Rheumatoid Arthritis - Other treatments

There is no special diet for rheumatoid arthritis. One hundred years ago, it was touted that "night-shade" foods, such as tomatoes, would aggravate rheumatoid arthritis. This is no longer accepted as true. Fish oil may have antiinflammatory beneficial effects, but so far this has only been shown in laboratory experiments studying inflammatory cells. Likewise, the benefits of cartilage preparations remain unproven. Symptomatic pain relief can often be achieved with oral acetaminophen (Tylenol) or over-the-counter topical preparations, which are rubbed into the skin. Antibiotics, in particular the tetracycline drug minocycline (Minocin), have been tried for rheumatoid arthritis recently in clinical trials. Early results have demonstrated mild to moderate improvement in the symptoms of arthritis. Minocycline has been shown to impede important mediator enzymes of tissue destruction, called metalloproteinases, in the laboratory as well as in humans.

The areas of the body, other than the joints, that are affected by rheumatoid inflammation are treated individually. Sjogren's syndrome (described above, see symptoms) can be helped by artificial tears and humidifying rooms of the home or office. Medicated eye drops, cortisporine ophthalmic drops (Restasis), are also available to help the dry eyes in those affected. Regular eye check-ups and early antibiotic treatment for infection of the eyes are important. Inflammation of the tendons (tendinitis), bursae (bursitis), and rheumatoid nodules can be injected with cortisone. Inflammation of the lining of the heart and/or lungs may require high doses of oral cortisone.

Proper, regular exercise is important in maintaining joint mobility and in strengthening the muscles around the joints. Swimming is particularly helpful because it allows exercise with minimal stress on the joints. Physical and occupational therapists are trained to provide specific exercise instructions and can offer splinting supports. For example, wrist and finger splints can be helpful in reducing inflammation and maintaining joint alignment. Devices, such as canes, toilet seat raisers, and jar grippers can assist daily living. Heat and cold applications are modalities that can ease symptoms before and after exercise.

Surgery may be recommended to restore joint mobility or repair damaged joints. Doctors who specialize in joint surgery are orthopedic surgeons. The types of joint surgery range from arthroscopy to partial and complete replacement of the joint. Arthroscopy is a surgical technique whereby a doctor inserts a tube-like instrument into the joint to see and repair abnormal tissues.

Total joint replacement is a surgical procedure whereby a destroyed joint is replaced with artificial materials. For example, the small joints of the hand can be replaced with plastic material. Large joints, such as the hips or knees, are replaced with metals. For more information, please read the Total Hip Replacement and Total Knee Replacement articles.

Finally, minimizing emotional stress can help improve the overall health of the patient with rheumatoid arthritis. Support and extracurricular groups afford patients time to discuss their problems with others and learn more about their illness.

Rheumatoid Arthritis - Newer treatments

Newer "second-line" drugs for the treatment of rheumatoid arthritis include leflunomide (Arava) and the "biologic" medications etanercept (Enbrel), infliximab (Remicade), anakinra (Kineret), adalimumab (Humira), rituximab (Rituxan), and abatacept (Orencia).

Leflunomide (Arava) is available to relieve the symptoms and halt the progression of the disease. It seems to work by blocking the action of an important enzyme that has a role in immune activation. Arava can cause liver disease, diarrhea, hair loss, and/or rash in some patients. It should not be taken just before or during pregnancy because of possible birth defects.

Other medications that represent a novel approach to the treatment of rheumatoid arthritis and are the products of modern biotechnology. These are referred to as the biologic medications or biological response modifiers. In comparison with traditional DMARDs, the biologic medications have a much more rapid onset of action and can have powerful effects on stopping progressive joint damage. In general, their methods of action are also more directed, defined, and targeted.

Etanercept, infliximab, and adalimumab are biologic medications. These medications intercept a protein in the joints (tumor necrosis factor or TNF) that causes inflammation before it can act on its natural receptor to "switch on " inflammation. This effectively blocks the TNF inflammation messenger from calling out to the cells of inflammation. Symptoms can be significantly, and often rapidly, improved in patients using these drugs. Etanercept must be injected subcutaneously once or twice a week. Infliximab is given by infusion directly into a vein (intravenously). Adalimumab is injected subcutaneously either every other week or weekly. Each of these medications will be evaluated by doctors in practice to determine what role they may have in treating various stages of rheumatoid arthritis. Research has shown that biological response modifiers also prevent the progressive joint destruction of rheumatoid arthritis. They are currently recommended for use after other second-line medications have not been effective. The biological response modifiers (TNF-inhibitors) are expensive treatments. They are also frequently used in combination with methotrexate and other DMARDs. Furthermore, it should be noted that the TNF-blocking biologics all are more effective when combined with methotrexate.

Anakinra is another biologic treatment that is used to treat moderate to severe rheumatoid arthritis. Anakinra works by binding to a cell messenger protein (IL-1, a proinflammation cytokine). Anakinra is injected under the skin daily. Anakinra can be used alone or with other DMARDs. The response rate of anakinra does not seem to be as high as with other biologic medications.

