have to give up playing football doesn’t mean you have to give up football.

Now, let’s take ballet, which was another hobby I had B.A. (before arthritis). Even though you could not—throughout the entire history of dance—find a worse ballerina, I enjoyed ballet. I liked its discipline, its form, the way—as long as I avoided the mirrors—it made me feel graceful. Well, as I’ve mentioned before, I now have significant deformities in my feet—pirouettes are out of the question (as if I could pirouette before). But that doesn’t mean that I have to give up ballet! Maybe grand jetes aren’t going to happen, but I can still stretch at the barre and practice floor work. In this case, letting go means accommodation, not giving up.

The Relationship(s)
It has been estimated (and I always have to wonder at the crepe-hangers who come up with these statistics) that 80% of marriages in which one spouse becomes chronically ill, will fail. As much as I would love to believe Mark Twain’s credo—“There are lies, damn lies and statistics”—it’s hard not to find that figure discouraging. There are so many aspects to RA—physical, mental, financial—that can devastate a good marriage…and can finish off an already shaky marriage.

Now, if you’re like me, you probably scream every time some well-meaning writer suggests counseling. After medical bills and medications, who can afford a therapist? Okay, that’s true. But ask yourself this: can you afford a divorce? And, more importantly, can you afford the black depression that comes with a bad marriage…on top of RA, too? A neutral party can do a lot of soothe that destructive anger that I believe is inherent to RA…and he/she can also help you rationalize the very understandable resentment that your spouse may be feeling, as well. If you have lousy insurance/no insurance, try the local mental health center—they operate on a sliding fee scale. And if your partner won’t come with you…go anyway. It can only help.

RA affects other relationships, as well. Relationships with family and friends can become strained and even fractious. While you should make every effort to preserve your friendships, there are some people—the ones I call the Pathologically Healthy—who will never even make an effort to understand how your life has changed. They may ignore you, avoid you or even belittle you. There is a strange narcissism that runs in some people—if they are not experiencing pain/illness, then it is not possible that you are. If you cannot educate a person like this (and in my experience, you can’t), then you might need to let go of this friendship.

Family, on the other hand, is a different matter. You cannot divorce or break up with family…and you can’t choose them the way you can choose your friends. Since you’re stuck with them, try this: the Buddhist principle of Emotional Detachment. This is not the same as indifference; it is more like viewing someone from the wide end of a telescope and making them seem far away. Try telling yourself that—even though you love Uncle Al—nothing he says to you or about you really matters; you are the only one who knows the truth about yourself.

The Job
The reason that I saved this category for last is that many people identify themselves with their career. With men, especially, the loss of a job can be even more devastating that divorce. When your career is gone, so is your sense of security and independence. And, very often, when you develop rheumatoid arthritis, many of us have to let go of our jobs.

Or do you? Is there some other capacity in which you could still perform your job, even if only on a part-time basis? If, for example, you were a firefighter, perhaps there are still avenues for you to fight fires without the physical strain. Working as a dispatcher seems like a reasonable alternative…or maybe even arson investigation/inspection.

In some cases, arthritis could offer new opportunities. In my past life, I worked as an interpreter for the deaf. I liked it well enough, but it wasn’t really my passion. RA has forced me out of the profession—which was a terrible blow at first—but now I am doing what I love most: writing. (Now, if only I could make some money…)

If  RA has robbed you of your career, don’t automatically assume that disability is your only alternative. While disability is great for those of us who have not other choice, studies have shown that people on disability tend to worsen. I believe it’s the jinx factor: you are paid to be disabled, hence, you truly become disabled. Try to think of disability as a temporary solution and put your tax dollars to work by registering with the Department of Rehabilitative Services. Not only do they have a database of thousands of jobs available for folks with various limiting conditions (I’m not going to use the “D” word), they also know of grants and scholarships for people who need to learn new skills.

When Letting Go is not Giving Up

* When it leads to less pain—either physically, mentally or psychically
* When it leads to other opportunities
* When it ultimately leads to enrichment
* When it feels like a relief
* When, unfortunately, we have no other choice

I believe that the stages of grief—denial, anger, bargaining, depression and acceptance—aren’t truly “stages” at all, but rather cycles that we must endure and accept as part of the RA way of life. While we should strive to do all we can, be as involved as we can, be as “normal” as possible, there are times when we all—Christian, Jew, Muslim, Hindu, pagan and atheist—need to heed the wisdom of: “Let go…Let God”.

