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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 conditions. Adults with arthritis and other rheumatic conditions incurred mean medical care expenditures of $6,978 in 2003, of which $1,635 was for prescriptions. Expenditures for adults with arthritis and other rheumatic conditions totaled $321.8 billion in 2003. Persons age 18 to 64 with arthritis and other rheumatic conditions earned $3,613 less than other persons. Of this amount, $1,590 in lost wages was attributable to arthritis and other rheumatic conditions.

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 osteo-arthritis, 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 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 idiopathic 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.

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. Fibromyalia affects millions of adults in the United States.

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. By conservative estimates, lupus affects about 150,000 people.

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.

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. An estimated 2.1 million Americans have gout.

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.

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 may restrict movement of nearby joints.

What Causes Rheumatic Disease?

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 idiopathic 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. By the year 2020, this number is expected to reach 60 million. Rheumatic diseases are a more frequent cause of activity limitation than heart disease, cancer, or diabetes.

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

• Rheumatoid arthritis occurs two to three times more often in women than in men.
• Scleroderma is more common in women than in men.
• Nine out of 10 people who have lupus are women.
• Nine out of 10 people who have fibromyalgia are women.
• Gout is more common in men than in women. 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).

The doctor will review the patient's medical history, conduct a physical examination, and obtain laboratory tests and x rays or other imaging tests. The doctor may need to see the patient more than once 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 any 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 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 anti-nuclear 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 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, 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 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 which 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., 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 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.

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.

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. These are the most common:

• Counterirritants - These ingredients, such as menthol, oil of wintergreen, eucalyptus oil, or camphor, work by irritating the nerve endings in the skin. This distracts the brain from the deeper source of pain. They are found in many products such as Eucalyptamint and Icy Hot.
• Salicylates - This ingredient works like aspirin, by blocking chemicals in the body that contribute to pain. Salicylates are found in Aspercreme, BenGay, Flexall, and several other over-the-counter preparations.
• Capsaicin - This natural ingredient found in cayenne peppers is an effective pain reliever for many. It is available in a number of products, including Zostrix and Capzasin-P.

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 contribute to inflammation and pain. However, each NSAID is a different chemical, and each has a slightly different effect on the body.

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.²

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 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 directly into the affected knee(s) or hip(s) to help provide temporary relief of pain and flexible joint movement.

Medical Devices

A number of devices may be used to treat some rheumatic diseases. For example, transcutaneous electrical nerve stimulation (TENS) has been found effective in modifying pain perception. TENS blocks pain messages to the brain with a small device that directs mild electric pulses to nerve endings that lie beneath the painful area of the skin.

Some health care facilities use a blood-filtering device called the Prosorba Column to filter out harmful antibodies in people with severe rheumatoid arthritis.

Heat and Cold Therapies

Heat and cold can both be used to reduce the pain and inflammation of arthritis. The patient and doctor can determine which one works best.

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

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

Hydrotherapy, Mobilization Therapy, and Relaxation Therapy

Hydrotherapy involves exercising or relaxing in warm water. The water takes some weight off painful joints, making it easier to exercise. It helps relax tense muscles and relieve pain.

Mobilization therapies include traction (gentle, steady pulling), massage, and manipulation. (Someone other than the patient moves stiff joints through their normal range of motion.) When done by a trained professional, these methods can help control pain, increase joint motion, and improve muscle and tendon flexibility.

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

Splints and Braces

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

Assistive Devices

A person with arthritis can use many kinds of devices to ease the pain. For example, using a cane when walking can reduce some of the weight placed on a knee or hip affected by arthritis. A shoe insert (orthotic) can ease the pain of walking caused by arthritis of the foot or knee. Other devices can help with activities such as opening jars, closing zippers, and holding pencils.

Surgery

Surgery may be required to repair damage to a joint after injury or to restore function or relieve pain in a joint damaged by arthritis. Many types of surgery are performed for arthritis. These include:

• 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 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 helpful in treating rheumatic diseases. These include products such as S-adenosylmethionine (SAM-e) for osteoarthritis and fibromyalgia, dehydroepiandrosterone (DHEA) for lupus, and glucosamine and chondroitin sulfate for osteoarthritis.