Rituxan is an antibody that was first used to treat lymphoma, a cancer of the lymph nodes. Rituxan can be effective in treating autoimmune diseases like rheumatoid arthritis because it depletes B-cells, which are important cells of inflammation and in producing abnormal antibodies that are common in these conditions. Rituxan is now available to treat moderate to severely active rheumatoid arthritis in patients who have failed the TNF-blocking biologics. Preliminary studies have shown that Rituxan was also found to be beneficial in treating severe rheumatoid arthritis complicated by blood vessel inflammation (vasculitis) and cryoglobulinemia.

Orencia is a recently developed biologic medication that blocks T-cell activation. Orencia is now available to treat adult patients who have failed a traditional DMARD or TNF-blocking biologic medication.

While biologic medications are often combined with traditional DMARDs in the treatment of rheumatoid arthritis, they are generally not used with other biologic medications because of unacceptable risk for serious infections.

The Prosorba column therapy involves pumping blood drawn from a vein in the arm into an apheresis machine or cell separator. This machine separates the liquid part of the blood (the plasma) from the blood cells. The Prosorba column is a plastic cylinder about the size of a coffee mug that contains a sand-like substance coated with a special material called Protein A. Protein A is unique in that it binds unwanted antibodies from the blood that promote the arthritis. The Prosorba column works to counter the effect of these harmful antibodies. The Prosorba column is indicated to reduce the signs and symptoms of moderate to severe rheumatoid arthritis in adult patients with long-standing disease who have failed or are intolerant to disease-modifying anti-rheumatic drugs (DMARDs). The exact role of this treatment is being evaluated by doctors, and it is not commonly used currently.

"Second-line" or "slow-acting" drugs (Disease-modifying anti-rheumatic drugs or DMARDs)

While "first-line" medications (NSAIDs and corticosteroids) can relieve joint inflammation and pain, they do not necessarily prevent joint destruction or deformity. Rheumatoid arthritis requires medications other than NSAIDs and corticosteroids to stop progressive damage to cartilage, bone, and adjacent soft tissues. The medications needed for ideal management of the disease are also referred to as disease-modifying anti-rheumatic drugs or DMARDs. They come in a variety of forms and are listed below. These "second-line" or "slow-acting" medicines may take weeks to months to become effective. They are used for long periods of time, even years, at varying doses. If effective, DMARDs can promote remission, thereby retarding the progression of joint destruction and deformity. Sometimes a number of second-line medications are used together as combination therapy. As with the first-line medications, the doctor may need to use different second-line medications before treatment is optimal.

Recent research suggests that patients who respond to a DMARD with control of the rheumatoid disease may actually decrease the known risk (small but real) of lymphoma that exists from simply having rheumatoid arthritis. The DMARDs are reviewed next.

Hydroxychloroquine (Plaquenil) is related to quinine and is also used in the treatment of malaria. It is used over long periods for the treatment of rheumatoid arthritis. Possible side effects include upset stomach, skin rashes, muscle weakness, and vision changes. Even though vision changes are rare, patients taking Plaquenil should be monitored by an eye doctor (ophthalmologist).

Sulfasalazine (Azulfidine) is an oral medication traditionally used in the treatment of mild to moderately severe inflammatory bowel diseases, such as ulcerative colitis and Crohn's colitis. Azulfidine is used to treat rheumatoid arthritis in combination with antiinflammatory medications. Azulfidine is generally well tolerated. Common side effects include rash and upset stomach. Because Azulfidine is made up of sulfa and salicylate compounds, it should be avoided by patients with known sulfa allergies.

Methotrexate has gained popularity among doctors as an initial second-line drug because of both its effectiveness and relatively infrequent side effects. It also has an advantage in dose flexibility (dosages can be adjusted according to needs). Methotrexate is an immune-suppression drug. It can affect the bone marrow and the liver, even rarely causing cirrhosis. All patients taking methotrexate require regular blood-test monitoring of blood counts and liver function blood tests.

Gold salts have been used to treat rheumatoid arthritis throughout most of the past century. Gold thioglucose (Solganal) and gold thiomalate (Myochrysine) are given by injection, initially on a weekly basis for months to years. Oral gold, auranofin (Ridaura), was introduced in the 1980s. Side effects of gold (oral and injectable) include skin rash, mouth sores, kidney damage with leakage of protein in the urine, and bone marrow damage with anemia and low white-cell count. Patients receiving gold treatment are regularly monitored with blood and urine tests. Oral gold can cause diarrhea. These gold drugs have lost such favor that many companies no longer manufacture them.

D-penicillamine (Depen, Cuprimine) can be helpful in selected patients with progressive forms of rheumatoid arthritis. Side effects are similar to those of gold. They include fever, chills, mouth sores, a metallic taste in the mouth, skin rash, kidney and bone marrow damage, stomach upset, and easy bruising. Patients on this medication require routine blood and urine tests. D-penicillamine can rarely cause symptoms of other autoimmune diseases.

Immunosuppressive medicines are powerful medications that suppress the body's immune system. A number of immunosuppressive drugs are used to treat rheumatoid arthritis. They include methotrexate (Rheumatrex, Trexall) as described above, azathioprine (Imuran), cyclophosphamide (Cytoxan), chlorambucil (Leukeran), and cyclosporine (Sandimmune). Because of potentially serious side effects, immunosuppressive medicines (other than methotrexate) are generally reserved for patients with very aggressive disease or those with serious complications of rheumatoid inflammation, such as blood vessel inflammation (vasculitis). The exception is methotrexate, which is not frequently associated with serious side effects and can be carefully monitored with blood testing. Methotrexate has become a preferred second-line medication as a result.

