General Questions on Arthritis:

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A: Calcinosis, which is the deposit of calcium in the soft tissues, is a complication of scleroderma. Such deposits can often occur on the hands and arms and may cause pain from inflammation. Occasionally, these deposits will break down, expelling calcium and possibly becoming infected. A variety of treatments have been tried for calcinosis, including oral medications such as colchicine, an anti-inflammatory that's used to treat gout; diltiazem, a calcium channel blocker; and warfarin, an anticoagulant; as well as injections of glucocorticoids directly into the deposits. It is difficult to determine the effectiveness of these treatments, because calcinosis sometimes clears up on its own. For large and painful calcium deposits, many doctors consider surgical excision an option. However, there is some concern that the tissues may not heal well after removal of this material.

David Pisetsky, MD, PhD, Rheumatologist

A: The surprising answer is that yes, losing weight will help - at least in an indirect way. Although no diet has been shown to actually stop or reverse arthritis, a common-sense low-fat diet is a good idea for anyone - whether they have arthritis or not. Numerous studies have shown obesity to be a risk factor for knee OA development and progression. Weight loss is beneficial. In fact, in one study, a loss of only 10 to 15 pounds in women of medium height decreased the risk of developing knee OA by one-half. The news is equally good for people who already have OA. Lower weight may not only reduce the risk of OA progression, it can also lessen OA symptoms in the knee. Furthermore, studies have shown that losing weight may help reduce your risk of developing another form of arthritis, gout, which occurs when crystals of uric acid, a bodily waste product, build up in the joints and other tissues.

An exercise program would be beneficial in a number of ways. For one, it can help you to reach your weight-loss goals. Despite the abundance of diet plans and advice out there, weight loss boils down to one thing: creating a calorie deficit. In other words, to lose weight you must expend more calories than you consume. Of course, you can burn calories while sitting or watching TV, but to create a deficit that way you'd have to restrict calories pretty severely - too severely to get all the nutrients your body requires. An exercising body burns calories at a much higher rate and allows you to lose weight more quickly and/or with less severe calorie restrictions.

Another benefit of exercise is that it strengthens muscles that surround and support the body's joints. During weight- bearing activity, up to three times a person's weight - in your case 510 pounds - is transmitted directly to the knees and hips. This can be a problem if you already have OA of the hip or knee. Strong muscles can help relieve this pressure on the joints.

If you're unsure what foods or how many calories you should be consuming to ensure both proper nutrition and weight loss, I would recommend you consider scheduling at least one session with a registered dietitian. A physical therapist could help design an exercise program that will hasten your weight loss and strengthen the appropriate muscles without putting undue stress on your arthritic joints. In general, I recommend exercises that avoid jarring the affected joints. Swimming, water exercise, low-impact aerobics and walking are generally good. The best is one you enjoy enough to stick with. The actual amount of weight you lose is not as important as the fact that you at least lose some weight. Even modest weight loss - as the study of women who lost10 to 15 pounds shows - can be beneficial and is an easier goal obtain. I recommend striving for modest goals at first. If you lose 10 to 15 pounds and want to lose more, set another goal. Remember, even a little bit helps. The same goes for exercise. I'm not surprised that the concept of weight loss for arthritis is unfamiliar to you. While most people have heard about diet and exercise for other diseases, the benefits of good lifestyle practices for arthritis are largely overlooked. But expect that to change.

A new effort by the Arthritis Foundation and the Centers for Disease Control and Prevention called the National Arthritis Action Plan (NAAP) should get that message out. The NAAP will guide the use and organization of our nation's health resources to combat arthritis and public misconceptions about it. The goal of NAAP is to achieve a greater recognition of the types of arthritis - among both the public and the medical establishment - its impact on society and what can be done to prevent, delay and better treat it.

Doyt Conn, MD, Rheumatologist

A: The Epstein-Barr virus (EBV) is a common virus that causes infectious mononucleosis, better known as "mono," a condition associated with fever, fatigue, weakness, sore throat and swollen glands. Some people with mono also have abnormal liver function and low blood count, which usually resolve once the mono does. Close contact, such as kissing, is the usual mode of transmission. Because mono's symptoms are similar to those of fibromyalgia, rheumatoid arthritis and chronic fatigue syndrome, there has long been an interest in a possible connection between EBV and these other conditions. At present there is no proof that EBV plays a role in these conditions. (In fact, most adults - whether they have arthritis nor not - have been infected with EBV at some point in their lives.) The topic of a possible EBV-arthritis relationship, however, remains an area of active investigation.

David S. Pisetsky, MD, PhD, Rheumatologist

A: Despite the fact that copper bracelets have been long been touted as an effective arthritis treatment, there is no scientific research proving they provide any therapeutic benefit for arthritis. Nor is there any research proving they don't. The practice of wearing copper bracelets for arthritis probably began around 100 years ago when some people discovered their arthritis symptoms eased while they wore the bracelets. However, such improvements were most likely due to the natural waxing and waning of the disease or the improvement of a problem that would have gotten better with time anyway.

