Category: Rheumatology

What is done during a joint aspiration/injection?

Joint injections or aspirations (taking fluid out of a joint) usually are performed with a cold spray or other local anesthesia in the office or hospital setting. After the skin surface is thoroughly cleaned, the joint is entered with a needle attached to a syringe. At this point, either joint fluid can be obtained (aspirated) and used for appropriate laboratory testing or medications can be injected into the joint space. This technique also applies to injections into a bursa or tendon sheath to treat bursitis and tendonitis, respectively.

What benefit is derived from a joint aspiration?

Joint aspiration usually is done for help with diagnosis or treatment. Fluid obtained from a joint aspiration can be examined by the physician or sent for laboratory analysis, which may include a cell count (the number of white or red blood cells), crystal analysis (to confirm the presence of gout or pseudogout), and/or culture (to determine if an infection is present inside the joint). Drainage of a large joint effusion can provide pain relief and improved mobility. Injection of a drug into the joint may yield complete or short-term relief of symptoms.

What benefit is derived from a joint injection?

Joint injections may decrease the accumulation of fluid and cells in the joint and may temporarily decrease pain and stiffness. They may be given to treat inflammatory joint conditions, such as rheumatoid arthritis, psoriatic arthritis, gout, tendonitis, bursitis and, occasionally, osteoarthritis.

What usually is injected into the joint space?

Corticosteroids (such as methylprednisolone and triamcinolone formulated to stay primarily in the joint) frequently are used. They are anti-inflammatory agents that slow down the accumulation of cells responsible for producing inflammation and pain within the joint space. Although corticosteroids may also be successfully used in osteoarthritis, their mode of action is less clear. Hyaluronic acid (Hyalgan®, Synvisc®, Orthovisc®) is a viscous lubricating substance that may relieve the symptoms of osteoarthritisof the knee for periods up to 6–12 months. Mode of action is not clear.

Which joints are commonly injected?

Commonly injected joints include the knee, shoulder, ankle, elbow, wrist, base of the thumb and small joints of the hands and feet. Hip joint injection may require the aid of an ultrasound or X-ray called fluoroscopy for guidance. Some small joints may be more easily aspirated or injected with aid of ultrasound.

What are the risks of joint injections and aspirations?

Occasional side effects include allergic reactions to the medicines injected into joints, to tape or the betadine used to clean the skin. Infections are extremely rare complications of joint injections and occur less than 1 time per 15,000 corticosteroid injections. Another uncommon complication is post-injection flare—joint swelling and pain several hours after the corticosteroid or hyaluronic acid injection—which occurs in approximately 1 out of 50 patients and usually subsides within several days. It is not known if joint damage may be related to too-frequent corticosteroid injections. Generally, repeated and numerous injections into the same joint/site should be discouraged. Other complications, though infrequent, include depigmentation (a whitening of the skin), local fat atrophy (thinning of the skin) at the injection site and rupture of a tendon located in the path of the injection.

Are there situations where a joint injection should not be given?

Yes. The most common reasons for not performing a joint injection are the presence of an infection in or around a joint and if someone has a serious allergy to one or more of the medications that are injected into a joint. If an infection is suspected, aspiration of joint fluid for cultures is essential.

To find a rheumatologist

For a listing of rheumatologists in your area,click here.

Learn more about rheumatologistsandrheumatology health professionals.

Reviewed February 2012

Written by Lan X. Chen and H. Ralph Schumacher, MD, and reviewed by the American College of Rheumatology Communications and Marketing Committee.

This patient fact sheet is provided for general education only. Individuals should consult a qualified health care provider for professional medical advice, diagnosis and treatment of a medical or health condition.

© 2012 American College of Rheumatology

Overview

Diffuse idiopathic skeletal hyperostosis (DISH) is a bony hardening of ligaments in areas where they attach to your spine.

Also known as Forestier’s disease, this condition might not cause symptoms or require treatment. If it does cause symptoms, the most common are mild to moderate pain and stiffness in your upper back. DISH can also affect your neck and lower back, and some people have DISH in other areas, such as shoulders, elbows, knees and heels.

DISH can be progressive. As it worsens, it can cause serious complications.

Symptoms

You might have no signs or symptoms with DISH. For those who have signs and symptoms, the upper portion of the back is most commonly affected. Signs and symptoms might include:

Stiffness. Stiffness may be most noticeable in the morning.

Pain. You might feel pain in your back or in other affected areas, such as your shoulder, elbow, knee orheel.

Loss of range of motion. You might notice this most when stretching side to side.

Difficulty swallowing or a hoarse voice. You might have these if you have DISH in your neck.

When to see a doctor

Make an appointment with your doctor if you have persistent pain or stiffness in any joint or in your back.

Causes

DISH is caused by the buildup of calcium salts in the ligaments and tendons and a hardening and overgrowth of bone. But what causes these to occur is unknown.

Risk factors

Doctors have some idea of what can increase your risk of the condition. Risk factors include:

Sex. Men are more likely to develop DISH.

Older age. DISH is most common in older adults, especially in people older than 50.

Diabetes and other conditions. People with type 2 diabetes might be more likely to develop DISH thanare those who don’t have diabetes. Other conditions that can raise insulin levels in your body may also increase your risk, including hyperinsulinemia, prediabetes and obesity.

Certain medications. Long-term use of medications called retinoids, such as isotretinoin (Amnesteem,Claravis, others), which are used to treat skin conditions such as acne, can increase your risk.

Complications

People with DISH are at risk of certain complications, such as:

Disability. Loss of range of motion in the affected joint can make it difficult to use that joint. For instance,DISH in your shoulder can make it difficult to use your arm.

Difficulty swallowing. Bone spurs in the neck can put pressure on your esophagus. The pressure frombone spurs can also cause a hoarse voice or sleep apnea, a sleep disorder in which you stop breathing repeatedly during sleep. Rarely, this can become serious and might require surgery to remove the bone spurs.

Spinal fracture. DISH can increase your risk of breaking bones in your spine, especially if you havemoderate to severe disease. Even minor injuries can cause fractures. Breaks might require surgery to repair.

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Type 2 Diabetes

WHAT IS DIABETES?

Diabetes is a problem with your body that causes blood glucose (sugar) levels to rise higher than normal. This is also called hyperglycemia.

When you eat your body breaks food down into glucose and sends it into the blood. Insulin then helps move the glucose from the blood into your cells. When glucose enters your cells, it is either used as fuel for energy right away or stored for later use. In a person with diabetes, there is a problem with insulin. But, not all people with diabetes have the same problem.

The types of diabetes are type 1, type 2, and a condition called gestational diabetes, which happens when pregnant. If you have diabetes, your body either doesn’t make enough insulin, it can’t use the insulin it does make very well, or both.

WHAT IS TYPE 2 DIABETES?