Conventional Therapies: Many of the therapies for OA and RA have the inflammatory component as their target. Glucocorticoids (steroids) have long been employed to control inflammation. Their use over the long-term is discouraged because of potential severe toxicities to muscle and other organs. However, over the past 20 years, treatment regimens have indicated that the commonly employed steroid prednisone in low doses of 7.5 mg or less may be employed over long periods and are usually well tolerated and safe. Non-steroidal anti-inflammatory drugs (NSAIDs) are also commonly used in initial treatment of RA and OA.

NSAIDs (i.e., diclofenac, tenoxicam, indomethacin, tenidap, ibuprofen, to name just a few) are powerful anti-inflammatory drugs that act by inhibiting several components of the inflammatory pathways, including macrophage function and by the pharmacological inhibition of prostaglandin synthesis, in general. Long-term use of NSAIDs can produce gastrointestinal side effects, and the gastrointestinal mucosa can be injured so that bleeding occurs without warning. However, NSAIDs may be the most common drug therapy in the treatment of OA. The so-called Disease Modifying Anti-Rheumatic Drugs (DMARDs) are usually not the first line of treatment in RA because of associated toxicity with long-term use. However, x-rays and clinical evidence of aggressive joint damage with progression in patients treated only with steroids or NSAIDs usually requires DMARDs to be employed in RA therapy. DMARDs are less commonly used in OA treatment. The DMARDs commonly employed in RA include, sulfasalazine (Azulfidine), hydroxychloroquine (Plaquenil) and methotrexate (Rheumatrex). These DMARDs appear to be less toxic than previously commonly employed DMARDs such as gold, penicillamine and azathioprine (Imuran). Methotrexate appears to be particularly effective in RA and combination therapy where multiple DMARDs may be required to fully regulate clinical symptoms of RA at different disease stages. Thus, DMARDs appear to alter the activity of inflammatory and immune cells active in the progression of RA.

Status of Novel Therapies:

Cox-2 inhibitors. NSAIDs inhibit the activity of enzymes, termed cyclooxygenase, required for the synthesis of prostaglandins and other eicosanoids. Prostaglandins synthesized by macrophages and other inflammatory cells are, in part, responsible for significant inflammation in arthritis. The finding in 1991 that a least two forms of cyclooxygenases exist, called Cox-1 and Cox-2, resulted in numerous experimental and clinical studies that showed that Cox-1 was a normal enzyme involved in tissue homeostasis, whereas Cox-2 was induced in that it was synthesized only at sites of inflammation. Thus, according to Dr. David Gotlieb, a South African rheumatologist, “Inhibition of Cox-1 is therefore undesirable… while the inhibition of Cox-2 is desirable.” Cox-2 inhibitors, such as celecoxib (Celebrex) are about 375-fold more selective for Cox-2 than Cox-1. Celebrex is effective in controlling the inflammation of arthritis with no significant complications when compared to placebo.

Inhibitors of tumor necrosis factor-alpha. Inflammatory arthritis is characterized, in part, by an increase in the amount of soluble mediators of inflammation called cytokines. One of these cytokines is tumor necrosis factor-alpha (TNF-alpha). Some RA patients resistant to conventional therapies with steroids, NSAIDs and even DMARDs have been treated with an anti-TNF-alpha antibody called infliximab (Remicade), which is a genetically engineered hybrid molecule made by combining human and mouse cell proteins or with another genetically engineered, human-derived molecule, etanercept (Enbrel). According to Drs. Maini and Taylor (Kennedy Institute of Rheumatology, London, UK) randomized phase II and III clinical trials of anti-TNF reagents have shown an acceptable safety profile and significant clinical efficacy in cases of RA that have not responded to conventional therapy. Anti-TNF combined with methotrexate appears to be particularly effective in RA patients whose disease persists even after therapy with DMARDs. However, RA patients with co-morbid conditions, including serious infection or cancer, are not advised to use anti-TNF therapies.