Immunosuppressive medications can depress bone-marrow function and cause anemia, a low white-cell count, and low platelet counts. A low white count can increase the risk of infections, while a low platelet count can increase the risk of bleeding. Methotrexate rarely can lead to liver cirrhosis and allergic reactions in the lung. Cyclosporin can cause kidney damage and high blood pressure. Because of potentially serious side effects, immunosuppressive medications are used in low doses, usually in combination with antiinflammatory agents.

"First-line" medications for Rheumatoid Arthritis

Acetylsalicylate (Aspirin), naproxen (Naprosyn), ibuprofen (Advil, Medipren, Motrin), and etodolac (Lodine) are examples of nonsteroidal antiinflammatory drugs (NSAIDs). NSAIDs are medications that can reduce tissue inflammation, pain, and swelling. NSAIDs are not cortisone. Aspirin, in doses higher than that used in treating headaches and fever, is an effective antiinflammatory medication for rheumatoid arthritis. Aspirin has been used for joint problems since the ancient Egyptian era. The newer NSAIDs are just as effective as aspirin in reducing inflammation and pain and require fewer dosages per day. Patients' responses to different NSAID medications vary. Therefore, it is not unusual for a doctor to try several NSAID drugs in order to identify the most effective agent with the fewest side effects. The most common side effects of aspirin and other NSAIDs include stomach upset, abdominal pain, ulcers, and even gastrointestinal bleeding. In order to reduce stomach side effects, NSAIDs are usually taken with food. Additional medications are frequently recommended to protect the stomach from the ulcer effects of NSAIDs. These medications include antacids, sucralfate (Carafate), proton-pump inhibitors (Prevacid, and others), and misoprostol (Cytotec). Newer NSAIDs include selective Cox-2 inhibitors, such as celecoxib (Celebrex), which offer antiinflammatory effects with less risk of stomach irritation and bleeding risk.

Corticosteroid medications can be given orally or injected directly into tissues and joints. They are more potent than NSAIDs in reducing inflammation and in restoring joint mobility and function. Corticosteroids are useful for short periods during severe flares of disease activity or when the disease is not responding to NSAIDs. However, corticosteroids can have serious side effects, especially when given in high doses for long periods of time. These side effects include weight gain, facial puffiness, thinning of the skin and bone, easy bruising, cataracts, risk of infection, muscle wasting, and destruction of large joints, such as the hips. Corticosteroids also carry some increased risk of contracting infections. These side effects can be partially avoided by gradually tapering the doses of corticosteroids as the patient achieves improvement of the disease. Abruptly discontinuing corticosteroids can lead to flares of the disease or other symptoms of corticosteroid withdrawal and is discouraged. Thinning of the bones due to osteoporosis may be prevented by calcium and vitamin D supplements. For further information on corticosteroids, please read the article on prednisone.

How is rheumatoid arthritis treated?

There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as seen on x-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications, rest, joint-strengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.

Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs" and slow-acting "second-line drugs" (also referred to as disease-modifying antirheumatic drugs or DMARDs). The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such as gold, methotrexate and hydroxychloroquine (Plaquenil) promote disease remission and prevent progressive joint destruction, but they are not antiinflammatory agents.

The degree of destructiveness of rheumatoid arthritis varies from patient to patient. Patients with uncommon, less destructive forms of the disease or disease that has quieted after years of activity ("burned out" rheumatoid arthritis) can be managed with rest, pain and antiinflammatory medications alone. In general, however, patients improve function and minimize disability and joint destruction when treated earlier with second-line drugs (disease-modifying antirheumatic drugs), even within months of the diagnosis. Most patients require more aggressive second-line drugs, such as methotrexate, in addition to antiinflammatory agents. Sometimes these second-line drugs are used in combination. In some patients with severe joint deformity, surgery may be necessary.

How is rheumatoid arthritis diagnosed?

The first step in the diagnosis of rheumatoid arthritis is a meeting between the doctor and the patient. The doctor reviews the history of symptoms, examines the joints for inflammation and deformity, the skin for rheumatoid nodules, and other parts of the body for inflammation. Certain blood and X-ray tests are often obtained. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and the blood and x-ray findings. Several visits may be necessary before the doctor can be certain of the diagnosis. A doctor with special training in arthritis and related diseases is called a rheumatologist.

The distribution of joint inflammation is important to the doctor in making a diagnosis. In rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are typically inflamed in a symmetrical distribution (affecting both sides of the body). When only one or two joints are inflamed, the diagnosis of rheumatoid arthritis becomes more difficult. The doctor may then perform other tests to exclude arthritis due to infection or gout. The detection of rheumatoid nodules (described above), most often around the elbows and fingers, can suggest the diagnosis.

Abnormal blood antibodies can be found in patients with rheumatoid arthritis. A blood antibody called "rheumatoid factor" can be found in 80% of patients. Citrulline antibody (also referred to as anti-citrulline antibody, anti-cyclic citrullinated peptide antibody, and anti-CCP) is present in most patients with rheumatoid arthritis. It is useful in the diagnosis of rheumatoid arthritis when evaluating patients with unexplained joint inflammation. A test for citrulline antibodies is most helpful in looking for the cause of previously undiagnosed inflammatory arthritis when the traditional blood test for rheumatoid arthritis, rheumatoid factor, is not present. Citrulline antibodies have been felt to represent the earlier stages of rheumatoid arthritis in this setting. Another antibody called "the antinuclear antibody" (ANA) is also frequently found in patients with rheumatoid arthritis.