The Glucosamine/Chondroitin Arthritis Intervention Trial (the results of which were published in 2006) assessed the effectiveness and safety of glucosamine and chondroitin sulfate when taken together or separately. The trial was cosponsored by the National Center for Complementary and Alternative Medicine and 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.

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 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 people who have the same disease, can make it easier to cope. The Arthritis Foundation has a wealth of information to help people with arthritis.

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

National Institute of Arthritis and Musculoskeletal and Skin Diseases 
National Institutes of Health
Web Site: http://www.niams.nih.gov

Acknowledgments

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

Source:

National Institutes of Health
National Institute of Arthritis and Musculoskeletal and Skin Diseases
Adapted from NIH Publication No. 08-4999

Reviewed by athealth on February 7, 2014.

What is Marijuana? Are there different kinds?

Marijuana is a green, brown, or gray mixture of dried, shredded leaves, stems, seeds, and flowers of the hemp plant (Cannabis sativa). Before the 1960s, many Americans had never heard of marijuana, but today it is the most often used illegal drug in the United States.

Cannabis is a term that refers to marijuana and other drugs made from the same plant. Strong forms of cannabis include sinsemilla (sin-seh-me-yah), hashish (“hash” for short), and hash oil. All forms of cannabis are mind-altering (psychoactive) drugs; they all contain THC (delta-9-tetrahydrocannabinol), the main active chemical in marijuana. They also contain more than 400 other chemicals.

Marijuana’s effect on the user depends on the strength or potency of the THC it contains. THC potency has increased since the 1970s and continues to increase still. The strength of the drug is measured by the average amount of THC in test samples confiscated by law enforcement agencies. For the year 2006, most ordinary marijuana contained, on average, 7 percent THC.

What are the current slang terms for marijuana?

There are many different names for marijuana. Slang terms for drugs change quickly, and they vary from one part of the country to another. They may even differ across sections of a large city.

Terms from years ago, such as pot, herb, grass, weed, Mary Jane, and reefer, are still used. You might also hear the names Aunt Mary, skunk, boom, gangster, kif, or ganja.

There are also street names for different strains or “brands” of marijuana, such as “Texas tea,” “Maui wowie,” and “chronic.” One book of American slang lists more than 200 terms for various kinds of marijuana.

How is marijuana used?

Most users roll loose marijuana into a cigarette (called a joint or a nail) or smoke it in a pipe or a water pipe, sometimes referred to as a bong. Some users mix marijuana into foods or use it to brew a tea. Another method is to slice open a cigar and replace the tobacco with marijuana, making what’s called a blunt. When the blunt is smoked with a 40-oz. bottle of malt liquor, it is called a “B-40.”

Marijuana cigarettes or blunts sometimes contain other substances as well, including crack cocaine—a combination known by various street names, such as “primos” or “woolies.” Joints and blunts sometimes are dipped in PCP and are called “happy sticks,” “wicky sticks,” “love boat,” “dust,” “wets,” or “tical.”

How many people smoke marijuana? At what age do children generally start?

A recent government survey tells us:

• Marijuana is the most frequently used illegal drug in the United States. Nearly 98 million Americans over the age of 12 have tried marijuana at least once.

• Over 14 million had used the drug in the month before the survey.

The Monitoring the Future Survey, which is conducted yearly, includes students from 8th, 10th, and 12th grades. In 2006, the survey found that 15.7 percent of 8th-graders have tried marijuana at least once, and among 10th-graders, 14.2 percent were “current” users (that is, have used within the past month). Among 12th-graders, 42.3 percent have tried marijuana at least once, and about 18 percent were current users.

Other researchers have found that use of marijuana and other drugs usually peaks in the late teens and early twenties, then declines in later years.

How can I tell if my child has been using marijuana?