In type 2 diabetes, your body does not use insulin properly. This is called insulin resistance. At first, the pancreas makes extra insulin to make up for it. Over time your pancreas isn’t able to keep up and can’t make enough insulin to keep your blood glucose levels normal. Type 2 is treated it with lifestyle changes, oral medications (pills), and insulin.

Some people with type 2 can control their blood glucose with healthy eating and being active. But, your doctor may need to also prescribe oral medications or insulin to help you meet your target blood glucose levels. Type 2 usually gets worse over time—even if you don’t need to take medications at first, you may need to later on.

HOW IS TYPE 2 DIFFERENT FROM TYPE 1?

In type 1, your body treats the cells that make insulin as invaders and destroys them. This can happen over a few weeks, months, or years. When enough of the cells are gone, your pancreas makes little or no insulin and blood glucose becomes dangerously high.

People with type 1 diabetes take insulin by injection with a syringe, an insulin pen, or an insulin pump.

WHAT CAUSES TYPE 2 DIABETES?

WHAT TREATMENTS ARE USED FOR TYPE 2 DIABETES?

HOW WILL I KNOW IF MY DIABETES TREATMENT IS WORKING?

Getting an A1C test at least twice a year helps you and your health care team keep track of how well you are controlling your blood glucose levels. A1C is part of your diabetes ABCs, which will tell you if your overall diabetes treatment is working. The ABCs of diabetes are:

A is for A1C or estimated average glucose (eAG)

Your A1C test tells you your average blood glucose for the past 2 to 3 months. It’s the blood check “with a memory.” Your health care provider may call this your estimated average glucose or eAG. The eAG gives your A1C results in the same units (mg/dl) as the glucose meter you use at home.

B is for blood pressure

Your blood pressure numbers tell you the force of blood inside your blood vessels. When your blood pressure is high, your heart has to work harder.

C is for cholesterol

Your cholesterol numbers tell you about the amount of fat in your blood. Some kinds of cholesterol can raise your risk for heart attack and stroke.

What is Sleep Hygiene?

‘Sleep hygiene’ is the term used to describe good sleep habits. Considerable research has gone into developing a set of guidelines and tips which are designed to enhance good sleeping, and there is much evidence to suggest that these strategies can provide long-term solutions to sleep difficulties. There are many medications which are used to treat insomnia, but these tend to be only effective in the short-term. Ongoing use of sleeping pills may lead to dependence and interfere with developing good sleep habits independent of medication, thereby prolonging sleep difficulties. Talk to your health professional about what is right for you, but we recommend good sleep hygiene as an important part of treating insomnia, either with other strategies such as medication or cognitive therapy or alone.

Sleep Hygiene Tips
1) Get regular. One of the best ways to train your body to sleep well is to go to bed and get up at more or less the same time every day, even on weekends and days off! This regular rhythm will make you feel better and will give your body something to work from.

2) Sleep when sleepy. Only try to sleep when you actually feel tired or sleepy, rather than spending too much time awake in bed.

3) Get up & try again. If you haven’t been able to get to sleep after about 20 minutes or more, get up and do something calming or boring until you feel sleepy, then return to bed and try again. Sit quietly on the couch with the lights off (bright light will tell your brain that it is time to wake up), or read something boring like the phone book. Avoid doing anything that is too stimulating or interesting, as this will wake you up even more.

4) Avoid caffeine & nicotine. It is best to avoid consuming any caffeine (in coffee, tea, cola drinks, chocolate, and some medications) or nicotine (cigarettes) for at least 4-6 hours before going to bed. These substances act as stimulants and interfere with the ability to fall asleep

5) Avoid alcohol. It is also best to avoid alcohol for at least 4-6 hours before going to bed. Many people believe that alcohol is relaxing and helps them to get to sleep at first, but it actually interrupts the quality of sleep.

6) Bed is for sleeping. Try not to use your bed for anything other than sleeping and sex, so that your body comes to associate bed with sleep. If you use bed as a place to watch TV, eat, read, work on your laptop, pay bills, and other things, your body will not learn this connection.

7) No naps. It is best to avoid taking naps during the day, to make sure that you are tired at bedtime. If you can’t make it through the day without a nap, make sure it is for less than an hour and before 3pm.
8) Sleep rituals. You can develop your own rituals of things to remind your body that it is time to sleep – some people find it useful to do relaxing stretches or breathing exercises for 15 minutes before bed each night, or sit calmly with a cup of caffeine-free tea.

9) Bathtime. Having a hot bath 1-2 hours before bedtime can be useful, as it will raise your body temperature, causing you to feel sleepy as your body temperature drops again. Research shows that sleepiness is associated with a drop in body temperature.

10) No clock-watching. Many people who struggle with sleep tend to watch the clock too much. Frequently checking the clock during the night can wake you up (especially if you turn on the light to read the time) and reinforces negative thoughts such as “Oh no, look how late it is, I’ll never get to sleep” or “it’s so early, I have only slept for 5 hours, this is terrible.”

11) Use a sleep diary. This worksheet can be a useful way of making sure you have the right facts about your sleep, rather than making assumptions. Because a diary involves watching the clock (see point 10) it is a good idea to only use it for two weeks to get an idea of what is going and then perhaps two months down the track to see how you are progressing.

12) Exercise. Regular exercise is a good idea to help with good sleep, but try not to do strenuous exercise in the 4 hours before bedtime. Morning walks are a great way to start the day feeling refreshed!

13) Eat right. A healthy, balanced diet will help you to sleep well, but timing is important. Some people find that a very empty stomach at bedtime is distracting, so it can be useful to have a light snack, but a heavy meal soon before bed can also interrupt sleep. Some people recommend a warm glass of milk, which contains tryptophan, which acts as a natural sleep inducer.

14) The right space. It is very important that your bed and bedroom are quiet and comfortable for sleeping. A cooler room with enough blankets to stay warm is best, and make sure you have curtains or an eyemask to block out early morning light and earplugs if there is noise outside your room.

15) Keep daytime routine the same. Even if you have a bad night sleep and are tired it is important that you try to keep your daytime activities the same as you had planned. That is, don’t avoid activities because you feel tired. This can reinforce the insomnia.

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People have long feared rheumatoid arthritis (commonly called RA) as one of the most disabling
types of arthritis. The good news is that the outlook has greatly improved for many people with
newly diagnosed (detected) RA. Of course, RA remains a serious disease, and one that can vary widely in symptoms (what you feel) and outcomes. Even so, treatment advances have made it possible to stop or at least slow the progression (worsening) of joint damage. Rheumatologists (/IAmA/ PatientCaregiver/HealthCareTeam /WhatisaRheumatologist)
now have many new treatments that target the inflammation that RA causes. They also understand better when and how to use treatments to get the best effects.

Fast Facts

Rheumatoid arthritis (RA) is the most common type of autoimmune arthritis. It is triggered by a faulty immune system (the body’s defense system) and affects the wrist and small joints of the hand, including the knuckles and the middle joints of the fingers.