A blood test called the sedimentation rate (sed rate) is a measure of how fast red blood cells fall to the bottom of a test tube. The sed rate is used as a crude measure of the inflammation of the joints. The sed rate is usually faster during disease flares and slower during remissions. Another blood test that is used to measure the degree of inflammation present in the body is the C-reactive protein. The rheumatoid factor, ANA, sed rate, and C-reactive protein tests can also be abnormal in other systemic autoimmune and inflammatory conditions. Therefore, abnormalities in these blood tests alone are not sufficient for a firm diagnosis of rheumatoid arthritis.

Joint x-rays may be normal or only show swelling of soft tissues early in the disease. As the disease progresses x-rays can show bony erosions typical of rheumatoid arthritis in the joints. Joint x-rays can also be helpful in monitoring the progression of disease and joint damage over time. Bone scanning, a radioactive test procedure, can demonstrate the inflamed joints.

The doctor may elect to perform an office procedure called arthrocentesis. In this procedure, a sterile needle and syringe are used to drain joint fluid out of the joint for study in the laboratory. Analysis of the joint fluid, in the laboratory, can help to exclude other causes of arthritis, such as infection and gout. Arthrocentesis can also be helpful in relieving joint swelling and pain. Occasionally, cortisone medications are injected into the joint during the arthrocentesis in order to rapidly relieve joint inflammation and further reduce symptoms.

What are the symptoms and signs of rheumatoid arthritis?

The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). Remissions can occur spontaneously or with treatment, and can last weeks, months, or years. During remissions, symptoms of the disease disappear, and patients generally feel well. When the disease becomes active again (relapse), symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies from patient to patient, and periods of flares and remissions are typical.

When the disease is active, symptoms can include fatigue, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis is common during disease flares. Also during flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis).

In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). The small joints of both the hands and wrists are often involved. Simple tasks of daily living, such as turning door knobs and opening jars can become difficult during flares. The small joints of the feet are also commonly involved. Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis, such as gout or joint infection. Chronic inflammation can cause damage to body tissues, cartilage and bone. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function. Rarely, rheumatoid arthritis can even affect the joint that is responsible for the tightening of our vocal cords to change the tone of our voice, the cricoarytenoid joint. When this joint is inflamed, it can cause hoarseness of voice.

Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than the joints. Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as Sjogren's syndrome. Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing or coughing. The lung tissue itself can also become inflamed, and sometimes nodules of inflammation (rheumatoid nodules) develop within the lungs. Inflammation of the tissue (pericardium) surrounding the heart, called pericarditis, can cause a chest pain that typically changes in intensity when lying down or leaning forward. The rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells. Decreased white cells can be associated with an enlarged spleen (referred to as Felty's syndrome) and can increase the risk of infections. Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure. Even though these nodules usually do not cause symptoms, occasionally they can become infected. A rare, serious complication, usually with long-standing rheumatoid disease, is blood-vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death. This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.

What causes rheumatoid arthritis?

The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, none has been proven as the cause. The cause of rheumatoid arthritis is a very active area of worldwide research. Some scientists believe that the tendency to develop rheumatoid arthritis may be genetically inherited. It is suspected that certain infections or factors in the environment might trigger the immune system to attack the body's own tissues, resulting in inflammation in various organs of the body such as the lungs or eyes.

Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines, such as tumor necrosis factor/TNF and interleukin-1/IL-1) are expressed in the inflamed areas.

Environmental factors also seem to play some role in causing rheumatoid arthritis. Recently, scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis.

What is rheumatoid arthritis?

Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body tissues are mistakenly attacked by its own immune system. The immune system is a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease.

While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. Typically, however, rheumatoid arthritis is a progressive illness that has the potential to cause joint destruction and functional disability.

Low Back Pain Exercises

Low back pain is very common among adults. It is often caused by overuse and muscle strain or injury. Treatment can help you stay as active as possible, and it will help you understand that some continued or repeated back pain is not surprising or dangerous.

Most low back pain can get better if you stay active, avoid positions and activities that may increase or cause back pain, use ice (during the acute phase), and take nonprescription pain relievers when you need them. When you no longer have acute pain, you may be ready for gentle strengthening exercises for your stomach, back, and legs, and perhaps for some stretching exercises. Exercise may not only help decrease low back pain, but it may also help you recover faster, prevent re-injury to your back, and reduce the risk of disability from back pain.

Exercises to reduce low back pain are not complicated and can be done at home without any special equipment.

It's important that you don't let fear of pain keep you from trying gentle activity. You should try to be active soon after noticing pain, and gradually increase your activity level. Too little activity can lead to loss of flexibility, strength, and endurance, and then to more pain.

Exercises that may help reduce or prevent low back pain include:

• Aerobic exercise, to condition your heart and other muscles, maintain health, and speed recovery.
• Strengthening exercises, focusing on your back, stomach, and leg muscles.
• Stretching exercises, to keep your muscles and other supporting tissues flexible and less prone to injury.