There are some signs you might be able to see. If someone is high on marijuana, he or she might:

• seem dizzy and have trouble walking;

• seem silly and giggly for no reason;

• have very red, bloodshot eyes; and

• have a hard time remembering things that just happened.

When the early effects fade, the user can become very sleepy.

Parents should be aware of changes in their child’s behavior, although this may be difficult with teens. Parents should look for withdrawal, depression, fatigue, carelessness with grooming, hostility, and deteriorating relationships with family members and friends. In addition, changes in academic performance, increased absenteeism or truancy, lost interest in sports or other favorite activities, and changes in eating or sleeping habits could be related to drug use. However, these signs may also indicate problems other than use of drugs.

In addition, parents should be aware of:

• signs of drugs and drug paraphernalia, including pipes and rolling papers.

• odor on clothes and in the bedroom

• use of incense and other deodorizers

• use of eye drops

• clothing, posters, jewelry, etc., promoting drug use

Why do young people use marijuana?

Children and young teens start using marijuana for many reasons. Curiosity and the desire to fit into a social group are common reasons. Certainly, youngsters who have already begun to smoke cigarettes and/or use alcohol are at high risk for marijuana use.

Also, our research suggests that the use of alcohol and drugs by other family members plays a strong role in whether children start using drugs. Parents, grandparents, and older brothers and sisters in the home are models for children to follow.

Some young people who take drugs do not get along with their parents. Some have a network of friends who use drugs and urge them to do the same (peer pressure). All aspects of a child’s environment—home, school, neighborhood—help to determine whether the child will try drugs.

Children who become heavily involved with marijuana can become dependent, making it difficult for them to quit. Others mention psychological coping as a reason for their use—to deal with anxiety, anger, depression, boredom, and so forth. But marijuana use is not an effective method for coping with life’s problems, and staying high can be a way of simply not dealing with the problems and challenges of growing up.

Researchers have found that children and teens (both male and female) who are physically and sexually abused are at greater risk than other young people of using marijuana and other drugs and of beginning drug use at an early age.

Does using marijuana lead to other drugs?

Long-term studies of high school students and their patterns of drug use show that very few young people use other drugs without first trying marijuana, alcohol, or tobacco. Though few young people use cocaine, for example, the risk of doing so is much greater for youth who have tried marijuana than for those who have never tried it. Although research has not fully explained this association, growing evidence suggests a combination of biological, social, and psychological factors is involved.

Researchers are examining the possibility that long-term marijuana use may create changes in the brain that make a person more at risk of becoming addicted to other drugs, such as alcohol or cocaine. Although many young people who use marijuana do not go on to use other drugs, further research is needed to determine who will be at greatest risk.

What are the effects of marijuana?

The effects of marijuana on each person depend on the

• type of cannabis and how much THC it contains;

• way the drug is taken (by smoking or eating);

• experience and expectations of the user;

• setting where the drug is used; and

• use of other drugs and/or alcohol.

Some people feel nothing at all when they first try marijuana. Others may feel high (intoxicated and/or euphoric).

It is common for marijuana users to become engrossed with ordinary sights, sounds, or tastes, and trivial events may seem extremely interesting or funny. Time seems to pass very slowly, so minutes feel like hours. Sometimes the drug causes users to feel thirsty and very hungry—an effect called “the munchies.”

What happens after a person smokes marijuana?

Within a few minutes of inhaling marijuana smoke, the user will likely feel, along with intoxication, a dry mouth, rapid heartbeat, some loss of coordination and balance, and a slower than normal reaction time. Blood vessels in the eye expand, so the user’s eyes look red.

For some people, marijuana raises blood pressure slightly and can double the normal heart rate. This effect can be greater when other drugs are mixed with marijuana, but users do not always know when that happens.

As the immediate effects fade, usually after 2 to 3 hours, the user may become sleepy.

How long does marijuana stay in the user's body?

THC in marijuana is readily absorbed by fatty tissues in various organs. Generally, traces (metabolites) of THC can be detected by standard urine testing methods several days after a smoking session. In heavy, chronic users, however, traces can sometimes be detected for weeks after they have stopped using marijuana.