Treatments have improved greatly and help many of those affected. For most people with RA, early treatment can control joint pain and swelling, and lessen joint damage.

Perform low impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and reduce pressure on your joints.

Studies show that people who receive early treatment for RA feel better sooner and more often, and are more likely to lead an active life. They also are less likely to have the type of joint damage that leads to joint replacement.

Seek an expert in arthritis: a rheumatologist. Expertise is vital to make an early diagnosis of RA and to rule out diseases that mimic RA, thus avoiding unneeded tests and treatments. Rheumatologists are experts in RA and can design a customized treatment plan that is best suited for you.

What is rheumatoid arthritis?
RA is the most common form of autoimmune arthritis, affecting more than 1.3 million Americans. Of these, about 75 percent are women. In fact, 1–3 percent of women may get rheumatoid arthritis in their lifetime. The disease most often begins between the fourth and sixth decades of life. However, RA can start at any age. RA is a chronic (longterm)
disease that causes pain, stiffness, swelling and limited motion and function of many joints. While RA can affect any joint, the small joints in the hands and feet tend to be involved most
often. Inflammation sometimes can affect organs as well, for instance, the eyes or lungs.

The stiffness seen in active RA is most often worst in the morning. It may last one to two hours (or even the whole day). Stiffness for a long time in the morning is a clue that you may have RA, since few other arthritic diseases behave this way.

For instance, osteoarthritis (/IAmA/PatientCaregiver/DiseasesConditions/Osteoarthritis) most often does not cause prolonged morning stiffness. Other signs and symptoms that can occur in RA include:

Loss of energy
Low fevers
Loss of appetite
Dry eyes and mouth from a related health problem, Sjogren’s syndrome (/IAmA/
PatientCaregiver/
DiseasesConditions/
Sjogrens Syndrome)
Firm lumps, called rheumatoid nodules, which grow beneath the skin in places such as the elbow and Hands

What causes rheumatoid arthritis?
RA is an autoimmune disease. This means that certain cells of the immune system do not work properly and start attacking healthy tissues — the joints in RA. The cause of RA is not known. Yet, new research is giving us a better idea of what makes the immune system attack the body and create inflammation. In RA, the focus of the inflammation is in the synovium, the tissue that lines the joint. Immune cells release inflammation causing chemicals. These chemicals can damage cartilage (the tissue that cushions between joints) and bone. Other things likely play a role in RA as well. For instance, genes that affect the immune system may
make some people more prone to getting RA.

How is rheumatoid arthritis diagnosed?
RA can be hard to detect because it may begin with subtle symptoms, such as achy joints or a little stiffness in the morning. Also, many diseases behave like RA early on. For this reason, if you or your primary care physician thinks you have RA, you should see a rheumatologist. A rheumatologist is a physician with the skill and knowledge to reach a correct diagnosis of RA and to make the most suitable treatment plan.

Diagnosis of RA depends on the symptoms and results of a physical exam, such as warmth, swelling and pain in the joints. Some blood tests also can help confirm RA. Telltale signs include:

Anemia (a low red blood cell count)

Rheumatoid factor (an antibody, or blood protein, found in about 80 percent of patients with RA in time, but in as few as 30 percent at the start of arthritis)

Antibodies to cyclic citrullinated peptides (pieces of proteins), or antiCCP
for short (found in 60–70 percent of patients with RA)

Elevated erythrocyte sedimentation rate (a blood test that, in most patients with RA, confirms the amount of inflammation in the joints)

Xrays can help in detecting RA, but may not show anything abnormal in early arthritis. Even so, these first Xrays may be useful later to show if the disease is progressing. Often, MRI and ultrasound scanning are done to help judge the severity of RA.

There is no single test that confirms an RA diagnosis for most patients with this disease. (This is above all true for patients who have had symptoms fewer than six months.) Rather, a doctor makes the diagnosis by looking at the symptoms and results from the physical exam, lab tests and Xrays.

How is rheumatoid arthritis treated?
Therapy for RA has improved greatly in the past 30 years. Current treatments give most patients good or excellent relief of symptoms and let them keep functioning at, or near, normal levels. With the right medications, many patients can achieve “remission” — that is, have no signs of active disease.

There is no cure for RA. The goal of treatment is to lessen your symptoms and poor function. Doctors do this by starting proper medical therapy as soon as possible, before your joints have lasting damage. No single treatment works for all patients. Many people with RA must change their treatment at least once during their lifetime.

Good control of RA requires early diagnosis and, at times, aggressive treatment. Thus, patients with a diagnosis of RA should begin their treatment with disease modifying
antirheumatic drugs — referred to as DMARDs. These drugs not only relieve symptoms but also slow progression of the disease. Often, doctors prescribe DMARDs along with nonsteroidal antiinflammatory drugs or NSAIDs and/or low dose corticosteroids, to lower swelling, pain and fever. DMARDs have greatly improved the symptoms, function and quality of life for nearly all patients with RA. Ask your rheumatologist about the need for DMARD therapy and the risks and benefits of these drugs.

Common DMARDs include methotrexate (/IAmA/ PatientCaregiver/ Treatments/MethotrexateRheumatrexTrexall) (Rheumatrex, Trexall, Otrexup, Rasuvo), leflunomide (/IAmA/PatientCaregiver/Treatments/LeflunomideArava)(Arava), ydroxychloroquine (/IAmA/PatientCaregiver/Treatments/HydroxychloroquinePlaquenil)(Plaquenil) and sulfasalazine (/IAmA/PatientCaregiver/Treatments/SulfasalazineAzulfidine)(Azulfidine).

Gold is an older DMARD that is often given as an injection into a muscle (such as Myochrysine), but can also be given as a pill — auranofin (Ridaura). The antibiotic minocycline (/IAmA/
PatientCaregiver/Treatments/MinocyclineMinocin)(Minocin) also is a DMARD, as well as the immune suppress antsazathioprine (/IAmA/PatientCaregiver/Treatments/AzathioprineImuran)
(Imuran) and cyclosporine (/IAm A/PatientCaregiver/ Treatments/CyclosporineNeoralSandimmuneGengraf) (Neoral, Sandimmune, Gengraf). These three drugs and gold are rarely prescribed for RA these days, because other drugs work
better or have fewer side effects.

Patients with more serious disease may need medications called biologic response modifiers or “biologic agents.” They can target the parts of the immune system and the signals that lead to inflammation and joint and tissue damage. FDAapproved drugs of this type include abatacept (/IAmA/PatientCaregiver/Treatments/AbataceptOrencia) (Orencia), adalimumab (Humira), anakinra (/iama/ patientcaregiver/ treatments/anakinrakineret) (Kineret), certolizumab (Cimzia), etanercept (Enbrel), golimumab (Simponi) infliximab (Remicade), rituximab (/iama/
patientcaregiver/ treatments/rituximabrituxanmabthera) (Rituxan, MabThera) and tocilizumab (/IAmA/ PatientCaregiver/Treatments/TocilizumabActemra) (Actemra). Most often, patients take these drugs with methotrexate, as the mix of medicines is more helpful.