Oral Collagen. “Ingesting low doses of Type II collagen (the collagen type found in articular cartilage of synovial joints) may help relieve the severe joint pain, swelling and stiffness of the disease. In a clinical trial to determine the efficacy of oral collagen, RA patients continued on NSAIDs or oral steroids, but prednisone use did not exceed 10 mg. daily. The mechanism of the action of oral collagen presumably involves a reduction in the severity of the immune response associated with RA. According to Dr. John Stuart, a rheumatologist at the University of Tennessee in Memphis, oral collagen, “has the tremendous advantage in that it has no side effects.” The use of oral collagen therapy as an adjunctive treatment in RA continues to be studied.

Prosorba column. At 1999, the first non-drug therapy to treat RA was approved by the FDA. While the mechanism of action is incompletely understood, the Prosorba column improves RA symptoms with moderate to severe disease. The column is manufactured of purified bacterial protein A covalently bonded to silica. In a trial to study the effectiveness of this treatment, RA patients for two hours weekly for 12 weeks had their blood passed through the Prosorba column. The protein A is thought to collect the circulating immune complexes and antibodies, which significantly contribute to RA pathology.

According to an article published on The Lancet Interactive, the device worked so well that a phase III trial was halted early. Almost 50 percent of the 109 RA patients on the study, who had RA for a mean of 15.5 years, have significant improvement in symptoms. Additional studies are needed to further ascertain the mechanism of action of the Prosorba column and whether or not it will be useful in treating other autoimmune disorders in addition to RA.

B Cell Depletion. RA is perpetuated by a chronic cycle in which “autoreactive B lymphocytes generate their own antigen, called IgG rheumatoid factor,” according to Dr. Jonathan C. Edwards (University College, London, UK). Studies were designed by his group to determine whether or not B lymphocyte depletion would lead to clinical remission in RA patients. A monoclonal antibody, called anti-CD20 was employed in combination with prednisolone and cyclophosphamide (Cytoxan) to treat 20 patients who had RA refractory to other therapies for about 20 years. The results of these studies were reported this month at the American College of Rheumatology annual meeting in Philadelphia. The majority of RA patients responded to B-lymphocyte depletion brought about by anti-CD20 and were able to discontinue DMARDs. Reappearance of RA symptoms in some patients correlated with increased levels of B lymphocytes. Side effects of this novel therapy were reported to be minimal. A formal controlled clinical trial is planned.

Both conventional and novel therapies for the medical treatment of OA and RA provide an increased armamentarium for use by physicians in the care of patients with these diseases. More recently, novel therapies are directed at altering specific pathways implicated in both the pathogenesis and progression of OA and RA. The discovery of new pathways in these diseases will offer additional targets for drug intervention and perhaps even gene therapy. A better understanding of the relevance of these pathways integral to the inhibition of immune system dysfunction and inflammation should provide us with important new treatments for OA and RA in the next few years.

Recently, my colleagues and I were examining x-rays from patients with osteoarthritis (OA) of the femoral joint. These patients were quite young when their OA was first diagnosed. In these OA patients, the disease was clinically significant when they were in their 20s or 30s whereas in the general population OA does not usually present clinically until individuals are in their 40s or 50s. Genetic testing of these individuals indicated that several family members had a similar age onset of OA. The genetic defect is a mutation in the predominating collagen type that makes up the matrix of articular cartilage of synovial joints. In the many cases of inherited OA that we have examined, this precocious form of OA began when patients were in their teens, which often resulted in a bilateral total joint replacement sometime thereafter. Looking at the post-operative x-rays, I remarked to one of my colleagues, tongue-in-cheek, “Well there’s the cure for OA.”

Naturally when we discuss “arthritis cures” we can always include surgical intervention, which removes the dysfunctional joint.

Extraordinary advances in the technological development of joint prostheses and their application leading to joint replacement surgery have improved the quality of life for individuals with advanced arthritis of the peripheral joints.

Generally speaking, another interpretation of the term “arthritis cure” could occur when a medical intervention consisting of drug therapy and/or rehabilitation or fitness strategies delays or otherwise makes unnecessary the need for joint replacement surgery.

In this case, the patient’s clinical symptoms improve or are totally alleviated, a so-called “clinical remission” ensues and the patient’s clinical status is sustained over long periods of time. Does such a scenario exist in the therapy of arthritis now, and if not, what novel therapies are being developed to produce such an outcome?

Arthritis is often thought of as one disease, but in reality, while the final common pathway resulting in loss of joint function may be similar for all the arthritides, the pathogenesis or origin of the disease differs depending on which form of arthritis we are considering.