Some exercises can aggravate back pain. If you have low back pain, avoid:

• Straight leg sit-ups.
• Bent leg sit-ups or partial sit-ups (curl-ups) when you have acute back pain.
• Lifting both legs while lying on your back (leg lifts).
• Lifting heavy weights above the waist (standing military press or bicep curls).
• Toe touches while standing.

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How is Carpal Tunnel Syndrome treated?

The choice of treatment for carpal tunnel syndrome depends on the severity of the symptoms and any underlying disease that might be causing the symptoms.
Initial treatment usually includes rest, immobilization of the wrist in a splint, and occasionally ice application. Patients whose occupations are aggravating the symptoms should modify their activities. For example, computer keyboards and chair height may need to be adjusted to optimize comfort. These measures, as well as periodic resting and range of motion stretching exercise of the wrists can actually prevent the symptoms of carpal tunnel syndrome that are caused by repetitive overuse. Underlying conditions or diseases are treated individually. Fractures can require orthopedic management. Obese individuals will be advised regarding weight reduction. Rheumatoid disease is treated with measures directed against the underlying arthritis. Wrist swelling that can be associated with pregnancy resolves in time after delivery of the baby!
Several types of medications have been used in the treatment of carpal tunnel syndrome. Vitamin B6 (pyridoxine) has been reported to relieve some symptoms of carpal tunnel syndrome, although it is not known how this medication works. Nonsteroidal anti-inflammatory drugs can also be helpful in decreasing inflammation and reducing pain. Side effects include gastrointestinal upset and even ulceration of the stomach. These medications should be taken with food and abdominal symptoms should be reported to the doctor. Corticosteroids can be given by mouth or injected directly into the involved wrist joint. They can bring rapid relief of the persistent symptoms of carpal tunnel syndrome. Side effects of these medications when given in short courses for carpal tunnel syndrome are minimal. However, corticosteroids can aggravate diabetes and should be avoided in the presence of infections.
Most patients with carpal tunnel syndrome improve with conservative measures and medications. Occasionally, chronic pressure on the median nerve can result in persistent numbness and weakness. In order to avoid serious and permanent nerve and muscle consequences of carpal tunnel syndrome, surgical treatment is considered. Surgery involves severing the band of tissue around the wrist to reduce pressure on the median nerve. This surgical procedure is called "carpal tunnel release." It can now be performed with a small diameter viewing tube, called an arthroscope, or by open wrist procedure. After carpal tunnel release, patients often undergo exercise rehabilitation. Though it is uncommon, symptoms can recur.

How is Carpal Tunnel Syndrome diagnosed?

The diagnosis of carpal tunnel syndrome is suspected based on the symptoms and the distribution of the hand numbness. Examination of the neck, shoulder, elbow, pulses, and reflexes can be performed to exclude other conditions that can mimic carpal tunnel syndrome. The wrist can be examined for swelling, warmth, tenderness, deformity, and discoloration. Sometimes tapping the front of the wrist can reproduce tingling of the hand, and is referred to as Tinel's sign of carpal tunnel syndrome. Symptoms can also at times be reproduced by the examiner by bending the wrist forward (referred to as Phalen's maneuver).
The diagnosis is strongly suggested when a nerve conduction velocity test is abnormal. This test involves measuring the rate of speed of electrical impulses as they travel down a nerve. In carpal tunnel syndrome, the impulse slows as it crosses through the carpal tunnel. A test of muscles of the extremity, electromyogram (EMG), is sometimes performed to exclude or detect other conditions that might mimic carpal tunnel syndrome.
Blood tests may be performed to identify medical conditions associated with carpal tunnel syndrome. These tests include thyroid hormone levels, complete blood counts, and blood sugar and protein analysis. X-ray tests of the wrist and hand might also be helpful.

How does a patient with carpal tunnel syndrome feel?

Patients with carpal tunnel syndrome initially feel numbness and tingling of the hand in the distribution of the median nerve (the thumb, index, middle, and part of the fourth fingers). These sensations are often more pronounced at night and can awaken patients from sleep. The reason symptoms are worse at night may be related to the flexed-wrist sleeping position and/or fluid accumulating around the wrist and hand while lying flat. Carpal tunnel syndrome may be a temporary condition that completely resolves or it can persist and progress.

As the disease progresses, patients can develop a burning sensation, cramping and weakness of the hand. Decreased grip strength can lead to frequent dropping of objects from the hand. Occasionally, sharp shooting pains can be felt in the forearm. Chronic carpal tunnel syndrome can also lead to wasting (atrophy) of the hand muscles, particularly those near the base of the thumb in the palm of the hand.

What conditions and diseases cause carpal tunnel syndrome?

For most patients, the cause of their carpal tunnel syndrome is unknown. Any condition that exerts pressure on the median nerve at the wrist can cause carpal tunnel syndrome. Common conditions that can lead to carpal tunnel syndrome include obesity, pregnancy, hypothyroidism, arthritis, diabetes, and trauma. Tendon inflammation resulting from repetitive work, such as uninterrupted typing, can also cause carpal tunnel symptoms. Carpal tunnel syndrome from repetitive maneuvers has been referred to as one of the repetitive stress injuries. Some rare diseases can cause deposition of abnormal substances in and around the carpal tunnel, leading to nerve irritation. These diseases include amyloidosis, sarcoidosis, multiple myeloma and leukemia.

What is carpal tunnel syndrome?