Janus kinase (JAK) inhibitors are another type of DMARD. People who cannot be treated with methotrexate alone may be prescribed a JAK inhibitor such as tofacitinib (/IAmA/
PatientCaregiver/ Treatments/TofacitinibCitrateXelijanz) (Xeljanz).

The best treatment of RA needs more than medicines alone. Patient education, such as how to cope with RA, also is important. Proper care requires the expertise of a team of providers, including rheumatologists, primary care physicians, and physical and occupational therapists. You will need frequent visits through the year with your rheumatologist. These checkups let your doctor track the course of your disease and check for any side effects of your medications. You likely also will need to repeat blood tests and Xrays or ultrasounds from time to time.

Living with rheumatoid arthritis
Research shows that people with RA, mainly those whose disease is not well controlled, have a higher risk for heart disease and stroke. Talk with your doctor about these risks and ways to lower them.

It is important to be physically active most of the time, but to sometimes scale back activities when the disease flares. In general, rest is helpful when a joint is inflamed, or when you feel tired. At these times, do gentle range of motion exercises, such as stretching. This will keep the joint flexible.

When you feel better, do low impact aerobic exercises, such as walking, and exercises to boost muscle strength. This will improve your overall health and reduce pressure on your joints. A physical or occupational therapist can help you find which types of activities are best for you, and at what level or pace you should do them.

Finding that you have a chronic illness is a life changing event. It can cause worry and sometimes feelings of isolation or depression. Thanks to greatly improved treatments, these feelings tend to decrease with time as energy improves, and pain and stiffness decrease. Discuss these normal feelings with your health care providers. They can provide helpful information and resources.

The rheumatologist’s role in the treatment of rheumatoid arthritis

RA is a complex disease, but many advances in treatment have occurred recently. Rheumatologists are doctors who are experts in diagnosing and treating arthritis and other diseases of the joints, muscles and bones. Thus, they are best qualified to make a proper diagnosis of RA. They can also advise patients about the best treatment options.

Updated August 2013. Written by Eric Ruderman, MD, and Siddharth Tambar, MD, and reviewed by the American College of Rheumatology Communications and Marketing Committee. This information is provided for general education only. Individuals should consult a qualified health care provider for professional medical advice, diagnosis and treatment of a medical or health condition.

© 2013 American College of Rheumatology

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Osteoarthritis (also known as OA) is a common joint disease that most often affects middle­age to elderly people. It is commonly referred to as “wear and tear” of the joints, but we now know that OA is a disease of the entire joint, involving the cartilage, joint lining, ligaments, and bone. Although it is more common in older people, it is not really accurate to say that the joints are just “wearing out.” It is characterized by breakdown of the cartilage (the tissue that cushions the ends of the bones between joints), bony changes of the joints, deterioration of tendons and ligaments, and various degrees of inflammation of the joint lining (called the synovium).

This arthritis tends to occur in the hand joints, spine, hips, knees, and great toes. The lifetime risk of developing OA of the knee is about 46 percent, and the lifetime risk of developing OA of the hip is 25 percent, according to the Johnston County Osteoarthritis Project, a long­term study from the University of North Carolina and sponsored by the Centers for Disease Control and Prevention (often called the CDC) and the National Institutes of Health.

OA is a top cause of disability in older people. The goal of osteoarthritis treatment is to reduce pain and improve function. There is no cure for the disease, but some treatments attempt to slow disease progression.
Fast Facts
Though some of the joint changes are irreversible, most patients will not need joint replacement surgery. OA symptoms (what you feel) can vary greatly among patients.
A rheumatologist can detect arthritis and prescribe the proper treatment. The goal of treatment in OA is to reduce pain and improve function.
Exercise is an important part of OA treatment, because it can decrease joint pain and improve function. At present, there is no treatment that can reverse the damage of OA in the joints. Researchers are trying to find ways to slow or reverse this joint damage.
What is osteoarthritis?
OA is a frequently slowly progressive joint disease typically seen in middle­aged to elderly people. In osteoarthritis, the cartilage between the bones in the joint breaks down. This causes the affected bones to slowly get bigger. The joint cartilage often breaks down because of mechanical stress or biochemical
changes within the body, causing the bone underneath to fail. OA can occur together with other types of arthritis, such as gout (/I­Am­A/Patient­Caregiver/Diseases­Conditions/Gout) or rheumatoid arthritis (/I­Am­ A/Patient­Caregiver/Diseases­Conditions/Rheumatoid­Arthritis).

OA tends to affect commonly used joints such as the hands and spine, and the weight­bearing joints such as the hips and knees. Symptoms include:

Joint pain and stiffness Knobby swelling at the joint
Cracking or grinding noise with joint movement Decreased function of the joint
Who gets osteoarthritis?
OA affects people of all races and both sexes. Most often, it occurs in patients age 40 and above. However, it can occur sooner if you have other risk factors (things that raise the risk of getting OA). Risk factors include:

Older age
Having family members with OA Obesity
Previous traumatic Joint injury or repetitive use (overuse) of joints Joint deformity such as unequal leg length, bowlegs or knocked knees
How is osteoarthritis diagnosed
Rheumatologists are doctors who are experts in diagnosing and treating arthritis and other diseases of the joints, muscles and bones. You may also need to see other health care providers, for instance, physical or occupational therapists and orthopedic doctors. Most often doctors detect OA based on the typical symptoms (described earlier) and on results of the physical exam. In some cases, X­rays or other imaging tests may be useful to tell the extent of disease or to help rule out other joint problems.
How do you treat osteoporosis?
There is no proven treatment yet that can reverse joint damage from OA. The goal of osteoarthritis treatment is to reduce pain and improve function of the affected joints. Most often, this is possible with a mixture of physical measures and drug therapy and, sometimes, surgery.

Physical measures: Weight loss and exercise are useful in OA. Excess weight puts stress on your knee joints and hips and low back. For every 10 pounds of weight you lose over 10 years, you can reduce the chance of developing knee OA by up to 50 percent. Exercise (/I­Am­A/Patient­Caregiver/Diseases­ Conditions/Exercise­and­Arthritis) can improve your muscle strength, decrease joint pain and stiffness, and

lower the chance of disability due to OA. Also helpful are support (“assistive”) devices, such as orthotics or a walking cane, that help you do daily activities. Heat or cold therapy can help relieve OA symptoms for a short time.

Certain alternative treatments such as spa (hot tub), massage, and chiropractic manipulation can help relieve pain for a short time. They can be costly, though, and require repeated treatments. Also, the long­term benefits of these alternative (sometimes called complementary or integrative) medicine treatments are unproven but are under study.