The most common form of arthritis is OA, affecting almost 80 percent of the population over the age of 50. OA has specific risk factors, namely, aging, obesity and repeated mechanical stress or trauma to joints, and so may be considered, in part, a “wear-and-tear” disorder of joints. Rheumatoid arthritis (RA), unlike OA, is an autoimmune disease because the immune system appears to react with self-antigens or self-proteins so that the immune system is activated to react with the body’s own tissue components. Thus, the body treats this response as if the tissue components were foreign proteins such as might occur when the normal immune response reacts to invading bacteria or viruses. There are contributing risk factors in RA as well. These include, allergy to foods, gut substances that might be exposed to peripheral blood, hereditary factors and exposure to certain microbes, which are in part an element of the hyperimmune response in the RA patient.

The final common pathway regardless of pathogenesis for both OA and RA involves inflammation. While OA is slowly progressive, activation of inflammatory cells appears to speed up the rate of progression to joint failure. Chronic inflammation is a hallmark of late-stage OA. Mild to chronic inflammation is a signature of RA at its inception. The proliferation of synovium in RA resulting in pannus causes significant aggressive destruction of cartilage and subchondral bone that is often irreversible. While the joints are mostly affected in RA and OA, in severe RA other organs may also be affected. These include the skin and lungs. The eyes also appear to be particular targets of the immune pathogenesis of RA. Muscle atrophy as a result of disuse is common, but the heart and blood vessels are less likely to be directly affected in RA.

to be continued…

Why Exercise?
When you first discussed exercise with your health care provider, he or she probably did not spend a lot of time talking about the benefits of exercise. Throughout our lives we’ve heard that exercise is “good for you,” but if you’re living with arthritis, exercise is particularly important. Exercise has been shown to increase muscle strength, endurance and flexibility and reduce weight. It has also been shown to reduce joint pain and stiffness, and improve overall sense of well-being.

Types of Exercise
As you’ve likely discussed with your health care provider, there are three main types of exercise that benefit people living with arthritis. Range-of-motion exercises are designed to help with flexibility and joint movement. In range-of-motion exercises, you move your joint through its entire range. For example, this might include rotating your wrist 360 degrees. Range-of-motion exercises should be performed daily or every other day. Your doctor can demonstrate the correct movements. Strengthening exercises are designed to make your muscles stronger in order to support and protect your joints. Strengthening exercises are also done daily, but shouldn’t be done when symptoms are flaring. Strengthening exercises may include the use of small weights, or water exercises. Aerobic/Endurance exercises are done to help control weight and improve your overall health. These exercises are usually done three times a week, for 20 to 30 minutes at a time.

Hints for Maintaining Your Exercise Program
After you’ve worked with your doctor or physical therapist to design an appropriate exercise program, the most difficult part of all is taking what you’ve learned and applying it to your daily life. For most of us, this is easy to do for the first few weeks, but becomes more difficult as time goes on. Try the tips below to help stay on track.

* Start small. Don’t begin your exercise program expecting to work out like an Olympic athlete. While it’s good to start with enthusiasm, starting a program that is too advanced can lead to pain – and decrease your chances of maintaining the program.

* Stretch. Along the same lines, don’t jump into each exercise session at “full swing.” Give your muscles a chance to warm up by stretching and doing range-of-motion exercises.

* Make exercise part of your routine. Like brushing your teeth, taking your vitamins, or any of the things you do every day, exercise should be established as part of your daily program. Set aside time each day to complete your program. Don’t forget to allocate time for stretching and cooling down.

* Make exercise a priority. Too often we drop exercise from our list of “to do’s” when we get busy or tired. It’s difficult to make something a priority when most of the benefits are long-term rather than immediate, but if you make exercise a daily priority you’re guaranteed to see results in your overall health.

* Give yourself a break. “No pain, no gain” definitely does not apply to people living with arthritis. Sometimes, some joints will hurt more than others. If you find that a particular exercise causes pain or inflammation, talk with your doctor about adjusting your exercise program.

* Distract yourself! If you’ve been sticking with the same exercise routine for more than a few weeks, you may have begun to tire of its repetition. Look for distractions while you’re exercising. For example, range-of-motion exercises can easily be done in front of the TV while your favorite program is on.