Carpus is derived from the Greek word "karpos" which means "wrist." The wrist is surrounded by a band of fibrous tissue that normally functions as a support for the joint. The tight space between this fibrous band and the wrist bone is called the carpal tunnel. The median nerve passes through the carpal tunnel to receive sensations from the thumb, index, and middle fingers of the hand. Any condition that causes swelling or a change in position of the tissue within the carpal tunnel can squeeze and irritate the median nerve. Irritation of the median nerve in this manner causes tingling and numbness of the thumb, index, and the middle fingers, a condition known as "carpal tunnel syndrome."

Does Medicare Cover Chiropractic Care?

Many of us frequently feel that we would like to use the services of a chiropractor, but we are in the dark as to the coverage, if any, that exists under Medicare. There is one, and only one service that is covered under Medicare Part B.

The one service that is covered is Chiropractic Manipulative Treatment (CMT) to treat a subluxation of your spine. There are strict rules that must be followed for the Medicare coverage to take place.

The main rule that must be adhered to is that you must obtain an x-ray, or you may utilize an existing CT scan or MRI, to meet the requirement. Medicare will not cover an x-ray that has been taken by your chiropractor. You will be responsible for the cost of the x-ray if your chiropractor or a member of his office has taken it.

If you do not have an x-ray taken and do not have an existing MRI or CT scan you will be responsible for the cost of the treatment. Medicare will not cover any other services performed or ordered by the chiropractor.

Medicare's chiropractic benefit will be determined by your medical need. If your claim is denied you always have the right to appeal it.

Office Chair Advice

Office Chair Posture

For most people, it is quite a challenge to maintain good posture while sitting in an office chair and working for long hours in front of a computer. In fact, a surprising number of people sit at the front of their office chair and hunch forward in an attempt to get closer to their computer screen. The computer is a very potent ‘consciousness absorbing’ device – it takes the mind away from the body and keeps it focused on what’s on the screen instead.

This article reviews a simple, practical way to counteract this tendency to hunch forward and instead improve posture by keeping the body anchored to the back of the office chair.

Upright Posture

Both the abdominal muscles in the front of the spine and the back muscles in the back of the spine work to hold the body erect, like two elastic bands positioned on either side of the spine. Forward leaning posture – hunching forward while sitting in an office chair - distorts this balancing system and places considerable strain on the back.

To illustrate the amount of strain on the back, think of the example of balancing a stationary motorcycle upright so that it doesn’t tip over. If the motorcycle is properly balanced it can be held upright easily with one hand. Similarly, when one sits upright in an office chair, the abdominal and back muscles work in unison to maintain an erect posture with only minimal effort.

However, if the motorcycle leans over a bit there is a significant difference in the amount of effort it takes to keep the bike from falling over to the ground. The more the motorcycle leans, the more effort is needed to keep it from falling over. Similarly, when people hunch forward while sitting on an office chair their back muscles have to work much harder to hold the body up and keep it from falling forward.

Simply put, leaning forward 30 degrees in an attempt to get closer to the computer screen puts 3 to 4 times more strain on the back, causing advanced wear and tear on the joint surfaces, the ligaments of the spine, and the discs located between the vertebrae¹. The back muscles are also negatively affected as the continuous added strain causes them to tighten up, reducing optimal blood and nutrient flow to the back muscles. Over time this posture leads to the development of tight, rigid muscles and joints, which makes them more prone to injury.

One of the biggest misconceptions with sitting is that it doesn’t require any muscular effort. This is absolutely false. The back muscles are continuously working to maintain the body in an upright posture while sitting. And for those who sit in an office chair and work for long periods of time at a computer in a hunched forward posture, the structures in the back suffer considerable strain.

Technique To Avoid Hunching While Sitting In An Office Chair

To avoid the natural tendency to hunch forward while sitting in an office chair and working at a computer, this simple technique is fool-proof. Place a tennis ball between the middle back and the office chair on each side of the spine. Holding the tennis ball (or similar ball) in place while sitting and working at a computer accomplishes three things:

• Because the mind senses the ball, it remains connected with the body instead of being completely absorbed by what is on the computer screen. Maintaining more awareness of the body allows one to more easily maintain better posture.
• By leaning back into the tennis ball an acupressure effect is created, which stimulates blood flow into the area and physically releases contracted muscle and connective tissue. The pressure of the ball also creates a central nervous system mediated analgesic effect that is somewhat similar to acupuncture, loosening tight areas while sitting in the office chair and getting work done².
• Importantly, if one does get absorbed into work and starts to lean forward the tennis ball will fall out, serving as a concrete reminder to stop hunching forward and straining the back.

Please note that the above technique and the advice provided on the following pages are effective, cost next to nothing, have no adverse side effects and are quite easy to do.

Does The Use Of Cell Phone cause Malignant Brain Tumor?

The use cell phone increases your risk of developing a malignant brain tumor by two to four times.

When Vini Khurana, PhD, an Australian (and Mayo Clinic–trained) neurosurgeon, announced that the link between cell-phone use and cancer was irrefutable--the result of his analysis of more than 100 studies--it set off alarm bells around the world. Use a cell phone, he said, and you increase your risk of developing a malignant brain tumor by two to four times. Until recently, the majority of research indicated little or no link between cell phones and cancer (the World Health Organization and the American Cancer Society maintain that cell phones pose no threat), but several new long-term studies have cast doubt about their safety. Given that cell phones and PDAs serve as lifelines for so many people--24 percent of 10- and 11-year-olds carry them--it raises urgent questions.