Drug therapy: Forms of drug therapy include topical, oral (by mouth) and injections (shots). You apply topical drugs directly on the skin over the affected joints. These medicines include capsaicin cream, lidocaine and diclofenac gel. Oral pain relievers such as acetaminophen are common first treatments. So are nonsteroidal anti­inflammatory drugs (often called NSAIDs (/I­Am­A/Patient­Caregiver/Treatments/NSAIDs)), which decrease swelling and pain.

In 2010, the government (FDA) approved the use of duloxetine (Cymbalta) for chronic (long­term) musculoskeletal pain including from OA. This oral drug is not new. It also is in use for other health concerns, such as mood disorders, nerve pain and fibromyalgia.

Patients with more serious pain may need stronger medications, such as prescription narcotics.

Joint injections with corticosteroids (sometimes called cortisone shots) or with a form of lubricant called hyaluronic acid can give months of pain relief from OA. This lubricant is given in the knee, and these shots may help delay the need for a knee replacement by a few years in some patients.

Surgery: Surgical treatment becomes an option for severe cases. This includes when the joint has serious damage, or when medical treatment fails to relieve pain and you have major loss of function. Surgery may involve arthroscopy, repair of the joint done through small incisions (cuts). If the joint damage cannot be repaired, you may need a joint replacement.

Supplements: Many over­the­counter nutrition supplements have been used for osteoarthritis treatment. Most lack good research data to support their effectiveness and safety. Among the most widely used are calcium, vitamin D and omega­3 fatty acids. To ensure safety and avoid drug interactions, consult your doctor or pharmacist before using any of these supplements. This is especially true when you are combining these supplements with prescribed drugs.
Living with osteoarthritis
There is no cure for OA, but you can manage how it affects your lifestyle. Some tips include:

Properly position and support your neck and back while sitting or sleeping. Adjust furniture, such as raising a chair or toilet seat.

Avoid repeated motions of the joint, especially frequent bending.
Lose weight if you are overweight or obese, which can reduce pain and slow progression of OA. Exercise each day.
Use adaptive devices that will help you do daily activities.

You might want to work with a physical therapist or occupational therapist to learn the best exercises and to choose arthritis assistive devices.

For additional information on osteoarthritis, you may want to visit the Arthritis Foundation’s website: www.arthritis.org (http://www.arthritis.org/).

Reviewed May 2015.Written by Thitinan Srikulmontree, MD, and reviewed by the American College of Rheumatology Communications and Marketing Committee. This information is provided for general education only. Individuals should consult a qualified health care provider for professional medical advice, diagnosis and treatment of a medical or health condition.

© 2015 American College of Rheumatology

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Simple exercises
Leg stretch Sit on the floor with your legs stretched out in front. Keeping your foot to the floor, slowly bend one knee until you feel it being comfortably stretched. Hold for 5 seconds. Straighten your leg as far as you can and hold for 5 seconds. Repeat 10 times with each leg.

Leg cross Sit on the edge of a table or bed. Cross your ankles over. Push your front leg backwards and back leg forwards against each other until the thigh muscles become tense. Hold for 10 seconds, then relax. Switch legs and repeat. Do 4 sets with each leg.

Sit/stands Sit on a chair. Without using your hands for support, stand up and then sit back down. Make sure each movement is slow and controlled. Repeat for 1 minute. As you improve, try to increase the number of sit/stands you can do in 1 minute and try the exercise from lower chairs or the bottom two steps of a staircase.

Step ups Step onto the bottom step of stairs with the right foot. Bring up the left foot, then step down with the right foot, followed by the left foot. Repeat with each leg until you get short of breath. Hold on to the bannister if necessary. As you improve, try to increase the number of steps you can do in 1 minute

Knee squats Hold onto a chair or work surface for support. Squat down until your kneecap covers your big toe. Return to standing. Repeat at least 10 times. As you improve, try to squat a little further. Don’t bend your knees beyond a right angle.

Summary • Knee pain can be caused by a number of different things. Whatever the cause, exercise and keeping to a healthy weight can reduce symptoms. • You can take painkillers to ease pain. Taking them before exercise can help you stay active without causing extra pain. • Try the exercises suggested here to help ease pain and prevent future symptoms.

How does the knee work? The knee joint is where the thigh and shin bones meet. The end of each bone is covered with cartilage, which allows the ends of the bones to move against each other almost without friction. The knee joint has two extra pieces of cartilage called menisci, which spread the load more evenly across the knee. The knee joint is held in place by four large ligaments. These are thick, strong bands which run within or just outside the joint capsule. Together with the capsule, the ligaments prevent the bones moving in the wrong directions or dislocating. The thigh muscles (quadriceps) also help to hold the knee joint in place.

What causes knee pain? There are many different causes of knee pain. A common cause is osteoarthritis, a condition that affects the body’s joints. The surfaces within the joint are damaged so the joint doesn’t move as smoothly as it should. Your doctor will be able to tell you what has caused your pain, but the information and exercises here will be relevant for most cases.

What can be done to help? Medication There are a number of different tablets and creams available. Painkillers such as paracetamol and ibuprofen may help and you should use them if you need to. It’s important that you take them regularly and at the recommended dose to help you control the pain and allow you to continue exercising. Don’t wait until your pain is severe before taking painkillers.

You shouldn’t take ibuprofen or aspirin if you’re pregnant or have asthma, indigestion or an ulcer until you’ve spoken to your doctor or pharmacist. Medication can have side effects so you should read the label carefully and check with your pharmacist if you have any queries.
If over-the-counter medication doesn’t work, your doctor may prescribe stronger painkillers or capsaicin cream, which you can rub directly onto the knee.

Physiotherapy If your knee pain is affecting your activity and is persisting, ask your GP about referral to a physiotherapist. Physiotherapy can help you to manage pain and improve your strength and flexibility. A physiotherapist can provide a variety of treatments, help you understand your problem and get you back to your normal activities.

Surgery Surgery may be recommended if your pain is very severe or you have mobility problems. Your doctor will discuss with you what the surgery may involve.

What can I do to help myself? • lose weight (if you’re overweight) • exercise – low-impact activities such as swimming, cycling and using a cross-trainer are particularly good.

Thigh muscle (quadriceps)exercises
Straight-leg raise (sitting) Sit well back in the chair with good posture. Straighten and raise one leg. Hold for a slow count to 10, then slowly lower your leg. Repeat this at least 10 times with each leg. If you can do this easily, try it with light weights on your ankles and with your toes pointing towards you. Try doing this every time you sit down.

Straight-leg raise (lying) Bend one leg at the knee. Hold the other leg straight and lift the foot just off the bed. Hold for a slow count of 5, then lower. Repeat 5 times with each leg. Try doing it in the morning and at night while lying in bed.

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Fibromyalgia is a common health problem that causes widespread pain and tenderness (sensitivity to touch). The pain and tenderness tend to come and go, and move about the body. Most often, people with this chronic (long­term) illness are fatigued (very tired) and have sleep problems. The diagnosis can be made with a careful examination.