* Make it a party! OK, “party” might be a bit of a stretch, but you can make exercise fun by doing it with other people. Check with your local Arthritis Foundation for classes in your area. Or invite a neighbor, friend, or your spouse to exercise with you, or even keep you company while you exercise.

Remember that these tips are provided to give you ideas. Experiment a little and find out what works best for you. If you can find a program that you enjoy and can stick to it, you’re sure to see long-term benefits in improved health.

Ayurveda: means “science of life.” This form of alternative therapy focuses on maintaining physical health and well-being so a person can pursue a greater spiritual development. The main emphasis is healthy living through a good diet, exercise, moderation and meditation. The practitioner is just an advisor. Each person must put the advice to use. The theory of this kind of therapy is centered at body energy. What the practitioners helps you achieve is a balance of energy within yourself and the forces around you. Most of the treatment has to do with your digestion and elimination systems. The idea is to purify the system by eliminating toxins, therefore restoring balance within the body.

Chinese Medicine: “Balancing Vital Energy.” This form of therapy also has to do with finding balance in the body. The Chinese describe it as the yin and yang energies. These two forces are often opposing, but need to be in balance for optimal health. The Chinese also believe in something called Qi, which loosely translated represents life itself. It is referred to as life flowing through our bodies. When the Qi is blocked somewhere in the body the person becomes sick and the practitioner must work with that person to unblock the Qi. To accomplish the unblocking and re-establish the balance between the yin and yang they prescribe acupuncture, acupressure and exercises called tai chi chuan and qi gong as well as other herbs and preparations.

Naturopathic Medicine: This form of therapy centers around the body healing itself by living a healthy lifestyle and giving the body what it needs to function properly. It focuses on the person and not the disease and also working with the patient to prevent disease. The doctor plays the part of a teacher, with the patient educating themselves on healthy habits. Some of the focus is on removing poisons and bad habits and encouraging things like exercise, positive attitudes and bringing balance into ones life. One of the key areas the practitioners focus on is nutrition. Modern naturopathic physicians study a variety of disciplines including, nutrition, manipulation, herbal medicine, hydrotherapy and counseling. This type of practitioner is not equipped to provide all the treatment you will need for arthritis. It is truly a complementary form of medicine; therefore you also will need a medical doctor to treat you as well.

Osteopathic Medicine: Today osteopathic doctors go through almost the identical education process as regular MDs. They can do surgery and write prescriptions and they can also specialize in other fields of medicine just as a regular MD. The big difference between a regular MD and an Osteopathic doctor is the Osteopathic doctor looks at the musculoskeletal system as the core of the problem. They feel that if they can help the patient get their bones and muscles in good working order that other problems will resolve themselves. They use manipulation of the entire bone structures of the body. Some other forms of therapy used include massage, relaxation, diet changes and also exercise.

Chiropractic: This form of alternative therapy is widely used. It is the third largest health-care profession. Millions of people each year seek the help of a chiropractor for the relief of back and neck pain. Many people find themselves going to a Chiropractor after an accident or injury. It is also a form of therapy that many people with musculoskeletal problems find relief from their discomfort. The focus of treatment is to realign the spine. Chiropractors feel if there are problems with the alignment of the spine (subluxation specifically) this causes pain and sometimes immobility and loss of function. By aligning the spine they feel the patient will benefit by a reduction in pain and an increase in overall mobility.

There are two different kinds of Chiropractors “straights” and “mixers.” Traditional or “straights” concentrate on just doing spinal manipulations. “Mixers” use several different approaches to treatment. Some include, electrical stimulation, ultrasound, herbal and vitamin therapies, and nutritional counseling. These practitioners may also have other certifications including massage therapy and physical therapy or work closely with practitioners that provide these complimentary services. “Mixers” use more of a comprehensive approach that involves more than just spinal manipulations. People with arthritis should use caution when seeking help from a chiropractor. Manipulating weak, diseased joints can cause more damage to the joint.