Can a user have a bad reaction?

Yes. Some users, especially those who are new to the drug or in a strange setting, may suffer acute anxiety and have paranoid thoughts. This is more likely to happen with high doses of THC. These scary feelings will fade as the drug’s effects wear off.

In rare cases, a user who has taken a very high dose of the drug can have severe psychotic symptoms and need emergency medical treatment.

Other kinds of bad reactions can occur when marijuana is mixed with other drugs, such as PCP or cocaine.

How is marijuana harmful?

Marijuana can be harmful in a number of ways, through immediate effects and through damage to health over time.

Marijuana hinders the user’s short-term memory (memory for recent events), and he or she may have trouble handling complex tasks. With the use of more potent varieties of marijuana, even simple tasks can be difficult.

Because of the drug’s effects on perceptions and reaction time, users could be involved in auto crashes. Drug users also may become involved in risky sexual behaviors, which could lead to the spread of HIV, the virus that causes AIDS.

Under the influence of marijuana, students may find it hard to study and learn. Young athletes could find their performance is off; timing, movements, and coordination are all affected by THC.

Some of the more long-range effects of marijuana use are described later in this document.

How does marijuana affect driving?

Marijuana affects many skills required for safe driving: alertness, concentration, coordination, and reaction time. Marijuana use can make it difficult to judge distances and react to signals and sounds on the road.

There are data showing that marijuana can play a role in motor vehicle crashes. Studies show that approximately 4–14 percent of drivers who sustained injury or died in traffic accidents tested positive for THC. In many of these cases, alcohol was detected as well. When users combine marijuana with alcohol, as they often do, the hazards of driving can be more severe than with either drug alone. In a study conducted by the National Highway Traffic Safety Administration, a moderate dose of marijuana alone was shown to impair driving performance; however, the effects of even a low dose of marijuana combined with alcohol were markedly greater than those of either drug alone.

In one study conducted in Memphis, Tennessee, researchers found that, of 150 reckless drivers who were tested for drugs at the arrest scene, 33 percent tested positive for marijuana, and 12 percent tested positive for both marijuana and cocaine. Data also show that while smoking marijuana, people display the same lack of coordination on standard “drunk driver” tests as do people who have had too much to drink.

What are the long-term effects of marijuana?

Although all of the long-term effects of marijuana use are not yet known, there are studies showing serious health concerns. For example, a group of scientists in California examined the health status of 450 daily smokers of marijuana, but not tobacco. They found that the marijuana smokers had more sick days and more doctor visits for respiratory problems and other types of illness than did a similar group who did not smoke either substance.

Findings so far show that the regular use of marijuana may play a role in cancer and problems of the immune and respiratory systems.

Cancer

It is hard to find out whether marijuana alone causes cancer, because many people who smoke marijuana also smoke cigarettes and use other drugs. Marijuana smoke contains some of the same cancer-causing compounds as tobacco, sometimes in higher concentrations. Studies show that someone who smokes five joints per day may be taking in as many cancer-causing chemicals as someone who smokes a full pack of cigarettes every day.

Tobacco smoke and marijuana smoke may work together to change the tissues lining the respiratory tract. Marijuana smoking could contribute to early development of head and neck cancer in some people.

Immune system

Our immune system protects the body from many agents that cause disease. It is not certain whether marijuana damages the immune system of people. But both animal and human studies have shown that marijuana impairs the ability of T-cells in the lungs’ immune system to fight off some infections.

Lungs and airways

People who smoke marijuana regularly may develop many of the same breathing problems that tobacco smokers have, such as daily cough and phlegm production, more frequent chest colds, a heightened risk of lung infections, and a greater tendency toward obstructed airways. Marijuana smokers usually inhale more deeply and hold their breath longer, which increases the lungs’ exposure to toxic chemicals and irritants.

What about pregnancy: Will smoking marijuana hurt the baby?