Fibromyalgia is most common in women, though it can occur in men. It most often starts in middle adulthood, but can occur in the teen years and in old age. You are at higher risk for fibromyalgia if you have a rheumatic disease (health problem that affects the joints, muscles and bones). These include osteoarthritis (/I­Am­ A/Patient­Caregiver/Diseases­Conditions/Osteoarthritis), lupus (/I­Am­A/Patient­Caregiver/Diseases­ Conditions/Lupus), rheumatoid arthritis (/I­Am­A/Patient­Caregiver/Diseases­Conditions/Rheumatoid­Arthritis) or ankylosing spondylitis (/I­Am­A/Patient­Caregiver/Diseases­Conditions/Spondyloarthritis).
Fast Facts

Fibromyalgia affects two to four percent of people, women more often than men.
Doctors diagnose fibromyalgia based on all the patient’s relevant symptoms (what you feel), no longer just on the number of tender places during an examination.
There is no test to detect this disease, but you may need lab tests or X­rays to rule out other health problems.
Though there is no cure, medications can reduce symptoms in some patients.
Patients also may feel better with proper self­care, such as exercise and getting enough sleep.

What is fibromyalgia?
Fibromyalgia is a chronic health problem that causes pain all over the body and other symptoms. Other symptoms of fibromyalgia that patients most often have are:

Tenderness to touch or pressure affecting muscles and sometimes joints or even the skin Severe fatigue
Sleep problems (waking up unrefreshed) Problems with memory or thinking clearly

Some patients also may have:

Depression or anxiety Migraine or tension headaches
Digestive problems: irritable bowel syndrome (commonly called IBS) or gastroesophageal reflux disease (often referred to as GERD)
Irritable or overactive bladder Pelvic pain
Temporomandibular disorder—often called TMJ (a set of symptoms including face or jaw pain, jaw clicking and ringing in the ears)

Symptoms of fibromyalgia and its related problems can vary in intensity, and will wax and wane over time. Stress often worsens the symptoms.
What causes fibromyalgia?
The causes of fibromyalgia are unclear. They may be different in different people. Fibromyalgia may run in families. There likely are certain genes that can make people more prone to getting fibromyalgia and the other health problems that can occur with it. Genes alone, though, do not cause fibromyalgia

There is most often some triggering factor that sets off fibromyalgia. It may be spine problems, arthritis, injury, or other type of physical stress. Emotional stress also may trigger this illness. The result is a change in the way the body “talks” with the spinal cord and brain. Levels of brain chemicals and proteins may change. For the person with fibromyalgia, it is as though the “volume control” is turned up too high in the brain’s pain processing centers.
How is fibromyalgia diagnosed?
A doctor will suspect fibromyalgia based on your symptoms. Doctors may require that you have tenderness to pressure or tender points at a specific number of certain spots before saying you have fibromyalgia, but they are not required to make the diagnosis (see the Box). A physical exam can be helpful to detect tenderness and to exclude other causes of muscle pain. There are no diagnostic tests (such as X­rays or blood tests) for this problem. Yet, you may need tests to rule out another health problem that can be confused with fibromyalgia.

Because widespread body pain is the main feature of fibromyalgia, health care providers will ask you to describe your pain. This may help tell the difference between fibromyalgia and other diseases with similar symptoms. Other conditions such as hypothyroidism (underactive thyroid gland) and polymyalgia rheumatica (/I­Am­A/Patient­Caregiver/Diseases­Conditions/Polymyalgia­Rheumatica) sometimes mimic fibromyalgia.
Blood tests can tell if you have either of these problems. Sometimes, fibromyalgia is confused with rheumatoid arthritis or lupus. But, again, there is a difference in the symptoms, physical findings and blood tests that will help your health care provider detect these health problems. Unlike fibromyalgia, these rheumatic diseases cause inflammation in the joints and tissues.

Criteria Needed for a Fibromyalgia Diagnosis

1. Pain and symptoms over the past week, based on the total of: Number of painful areas out of 19 parts of the body Plus level of severity of these symptoms: a. Fatigue b. Waking unrefreshed c. Cognitive (memory or thought) problems Plus number of other general physical symptoms
2. Symptoms lasting at least three months at a similar level
3. No other health problem that would explain the pain and other symptoms

Source: American College of Rheumatology, 2010
How is fibromyalgia treated?
There is no cure for fibromyalgia. However, symptoms can be treated with both medication and non­drug treatments. Many times the best outcomes are achieved by using multiple types of treatments.

Medications: The U.S. Food and Drug Administration has approved three drugs for the treatment of fibromyalgia. They include two drugs that change some of the brain chemicals (serotonin and norepinephrine) that help control pain levels: duloxetine (Cymbalta) and milnacipran (Savella). Older drugs that affect these same brain chemicals also may be used to treat fibromyalgia. These include amitriptyline (Elavil) and cyclobenzaprine (Flexeril). Other antidepressant drugs can be helpful in some patients. Side effects vary by the drug. Ask your doctor about the risks and benefits of your medicine.

The other drug approved for fibromyalgia is pregabalin (Lyrica). Pregabalin and another drug, gabapentin (Neurontin), work by blocking the over activity of nerve cells involved in pain transmission. These medicines may cause dizziness, sleepiness, swelling and weight gain.

Doctors do not recommend opioid narcotics for treating fibromyalgia. The reason for this is that research evidence suggests these drugs are not of great benefit to most people with fibromyalgia. In fact, they may cause greater pain sensitivity or make pain persist. Tramadol (Ultram) may be used to treat fibromyalgia pain if short­term use of an opioid narcotic is needed. Over­the­counter medicines such as acetaminophen (Tylenol) or nonsteroidal anti­inflammatory drugs (commonly called NSAIDs (/I­Am­A/Patient­ Caregiver/Treatments/NSAIDs)) like ibuprofen (Advil, Motrin) or naproxen (Aleve, Anaprox) are not effective for fibromyalgia pain. Yet, these drugs may be useful to treat the pain triggers of fibromyalgia. Thus, they are most useful in people who have other causes for pain such as arthritis in addition to fibromyalgia.

For sleep problems, some of the medicines that treat pain also improve sleep. These include cyclobenzaprine (Flexeril), amitriptyline (Elavil), gabapentin (Neurontin) or pregabalin (Lyrica). It is not recommended that patients with fibromyalgia take sleeping medicines like zolpidem (Ambien) or benzodiazepine medications.

Other Therapies: People with fibromyalgia should use non­drug treatments as well as any medicines their doctors suggest. Research shows that the most effective treatment for fibromyalgia is physical exercise. Physical exercise should be used in addition to any drug treatment. Patients benefit most from aerobic exercises. Other body­based therapies including Tai Chi and yoga can ease fibromyalgia symptoms.

Cognitive behavioral therapy is a type of therapy focused on understanding how thoughts and behaviors affect pain and other symptoms. CBT and related treatments such as mindfulness can help patients learn symptom reduction skills that lessen pain.