Mind-Body Connection: There are many therapies that are practiced by individuals for pain relief and stress reduction. Most people use these with other forms of conventional therapy. It has been well documented that negative emotions such as stress, depression and anxiety can increase symptoms and result in more pain and loss of function. The mind-body connection and how it can be used to help a person get control over symptoms and their life is an accepted form of therapy. This fact was proven a few decades ago when researchers used a placebo on a group of patients. In a controlled study some patients were given the real medicine and others were give a sugar pill or placebo. It was proven in several research studies that about 30 percent of the people in the studies responded the same whether they got the medication or the placebo. From this research they concluded that there was something to the mind, body connection and how a patients physical well-being was affected by their mental health. Because of these studies and others like them the whole field of mind-body therapy immerged. Some of the more common forms of mind-body therapies follow.

Biofeedback: This is a method where electronic monitors are used to teach the patients how to lower muscle tension and reduce pain. It is performed at a clinic initially and then as the patients become familiar with the process they can do it at home. Basically an electrical monitor is used to detect tension at a specific area of the body. The patient is lead through a series of relaxation exercises focusing on that area of the body to help relieve the tension. The monitor is used to help the patient or clinician detect a change in how the muscle is reacting to the relaxation techniques. This form of therapy takes concentrated work on the part of the patient. The results come over time as the patients become more in tune with their bodies and can focus on certain areas of the body. It also requires a place where the patient can go and not be interrupted and can feel safe.

Meditation: People who practice meditation find it helps relieve tension, pain, stress and depression. It is a form of therapy that develops an inner calmness when practiced regularly. Meditation is not a form of therapy that can be learned and applied overnight. It takes practice, focus and belief in the process. Usually the longer a person practices the more effective the outcome.

Hypnosis: There is self-hypnosis and being hypnotized by a professional. This form of therapy has been used for several conditions: weight reduction, smoking cessation, pain reduction and a number of other problems. The way it works is through different techniques that alter your consciousness and help you focus your attention. This is another form of therapy that you have to believe in or it will not work for you.

Other forms of mind-body therapy used are visualization, guided imagery, relaxation, deep breathing, progressive muscle relaxation, tai chi and yoga to name a few. In addition to the mind-body aspect of treating symptoms there are other specific forms of therapy that I want to mention.

Massage in its many different forms has shown to be beneficial in treating symptoms. When looking for a massage therapist you might want to educate yourself on the different techniques used in massage. These are a few of the more common types: reflexology, craniosacral, deep tissue, trigger point, myofascial release and acupressure. Each one of these techniques concentrates on a specific area of the body or amount of pressure used. This is one form of therapy that people either get good results or no results and it usually only takes one or two session to find out if it will benefit you. Educate yourself and find out what kind of training your therapist has before you schedule an appointment. The information you collect can mean the difference between helping you and causing more damage to your joints.

Other segments of alternative therapy are diet, supplements, herbs, teas and things like bee venom, magnets and copper bracelets. I am not going to elaborate on these forms of therapy because the benefits derived from them are controversial and lack scientific explanation. There are articles written about these forms of therapy if you have an interest and want to investigate them.

In closing one thing I would like to emphasize is that each person with arthritis needs to find his/her own unique remedies. Even though some 22 million people have osteoarthritis, each one of them needs to find the right treatment program for themselves. That program may include several different treatment modes, combining conventional with alternative. Just as each person is an individual, his or her approach to treating illness should also be tailored specifically for that individual.

Over the last 47 years of battling with rheumatoid arthritis I have used many different forms of therapy in my treatment program. One treatment plan will not last forever so we all must constantly be educating ourselves about new therapies whether they are conventional or alternative.

It is especially important to pay attention to this disease, not only because it can be disabling, but also because probably the most important single lifestyle factor that prevents major fatal diseases is exercise. It is crucial that we keep our joints in as good condition as possible, so that we can be as active as we choose in order to maintain healthy cardiovascular systems and many other vital systems in our bodies.

Injuries, overuse, excessive weight or pressure on the joints, or biochemical changes in the joint cartilage can trigger the process that causes deterioration of the cartilage, the lubricated cushion that keeps the joints working smoothly and freely. If old cartilage is degraded faster than new cartilage is formed, the result is deterioration. In early stages, not enough proteoglycans, glucosaminoglycans and collagen are produced to rebuild cartilage. As the cartilage thins and loses its elasticity, it becomes more prone to damage due to excessive use and injury. Then inflammation can occur. Bone exposure from loss of cartilage causes minute fractures and over-growth of bone with sharp edges within the joint. This then leads to pain, stiffness, swelling and deformity.