Do cell phones cause cancer?

Maybe…with extended use. Mobile-phone users are twice as likely to develop malignant, difficult-to-treat brain tumors called gilomas, according to a first-of-its-kind study that analyzed the effects of cell-phone use over 10 years or more and was published last year in the journal Occupational Environmental Medicine. The Bioinitiative Working Group, an international coalition of scientists and public-health experts, recently published a hefty report detailing the link between the nonionizing radiation caused by a cell phone's electromagnetic fields (EMFs) and cancer, DNA damage, Alzheimer's, and other diseases. "The cells in the body react to EMFs in cell phones just like they do to other environmental toxins, including heavy metals and chemicals," says Martin Blank, PhD, a professor in bioelectromagnetics at Columbia University and one of the report's authors. The study found that risk from cell-phone use starts at 260 lifetime hours.

Do cell phones emit radiation only when you are talking?

No. "Cell phones give off radiation any time they're turned on so that they can communicate with base stations," says Lou Bloomfield, PhD, professor of physics at the University of Virginia and author of How Everything Works: Making Physics Out of the Ordinary. "The radiation emitted, however, is stronger and more frequent when you're talking or messaging." Also, the greater distance you are from a base station, the more radiation your phone must emit in order to get a signal, which is why your phone feels hot when you have low reception. That heat you feel is radiation. The Bioinitiative study found that adverse effects to DNA can also occur before the phone heats up. To reduce your exposure, make calls only when you have strong reception, hang up before your phone heats up, and store your phone away from your body when it's not in use.

Medicare Coverage For Chiropractic Care and Deductible Periods

How does Medicare work with chiropractic care?

Numerous misunderstanding of charges for the $100 deductible are not sent to the Medicare, and that the $100 can be met by going to more than one physician - for example, if the chiropractor sends the patient to a medical doctor for their high blood pressure. If each charges $65.00, this is when Medicare jumps in and starts paying the 80%. But why do we have to pay $100 in December, then if we need to go back in January we have to pay the $100 again? A year is just starting but what if you only had one month of charges in the previous year? Why are the x-rays not covered by a chiropractor when they must x-ray before they can treat a person?

Until recently, in order for chiropractic care to qualify for Medicare coverage there was a Catch 22. Medicare required an annual x-ray, but did not cover the cost of the x-ray. The coverage was only for the chiropractor's "manual manipulation of the spine for correcting a subluxation." There are no limits to the number of treatments as long as they are medically necessary to correct a specific condition.

Medicare no longer requires the annual x-ray, and still does not provide any coverage for them. New chiropractic patients, or patients who have not had an x-ray for some time however, may still require an x-ray for their course of chiropractic treatment as you have pointed out.

There is an initial $100 annual deductible for Medicare Part B (medical services). The annual deductible period is January 1 through December 31. Even if you only require care in December and do not have enough charges to satisfy your $100 deductible, it starts all over again in the new calendar year. This works the same way for most Medigap health insurance as well. You or your Medigap insurance are responsible for the paying the $100 Part B deductible. Once that is paid for then Medicare pays 80% of the Medicare approved charges.

Medicare X-rays Coverage for Chiropractors

If you are on Medicare and you get X-rays taken by or for your chiropractor, you may need to watch your pocketbook starting in the near future. Chiropractors often take diagnostic X-rays when evaluating their patients, but since the year 2000, they have not been required to do so. Before then, if a chiropractor determined that her or his patient needed an "adjustment" (the hallmark of this treatment specialty), the burden of proof was on them, and they had to show - by means of x-rays that a subluxation existed in the patient’s spine. Because of that requirement, Centers for Medicare and Medicaid Services felt it was fair to reimburse patients for any radiology associated with chiropractic diagnosis (making an exception to the rule that all x-rays had to be ordered by patients’ primary physicians).

In 2000, the requirement to prove via x-ray that a spinal subluxation was present before administering chiropractic treatment was lifted. But the CMS continued to pay for diagnostic radiology provided by chiropractors just the same. Now they are proposing to do away with that reimbursement benefit.

Medicare is the largest payer of health care costs in the U.S. The proposed rule is accepting comments until August 31. On the CMS website, the file code for making comments is CMS-1385-P.

Medicare & Medicaid Coverage For Chiropractic Therapy

The Center for Medicare and Medicaid Services (CMS) has revised its requirements for chiropractic billing of "active/corrective" treatment and "maintenance" therapy.

Under the Medicare program, active therapy (AT) is a course of treatment that provides "reasonable expectation of recovery or improvement of function" whereas maintenance therapy is defined as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.

Under Medicare, chiropractic maintenance therapy is not considered medically reasonable or necessary and has never been a covered service. The 2003 Improper Medicare FFS Payments report indicates that chiropractors filed claims incorrectly 30.6% of the time and had the highest compliance error rate among the professions whose services are covered. The new policy was established with the hope that specifying which claims are for active/corrective therapy and which are for maintenance therapy will enable more accurate billing and facilitate the claims review process.

Under Medicare, coverage extends only to "treatment by means of manual manipulation of the spine to correct a subluxation," provided such treatment is legal in the State where performed. No other service furnished or ordered by chiropractors are covered.