Doctors advise pregnant women not to use any drugs because they might harm the growing fetus. Although one animal study has linked marijuana use to loss of the fetus very early in pregnancy, two studies in humans found no association between marijuana use and early pregnancy loss. More research is necessary to fully understand the effects of marijuana use on pregnancy outcomes.

Some scientific studies have found that babies born to women who used marijuana during their pregnancy display altered responses to visual stimulation, increased tremors, and a high-pitched cry, which may indicate problems with nervous system development. During preschool and early school years, marijuana-exposed children have been reported to have more behavioral problems and difficulties with sustained attention and memory than nonexposed children.

Researchers are not certain whether any effects of maternal marijuana use during pregnancy persist as the child grows up; however, because some parts of the brain continue to develop into adolescence, it is also possible that certain kinds of problems will become more evident as the child matures.

What happens if a nursing mother uses marijuana?

When a nursing mother uses marijuana, some of the THC is passed to the baby through breast milk. This is a matter for concern, because the THC in the mother’s milk is much more concentrated than that in the mother’s blood. One study has shown that the use of marijuana by a mother during the first month of breastfeeding can impair the infant’s motor development (control of muscle movement). This work has not been replicated, although similar anecdotal reports exist. Further research is needed to determine whether THC transmitted in breast milk has harmful effects on development.

How does marijuana affect the brain?

THC affects the nerve cells in the part of the brain where memories are formed. This makes it hard for the user to recall recent events (such as what happened a few minutes ago). It is hard to learn while high—a working short-term memory is required for learning and performing tasks that call for more than one or two steps.

Among a group of long-time heavy marijuana users in Costa Rica, researchers found that the people had great trouble when asked to recall a short list of words (a standard test of memory). People in that study group also found it very hard to focus their attention on the tests given to them.

As people age, they normally lose nerve cells in a region of the brain that is important for remembering events. Chronic exposure to THC may hasten the age-related loss of these nerve cells. In one study, researchers found that rats exposed to THC every day for 8 months (about 1/3 of their lifespan) showed a loss of brain cells comparable to rats that were twice their age. It is not known whether a similar effect occurs in humans. Researchers are still learning about the many ways that marijuana could affect the brain.

Can the drug cause mental illness?

Scientists do not yet know whether the use of marijuana causes mental illness. Among the difficulties in this kind of research are determining whether drug use precedes or follows mental health problems; whether one causes the other; and/or whether both are due to other factors such as genetics or environmental conditions. High doses of marijuana can induce psychosis (disturbed perceptions and thoughts), and marijuana use can worsen psychotic symptoms in people who have schizophrenia. There is also evidence of increased rates of depression, anxiety, and suicidal thinking in chronic marijuana users. However, it is not yet clear whether marijuana is being used in an attempt to self-medicate an already present, but otherwise untreated, mental health problem or whether marijuana use leads to mental disorders (or both).

Do marijuana users lose their motivation?

Some frequent, long-term marijuana users show signs of a lack of motivation (sometimes termed “amotivational syndrome”). Their problems include not caring about what happens in their lives, no desire to work regularly, fatigue, and a lack of concern about how they look. As a result of these symptoms, some users tend to perform poorly in school or at work. Scientists are still studying these problems.

Can a person become addicted to marijuana?

Yes. Although not everyone who uses marijuana becomes addicted, when a user begins to seek out and take the drug compulsively, that person is said to be dependent on the drug or addicted to it. In 2004, more than 298,317 people entering drug treatment programs reported marijuana as their primary drug of abuse, showing they needed help to stop using.

Some heavy users of marijuana show signs of withdrawal when they do not use the drug. They develop symptoms such as restlessness, loss of appetite, trouble sleeping, weight loss, and shaky hands.

According to one study, marijuana use by teens who have prior serious antisocial problems can quickly lead to dependence on the drug. That study also found that, for troubled teens using tobacco, alcohol, and marijuana, progression from their first use of marijuana to regular use was about as rapid as their progression to regular tobacco use and more rapid than the progression to regular use of alcohol.