Conventional medical therapy such as non-steroidal anti-inflammatory drugs (NSAIDS) can reduce pain and inflammation, but they do not slow the deterioration of the joints, and in fact they cause more degradation of the cartilage if they are used regularly for a long time.

As with other chronic disease, it would make the most sense to prevent these changes from happening, and after they begin to occur, to provide the best support for the cartilage to repair itself.

One important support is proper exercise. Since there is no blood circulation in the cartilage, the cells can only get nourishment by a sponge-like action that comes from squeezing and releasing the cartilage through weight-bearing or other force-producing exercise. The pressure on the joint also has to be not excessive or too repetitive; therefore, obesity and activities that are too repetitive can cause harm. For example, running on hard pavement without properly cushioned shoe soles more than 10 miles per week could cause repetitive injury. Other similar excessive wear on joints could do the same.

What are some of the biochemical factors that promote cartilage deterioration? Dr. Sutter points out that free radical damage is being implicated increasingly in this disease, and research has shown that antioxidant nutrients do protect against degradation of cartilage.

If this is so, then all the other preventive measures that prevent free radical generation, applicable in most other degenerative diseases, could be applied here. Avoiding excess chemical and radiation exposure, avoiding high-fat foods and fried foods, managing and decreasing stress, improving detoxification ability, reducing allergic reactions, preventing diabetes and insulin resistance, and minimizing the use of prescription and non-prescription drugs, all are things that can reduce free radical damage. Eating foods high in antioxidants, such as colored fruits and vegetables, and taking antioxidant supplements also helps quench free radicals.

Also, any nutrient that prevents inflammation could slow or reverse the inflammatory stage of this cartilage deterioration. Foods high in ogega-3 fatty acids such as fish and vegetables, certain nuts and flax oil, and foods low in saturated fat could reduce tendencies for inflammation.

Drs. Alan Gaby, M.D., and Jonathan V. Wright, M.D., have found in their experience that some people are sensitive to foods in the nightshade family such as potatoes, peppers, tomatoes, eggplant, etc., and that they improve in arthritis symptoms when avoiding them.

I have found in my practice that several people were sensitive to other foods that, when eliminated, made the arthritis symptoms disappeared, in this case often the food was orange juice. It can be useful to do an elimination diet to try to detect which specific foods may be causing flare-ups of pain and inflammation for that particular person.

Dr. Sutter lists many nutrient supplements that can decrease free radicals, reduce inflammation, and supply building blocks for the cartilage cells to use to make new cartilage.

Glucosamine sulfate and chondroitin sulfate supply material for making more glucosaminoglycans, proteogllycans and synovial fluid, for building new cartilage. Vitamins E and C are important antioxidants that prevent free radical damage. Niacinamide helps to reduce inflammation by slowing the synthesis of nitric oxide (NO), which is a potent trigger for the degradation of cartilage. N-acetylcysteine, a nutrient also produced by the body, helps to reduce inflammation and increase production of the body’s own antioxidant, glutathione. Selenium assists vitamin E in antioxidant activity. Zinc, copper and manganese are needed for production of the body’s own antioxidant, superoxide dismutase (SOD).

Human studies have shown effectiveness in reducing symptoms of osteoarthritis with these aforementioned supplements. Several herbs have also been found in human studies to reduce symptoms, probably by reducing inflammation. These are ginger and turmeric (common kitchen spices), and boswellia serrata, a traditional Ayurvedic anti-inflammatory herb related to frankincense.

The amounts of the supplements our recommends are as follows: (Note: Caution should be exercised if turmeric or ginger is used in combination with drugs that prevent blood clotting, and niacinamide in these doses recommended should be done under a physician’s supervision, possibly with blood tests for liver function.)

Glucosamine sulfate — 500 milligrams three times daily.
Chondroitin sulfate — 400 milligrams two to three times daily.
Vitamin E — 400 to 800 IU per day.
Vitamin E — 500 milligrams three times daily.
Niacinamide — 500 milligrams two to three times daily.
N-acetylcysteine — 200 milligrams two to three times daily.
Selenium — 200 to 400 micrograms per day.
Zinc — 5 milligrams three times daily.
Copper — 2 milligrams per day.
Manganese — 20 milligrams per day.
Boswellia standardized extract — equivalent to 150 milligrams boswellic acids three times daily
Turmeric standardized extract — equivalent to 150 milligrams curcuminoids three times daily
Ginger standardized extract — equivalent to 10 milligrams gingerols three times daily

There are several homeopathic remedies that also have been useful in osteoarthritis.