In order for a treatment program to be considered active therapy (AT):

• The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment,
• The manipulative services rendered must have a direct therapeutic relationship to the patient's condition and provide reasonable expectation of recovery or improvement of function. The patient must have a subluxation of the spine as demonstrated by x-ray or physical exam.

Medicare regulations further describe "subluxations" as:

• Acute subluxation: A patient's condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the patient's condition.
• Chronic subluxation: A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.

Claims for spinal manipulation are billed with procedure codes 98940, 98941, or 98942. As of October 4, claims must include the AT modifier (e.g., 98940-AT) if active/corrective treatment is performed or no modifier if maintenance therapy is performed. Every claim for chiropractic active/corrective treatment with or without the AT modifier will continue to be denied if the services exceed frequency limits of "reasonable and necessary" services as defined by contracting that reviews the claims.

The policy manual also notes:

The chiropractor should be afforded the opportunity to effect improvement or arrest or retard deterioration in such condition within a reasonable and generally predictable period of time. Acute subluxation (e.g., strains or sprains) problems may require as many as 3 months of treatment but some require very little treatment. In the first several days, treatment may be quite frequent but decreasing in frequency with time or as improvement is obtained.

Chronic spinal joint condition implies, of course, the condition has existed for a longer period of time and that, in all probability, the involved joints have already "set" and fibrotic tissue has developed. This condition may require a longer treatment time, but not with higher frequency.

Some chiropractors have been identified as using an "intensive care" concept of treatment. Under this approach multiple daily visits (as many as four or five in a single day) are given in the office or clinic and so-called room or ward fees are charged since the patient is confined to bed usually for the day. The room or ward fees are not covered and reimbursement under Medicare will be limited to not more than one treatment per day.

Much of the problem with chiropractic Medicare claims is related to the way the law covering their services was written. In 1972, in response to vigorous lobbying by chiropractors, Congress called ordered limited coverage of chiropractic services under Medicare. The law, which took effect in 1973, called for payment for the treatment of "subluxations demonstrated by x-rays to exist." A few weeks after the law was passed, Doyl Taylor, head of the AMA Department of Investigation stated that when chiropractic inclusion appeared inevitable, the "subluxation" language was inserted with the hope of preventing chiropractors from actually being paid. The idea's originator thought that because chiropractic's traditional (metaphysical) "subluxation" were visible only to chiropractors, this provision would sabotage their coverage. After the law was passed, however, two things happened to enable payment. First, chiropractors held a consensus conference that redefined "subluxations" to include common findings that others could see. Second, according to Taylor, the government officials responsible for interpreting the new law "decided that Congress intended chiropractors to be paid for something." The regulators then defined subluxation as "an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebrae demonstrable . . . to individuals trained in the reading of x-rays" and stipulated that the "primary diagnosis" must be a subluxation.

The best strategy for patients who undergo chiropractic care for back pain is to stop going when they feel better. However, many chiropractors advise lifetime periodic spinal examinations and adjustments for what they call "preventative maintenance." Because "maintenance care" lacks a plausible rationale and has never been proven beneficial, insurance companies do not knowingly pay for it. The new Medicare regulations are an attempt to make it simpler to identify "maintenance care" so claims for it can be denied automatically.

Non-Surgical Spinal Decompression

Triton Spinal Decompression is FDA cleared and has high success rate for pain associated with herniated or bulging discs...even after failed surgery. It is a non-surgical, traction based therapy for the relief of back and leg pain or neck and arm pain.

Treatment For Many Spinal Conditions

Many patients - some with MRI documented disc herniations - have achieved "good" to "excellent" results after spinal decompression therapy.

Will DTS Therapy Treatments Hurt? Is It Safe?

DTS Therapy treatments are one of the most gentle and comfortable therapies available. The treatments utilize equipment with proven safety and efficacy. Most patients report a mild sense of stretch on their back or hips, and often fall asleep during treatments sessions. The DTS System is produced by the world's largest manufacturer of hospital based rehabilitation equipment, with over 58 years of experience.

DTS ADVANTAGES

• Extremely Safe
• Likely Effective
• FDA Cleared
• Non-Surgical
• Affordable Cost

Therapy sessions typically last less than 20 minutes, and most patients feel pain relief with as few as 6-10 treatments. It is important to remember however, that pain subsiding does not infer that your discs and spine are healed, so it is critical that patients stick with the treatment protocol prescribed by their practitioners in order to achieve the full value of DTS Therapy.

How Much Will It Cost?

Our office visits vary as to the extent of care needed, (DTS Therapy, adjustments, cold laser therapy, muscle stimulation, ultrasound, massage, etc.). However we promise to only do those procedures necessary for your fullest recovery. You always have the choice as to the extent of care. Our staff will review all costs, payment options and insurance coverage up front. We want to help, and believe finances shouldn't stand in the way of you and good health.

Why This Treatments System Is So Effective?

The award winning computerized traction head is the key. The preprogrammed patterns for ramping up and down the amount of axial distraction eliminates muscle guarding and permits decompression to occur at the disc level.

Don't Risk Surgery

Spinal decompression has saved many people from spinal surgery. If you are suffering from a degenerated or herniated disc, don't risk surgery until you have explored safe and effective spinal decompression!