What is "tolerance" for marijuana?

“Tolerance” means that the user needs increasingly larger doses of the drug to get the same desired results that he or she previously got from smaller amounts. Some frequent, heavy users of marijuana may develop tolerance for it.

Are there treatments to help marijuana users?

Up until a few years ago, it was hard to find treatment programs specifically for marijuana users. Treatments for marijuana dependence were much the same as therapies for other drug abuse problems. These include behavioral therapies, such as cognitivebehavioral therapy; multisystemic therapy; individual and group counseling; and regular attendance at meetings of support groups, such as Narcotics Anonymous.

Recently, researchers have been testing different ways to attract marijuana users to treatment and help them abstain from drug use. There are currently no medications for treating marijuana dependence. Treatment programs focus on counseling and group support systems. From these studies, drug treatment professionals are learning which characteristics of users are predictors of success in treatment and which approaches to treatment can be most helpful.

Further progress in treatment to help marijuana users includes a number of programs set up to help adolescents in particular. Some of these programs are in university research centers, where most of the young patients report marijuana as their drug of choice. Others are in independent adolescent treatment facilities. Family physicians can be a good source for information and help in dealing with adolescents’ marijuana problems.

Can marijuana be used as medicine?

There has been much debate in the media about the possible medical use of marijuana. Under U.S. law since 1970, marijuana has been a Schedule I controlled substance. This means that the drug, at least in its smoked form, has no commonly accepted medical use.

In considering possible medical uses of marijuana, it is important to distinguish between whole marijuana and pure THC or other specific chemicals derived from cannabis. Whole marijuana contains hundreds of chemicals, some of which may be harmful to health.

THC, manufactured into a pill that is taken by mouth, not smoked, can be used for treating the nausea and vomiting that go along with certain cancer treatments and is available by prescription. Another chemical related to THC (nabilone) has also been approved by the Food and Drug Administration for treating cancer patients who suffer nausea. The oral THC is also used to help AIDS patients eat more to keep up their weight.

Scientists are studying whether marijuana, THC, and related chemicals in marijuana (called cannabinoids) may have other medical uses. According to scientists, more research needs to be done on marijuana’s side effects and potential benefits before it can be recommended for medical use. However, because of the adverse effects of smoking marijuana, research on other cannabinoids appears more promising for the development of new medications.

How can I prevent my child from getting involved with marijuana?

There is no magic bullet for preventing teen drug use. But parents can be influential by talking to their children about the dangers of using marijuana and other drugs, and by remaining actively engaged in their children’s lives. Even after teens enter high school, parents can stay involved in schoolwork, recreation, and social activities with their children’s friends. Research shows that appropriate parental monitoring can reduce future drug use, even among those adolescents who may be prone to marijuana use, such as those who are rebellious, cannot control their emotions, and experience internal distress. To address the issue of drug abuse in your area, it is important to get involved in drug abuse prevention programs in your community or your child’s school. Find out what prevention programs you and your children can participate in together.

Talking to your children about marijuana

As this booklet has shown, marijuana can pose a particular threat to the health and well-being of children and adolescents at a critical point in their lives—when they are growing, learning, maturing, and laying the foundation for their adult years. As a parent, your children look to you for help and guidance in working out problems and in making decisions, including the decision not to use drugs. As a role model, your decision to not use marijuana and other illegal drugs will reinforce your message to your children.

There are numerous resources, many right in your own community, where you can obtain information so that you can talk to your children about drugs. To find these resources, you can consult your local library, school, or community service organization.

The National Institute on Drug Abuse offers an extensive collection of publications, videotapes, and educational materials to help parents talk to their children about drug use. For more information on marijuana and other drugs, contact:

National Clearinghouse for Alcohol and Drug Information (NCADI)
P.O. Box 2345
Rockville, MD 20847
1-800-729-6686
(TDD Number 1-800-487-4889)

And/or visit NIDA’s Web sites at:

www.drugabuse.gov
www.marijuana-info.org
www.teens.drugabuse.gov