Physical therapy can be useful in designing the proper exercise and activities to do for a person suffering from arthritis.

There is much we can do by way of natural therapies that can prevent or reduce osteoarthritis and its pain and inflammation, a disease for which it was once thought there was nothing that could be done for it.

Several medical therapies and life-style activities changes now exist for the treatment of osteoarthritis. However, at this point, their use is based solely on treating the symptoms of osteoarthritis, including pain, swelling from inflammation and reduced joint movement. Among the medicines employed, corticosteroids can be administered directly into the affected joint. Corticosteroids remain the most potent anti-inflammatory drugs employed in the therapy of osteoarthritis. There are reasons to minimize the use of injectable corticosteroids or oral formulations as these drugs have significant side-effects when employed for long periods of time. Aspirin and aspirin-like drugs were developed to reduce inflammation and so they are very useful in the medical therapy of osteoarthritis. This class of drugs, the non-steroidal anti-inflammatory drugs (NSAIDs) target a class of molecules called prostaglandins which are very much involved in the inflammatory processes accompanying osteoarthritis. NSAIDs inhibit an enzyme, called cyclooxygenase, which is required for the production of prostaglandins. However, the same enzyme is also required for normal function of the gastrointestinal mucosa, which lines the stomach and for normal kidney function. Long-term use of NSAIDs can result in gastrointestinal bleeding. It was for this reason that a new class of NSAIDs were developed, which reduce cyclooxygenase only at sites of inflammation and spare the normal cyclooxygenase. These so-called COX-II inhibitors are now widely employed for the medical therapy of osteoarthritis.

Naturally occurring substances such as glucosamine, chondroitin sulfate and hyaluronic acid has been used for treating patients with osteoarthritis with varying results. Nutritional supplements such as glucosamine and chondroitin sulfate may be more efficacious in maintaining cartilage health in symptom-free individuals than in restoring function in patients with osteoarthritis.

The development and continuous refinement of prostheses for joint replacement surgery for osteoarthritis of the knee and other joints has been instrumental in improving the quality of life for individuals for whom medical therapy is no longer feasible. While it has been argued that knee replacement surgery is underutilized, it is an intervention that is not without problems. It is a significant cost to health insurers and in many cases, the original replacement must be revised over time adding additional costs to our health delivery system.

People should be aware of how life-style modifications affect their chance of developing osteoarthritis. Physical exercise may be a risk factor for developing osteoarthritis, but in and of itself does not appear to accelerate minor damage to the cartilage. Thus, a well-designed and carefully monitored physical exercise program should be maintained to provide muscle tone support and to promote cardiovascular fitness. Prior participation and regular participation in sports resulting in the potential for repetitive trauma may play more of a role than the proposal to maintain a moderate physical exercise program. Normal symptom-free individuals should not avoid physical exercise in an attempt to forestall the development of osteoarthritis. In certain families, however, where individuals have the potential to develop precocious forms of osteoarthritis as a result of a genetic disorder in the joint cartilage, physical exercise may play a greater role in the progression of disease activity. In these individuals, a diagnosis of increased risk for developing osteoarthritis based on the results of genetic testing could provide needed information allowing for a more prudent physical exercise plan to be developed for these individuals.

We are certainly aware of the fact that individuals sustaining major injury to the knee such as rupture of the meniscus or anterior cruciate ligament may proceed to develop osteoarthritis in the absence of any other risk factors. Surgical repair of the knee damage and physical rehabilitation is commonly employed to prevent such an outcome.

What about weight reduction? While obesity has clearly been determined to be a risk factor for developing knee osteoarthritis, unlike the other risk factors previously mentioned (physical exercise and/or trauma), recent studies by Cooper and colleagues now suggest that only obesity defined a body mass index (BMI) of 22.7-25.4 or greater was associated with progression of osteoarthritis of the knee as measured by x-ray analysis. A weight-reduction plan should be designed for individuals who have an x-ray diagnosis of knee osteoarthritis in its early stages. This life-style change becomes important as attempts are made to medically regulate the progression of osteoarthritis over time.