Other complementary and alternative therapies (sometimes called CAM or integrative medicine), such as acupuncture, chiropractic and massage therapy, can be useful to manage fibromyalgia symptoms. Many of these treatments, though, have not been well tested in patients with fibromyalgia.
Living with fibromyalgia
Even with the many treatment options, patient self­care is vital to improving symptoms and daily function. In concert with medical treatment, healthy lifestyle behaviors can reduce pain, increase sleep quality, lessen fatigue and help you cope better with fibromyalgia. With proper treatment and self­care, you can get better and live a more normal life. Here are some self­care tips for living with fibromyalgia:

Make time to relax each day. Deep­breathing exercises and meditation will help reduce the stress that can bring on symptoms.
Set a regular sleep pattern. Go to bed and wake up at the same time each day. Getting enough sleep lets your body repair itself, physically and mentally. Also, avoid daytime napping and limit caffeine intake, which can disrupt sleep. Nicotine is a stimulant, so those fibromyalgia patients with sleep problems should stop smoking.
Exercise often. This is a very important part of fibromyalgia treatment. While difficult at first, regular exercise often reduces pain symptoms and fatigue. Patients should follow the saying, “Start low, go slow.” Slowly add daily fitness into your routine. For instance, take the stairs instead of the elevator, or park further away from the store. As your symptoms decrease with drug treatments, start increasing your activity. Add in some walking, swimming, water aerobics and/or stretching exercises, and begin to do things that you stopped doing because of your pain and other symptoms. It takes time to create a comfortable routine. Just get moving, stay active and don’t give up!
Educate yourself. Nationally recognized organizations like the Arthritis Foundation and the National Fibromyalgia Association are great resources for information. Share this information with family, friends and co­workers.
Look forward, not backward. Focus on what you need to do to get better, not what caused your illness.

The role of the rheumatologist
Fibromyalgia is not a form of arthritis (joint disease). It does not cause inflammation or damage to joints, muscles or other tissues. However, because fibromyalgia can cause chronic pain and fatigue similar to arthritis, some people may think of it as a rheumatic condition. As a result, often a rheumatologist detects this disease (and rules out other rheumatic diseases). Your primary care physician can provide all the other care and treatment of fibromyalgia that you need.
Additional Information
The American College of Rheumatology has compiled this list to give you a starting point for your own additional research. The ACR does not endorse or maintain these Web sites, and is not responsible for any information or claims provided on them. It is always best to talk with your rheumatologist for more information and before making any decisions about your care.

Fibromyalgia Network (http://www.fmnetnews.com)

National Institute of Arthritis and Musculoskeletal and Skin Diseases (http://www.niams.nih.gov/hi/topics/fibromyalgia/fibrofs.htm) National Fibromyalgia Association (http://www.fmaware.org)
National Fibromyalgia and Chronic Pain Association (http://www.fmcpaware.org) National Fibromyalgia Partnership, Inc. (http://www.fmpartnership.org)
The American Fibromyalgia Syndrome Association, Inc. (http://www.afsafund.org)

Updated May 2015
Written by Leslie J. Crofford, MD, and reviewed by the American College of Rheumatology Communications and Marketing Committee. This information is provided for general education only. Individuals should consult a qualified health care provider for professional medical advice, diagnosis and treatment of a medical or health condition.

© 2015 American College of Rheumatology. All rights reserved.

Fibromyalgia is a common health problem that causes widespread pain and tenderness (sensitivity to touch). The pain and tenderness tend to come and go, and move about the body. Most often, people with this chronic (long­term) illness are fatigued (very tired) and have sleep problems. The diagnosis can be made with a careful examination.

Fibromyalgia is most common in women, though it can occur in men. It most often starts in middle adulthood, but can occur in the teen years and in old age. You are at higher risk for fibromyalgia if you have a rheumatic disease (health problem that affects the joints, muscles and bones). These include osteoarthritis (/I­Am­ A/Patient­Caregiver/Diseases­Conditions/Osteoarthritis), lupus (/I­Am­A/Patient­Caregiver/Diseases­ Conditions/Lupus), rheumatoid arthritis (/I­Am­A/Patient­Caregiver/Diseases­Conditions/Rheumatoid­Arthritis) or ankylosing spondylitis (/I­Am­A/Patient­Caregiver/Diseases­Conditions/Spondyloarthritis).
Fast Facts

Fibromyalgia affects two to four percent of people, women more often than men.
Doctors diagnose fibromyalgia based on all the patient’s relevant symptoms (what you feel), no longer just on the number of tender places during an examination.
There is no test to detect this disease, but you may need lab tests or X­rays to rule out other health problems.
Though there is no cure, medications can reduce symptoms in some patients.
Patients also may feel better with proper self­care, such as exercise and getting enough sleep.

What is fibromyalgia?
Fibromyalgia is a chronic health problem that causes pain all over the body and other symptoms. Other symptoms of fibromyalgia that patients most often have are:

Tenderness to touch or pressure affecting muscles and sometimes joints or even the skin Severe fatigue
Sleep problems (waking up unrefreshed) Problems with memory or thinking clearly

Some patients also may have:

Depression or anxiety Migraine or tension headaches
Digestive problems: irritable bowel syndrome (commonly called IBS) or gastroesophageal reflux disease (often referred to as GERD)
Irritable or overactive bladder Pelvic pain
Temporomandibular disorder—often called TMJ (a set of symptoms including face or jaw pain, jaw clicking and ringing in the ears)

Symptoms of fibromyalgia and its related problems can vary in intensity, and will wax and wane over time. Stress often worsens the symptoms.
What causes fibromyalgia?
The causes of fibromyalgia are unclear. They may be different in different people. Fibromyalgia may run in families. There likely are certain genes that can make people more prone to getting fibromyalgia and the other health problems that can occur with it. Genes alone, though, do not cause fibromyalgia

There is most often some triggering factor that sets off fibromyalgia. It may be spine problems, arthritis, injury, or other type of physical stress. Emotional stress also may trigger this illness. The result is a change in the way the body “talks” with the spinal cord and brain. Levels of brain chemicals and proteins may change. For the person with fibromyalgia, it is as though the “volume control” is turned up too high in the brain’s pain processing centers.
How is fibromyalgia diagnosed?
A doctor will suspect fibromyalgia based on your symptoms. Doctors may require that you have tenderness to pressure or tender points at a specific number of certain spots before saying you have fibromyalgia, but they are not required to make the diagnosis (see the Box). A physical exam can be helpful to detect tenderness and to exclude other causes of muscle pain. There are no diagnostic tests (such as X­rays or blood tests) for this problem. Yet, you may need tests to rule out another health problem that can be confused with fibromyalgia.

Because widespread body pain is the main feature of fibromyalgia, health care providers will ask you to describe your pain. This may help tell the difference between fibromyalgia and other diseases with similar symptoms. Other conditions such as hypothyroidism (underactive thyroid gland) and polymyalgia rheumatica (/I­Am­A/Patient­Caregiver/Diseases­Conditions/Polymyalgia­Rheumatica) sometimes mimic fibromyalgia.
Blood tests can tell if you have either of these problems. Sometimes, fibromyalgia is confused with rheumatoid arthritis or lupus. But, again, there is a difference in the symptoms, physical findings and blood tests that will help your health care provider detect these health problems. Unlike fibromyalgia, these rheumatic diseases cause inflammation in the joints and tissues.

Criteria Needed for a Fibromyalgia Diagnosis

1. Pain and symptoms over the past week, based on the total of: Number of painful areas out of 19 parts of the body Plus level of severity of these symptoms: a. Fatigue b. Waking unrefreshed c. Cognitive (memory or thought) problems Plus number of other general physical symptoms
2. Symptoms lasting at least three months at a similar level
3. No other health problem that would explain the pain and other symptoms

Source: American College of Rheumatology, 2010
How is fibromyalgia treated?
There is no cure for fibromyalgia. However, symptoms can be treated with both medication and non­drug treatments. Many times the best outcomes are achieved by using multiple types of treatments.

Medications: The U.S. Food and Drug Administration has approved three drugs for the treatment of fibromyalgia. They include two drugs that change some of the brain chemicals (serotonin and norepinephrine) that help control pain levels: duloxetine (Cymbalta) and milnacipran (Savella). Older drugs that affect these same brain chemicals also may be used to treat fibromyalgia. These include amitriptyline (Elavil) and cyclobenzaprine (Flexeril). Other antidepressant drugs can be helpful in some patients. Side effects vary by the drug. Ask your doctor about the risks and benefits of your medicine.

The other drug approved for fibromyalgia is pregabalin (Lyrica). Pregabalin and another drug, gabapentin (Neurontin), work by blocking the over activity of nerve cells involved in pain transmission. These medicines may cause dizziness, sleepiness, swelling and weight gain.

Doctors do not recommend opioid narcotics for treating fibromyalgia. The reason for this is that research evidence suggests these drugs are not of great benefit to most people with fibromyalgia. In fact, they may cause greater pain sensitivity or make pain persist. Tramadol (Ultram) may be used to treat fibromyalgia pain if short­term use of an opioid narcotic is needed. Over­the­counter medicines such as acetaminophen (Tylenol) or nonsteroidal anti­inflammatory drugs (commonly called NSAIDs (/I­Am­A/Patient­ Caregiver/Treatments/NSAIDs)) like ibuprofen (Advil, Motrin) or naproxen (Aleve, Anaprox) are not effective for fibromyalgia pain. Yet, these drugs may be useful to treat the pain triggers of fibromyalgia. Thus, they are most useful in people who have other causes for pain such as arthritis in addition to fibromyalgia.

For sleep problems, some of the medicines that treat pain also improve sleep. These include cyclobenzaprine (Flexeril), amitriptyline (Elavil), gabapentin (Neurontin) or pregabalin (Lyrica). It is not recommended that patients with fibromyalgia take sleeping medicines like zolpidem (Ambien) or benzodiazepine medications.

Other Therapies: People with fibromyalgia should use non­drug treatments as well as any medicines their doctors suggest. Research shows that the most effective treatment for fibromyalgia is physical exercise. Physical exercise should be used in addition to any drug treatment. Patients benefit most from aerobic exercises. Other body­based therapies including Tai Chi and yoga can ease fibromyalgia symptoms.

Cognitive behavioral therapy is a type of therapy focused on understanding how thoughts and behaviors affect pain and other symptoms. CBT and related treatments such as mindfulness can help patients learn symptom reduction skills that lessen pain.

Other complementary and alternative therapies (sometimes called CAM or integrative medicine), such as acupuncture, chiropractic and massage therapy, can be useful to manage fibromyalgia symptoms. Many of these treatments, though, have not been well tested in patients with fibromyalgia.
Living with fibromyalgia
Even with the many treatment options, patient self­care is vital to improving symptoms and daily function. In concert with medical treatment, healthy lifestyle behaviors can reduce pain, increase sleep quality, lessen fatigue and help you cope better with fibromyalgia. With proper treatment and self­care, you can get better and live a more normal life. Here are some self­care tips for living with fibromyalgia:

Make time to relax each day. Deep­breathing exercises and meditation will help reduce the stress that can bring on symptoms.
Set a regular sleep pattern. Go to bed and wake up at the same time each day. Getting enough sleep lets your body repair itself, physically and mentally. Also, avoid daytime napping and limit caffeine intake, which can disrupt sleep. Nicotine is a stimulant, so those fibromyalgia patients with sleep problems should stop smoking.
Exercise often. This is a very important part of fibromyalgia treatment. While difficult at first, regular exercise often reduces pain symptoms and fatigue. Patients should follow the saying, “Start low, go slow.” Slowly add daily fitness into your routine. For instance, take the stairs instead of the elevator, or park further away from the store. As your symptoms decrease with drug treatments, start increasing your activity. Add in some walking, swimming, water aerobics and/or stretching exercises, and begin to do things that you stopped doing because of your pain and other symptoms. It takes time to create a comfortable routine. Just get moving, stay active and don’t give up!
Educate yourself. Nationally recognized organizations like the Arthritis Foundation and the National Fibromyalgia Association are great resources for information. Share this information with family, friends and co­workers.
Look forward, not backward. Focus on what you need to do to get better, not what caused your illness.

The role of the rheumatologist
Fibromyalgia is not a form of arthritis (joint disease). It does not cause inflammation or damage to joints, muscles or other tissues. However, because fibromyalgia can cause chronic pain and fatigue similar to arthritis, some people may think of it as a rheumatic condition. As a result, often a rheumatologist detects this disease (and rules out other rheumatic diseases). Your primary care physician can provide all the other care and treatment of fibromyalgia that you need.
Additional Information
The American College of Rheumatology has compiled this list to give you a starting point for your own additional research. The ACR does not endorse or maintain these Web sites, and is not responsible for any information or claims provided on them. It is always best to talk with your rheumatologist for more information and before making any decisions about your care.

Fibromyalgia Network (http://www.fmnetnews.com)

National Institute of Arthritis and Musculoskeletal and Skin Diseases (http://www.niams.nih.gov/hi/topics/fibromyalgia/fibrofs.htm) National Fibromyalgia Association (http://www.fmaware.org)
National Fibromyalgia and Chronic Pain Association (http://www.fmcpaware.org) National Fibromyalgia Partnership, Inc. (http://www.fmpartnership.org)
The American Fibromyalgia Syndrome Association, Inc. (http://www.afsafund.org)

Updated May 2015
Written by Leslie J. Crofford, MD, and reviewed by the American College of Rheumatology Communications and Marketing Committee. This information is provided for general education only. Individuals should consult a qualified health care provider for professional medical advice, diagnosis and treatment of a medical or health condition.

© 2015 American College of Rheumatology. All rights reserved.