Over the past 10 years curious minds have developed numerous theories as to why copper bracelets might work. These current claims are most likely based on the theory that complexes of copper (copper salicylates, or salts) have antioxidant properties that might prevent free radicals (unstable oxygen molecules) from damaging joints. The theory is that copper salts can be absorbed through the skin from a copper bracelet to fight joint damage. The reality is that skin cannot absorb from a bracelet anywhere near the amount of copper salts needed to fight free radicals. In fact, some bracelets have a lacquered surface that prevents tarnish but also prevents any absorption of copper salts. You would get more for your money if you ate foods rich in antioxidants (beta-carotene and vitamins C and E) or took antioxidant supplements by mouth, instead of trying to absorb them through your skin. Indeed, many studies have shown that higher levels of vitamin C (an antioxidant vitamin) are associated with a reduced risk of OA progression or pain.

I have had many patients who wore copper bracelets and experienced absolutely no effect on their arthritis. I have to wonder why my patients never quite seem to be lucky enough to get the "miracle cures" promised by sellers of these products. However, I won't discourage my patients from trying anything that is safe and reasonably priced. A copper bracelet certainly won't harm you - but it probably won't help you either.

James McKoy, MD, Rheumatologist

A: It is certainly possible for a patient with severe osteoporosis to have total hip replacement surgery. But as you probably know, osteoporosis makes the procedure more risky; having very thin, soft bone increases the risk of hip fractures and prosthesis loosening. Still, extra steps taken during surgery can help reduce those risks. Surgeons may opt to add a bone graft to the hip socket, if it is badly eroded, or to the femur (upper leg bone), if it is very thin. After surgery, your doctor may recommend protective measures, such as the use of a walker or wheelchair. Because osteoporosis can affect the long-term effectiveness of hip replacement, pre-operative treatment is important. There are several effective prescription medications for osteoporosis. If you're not on one, ask your doctor which one would be best for you. In addition, be sure to consume plenty of calcium, avoid smoking and alcohol use, and try to exercise regularly.

Jeffrey T. Nugent, MD, Orthopaedic Surgeon

A: It's understandable that you are not familiar with Paget's disease of the bone, because it is relatively uncommon.

Named for Sir James Paget, who first described the disease in the 19th century, Paget's disease of the bone occurs when a malfunction in the normal process of bone breakdown and rebuilding leads to excessive and disorganized new bone growth. As a result, the new bone that is produced is highly vascular (meaning, it contains a lot of blood vessels) and is enlarged and softer than normal bone.

The accelerated bone growth, along with the resulting changes in bone structure, are among the features that differentiate Paget's disease from osteoporosis, another bone disease. In osteoporosis, bone breakdown exceeds bone growth, leading to thin, fragile bones. Also unlike osteoporosis, Paget's disease is slightly more common in men. It often begins between the ages of 50 and 70, and people of Western-European descent are more likely than African Americans to be affected.

Although Paget's disease is often painless, some people experience bone warmth and pain. Sometimes the pain comes from the joints. Because Paget's disease tends to affect the bones of the pelvis and legs and because bone changes may alter mechanical structure of the joints, painful osteoarthritis of the hips or knees can occur. Other common sites of Paget's disease are the skull, lower spine and sacrum (the tail bone).

A: The optic nerve is the large nerve that travels from the eye to the brain and carries information for sight. As part of the nervous system, the nerve cannot develop arthritis, which, by definition, involves the joints. The optic nerve can be damaged, however, by several different disease processes -- some of which are arthritis-related, some not -- resulting in impairment or loss of vision.

Optic neuritis refers to inflammation of the optic nerve. It often occurs as a part of multiple sclerosis and sometimes systemic lupus erythematosus. The nerve can also be damaged by infection or tumors as well as conditions that block its blood supply. Another possibility is temporal arteritis (also called cranial or giant cell arteritis). Sometimes considered an arthritis-related condition, temporal arteritis involves inflammation and occlusion, or blockage, of the small blood vessels to the optic nerve. This, too, can impair vision.

Because optic neuritis has many different causes, a complete evaluation by an experienced specialist is essential to assure the proper diagnosis and treatment. In the case of temporal arteritis, corticosteroids are used to treat the underlying vessel inflammation.

David Pisetsky, MD, PhD, Rheumatologist

A: A corticotomy is one type of osteotomy, a surgical procedure in which the bones of the leg are realigned to relieve pain and restore function to an arthritic knee. The standard procedure involves surgically cutting and realigning the bone above the knee using staples or plates and screws for fixation.

Corticotomy, an alternative method, is less invasive. It involves a small cut in the tibia, or shin bone, and the attachment of an external device that surrounds the leg. Over time, the doctor gradually changes the bone's position to improve position by adjusting the pins that attach the device to the bone. The risk of complications for corticotomies is low and accuracy of alignment is high when done by a surgeon experienced in the procedure.

Many orthopaedic surgeons don't recommend knee replacements for patients who are young, overweight or very active. In these cases, a corticotomy or osteotomy may produce better results. These techniques can sometimes "buy time," putting off knee replacements; other times they can make knee replacements unnecessary, even after many years.

Jeffrey Nugent, MD, Orthopaedic Surgeon

A. Yes, it is certainly possible that your flat feet are contributing to your pain. The most common cause of flat feet is ligament laxity resulting in hypermobile, or overly flexible, joints in the feet.

In this condition, when you put weight on your feet, there are no visible arches. Doing so causes the weight distribution at the feet to change, and can result in pain in places such as the knees, hips and low back.

I would recommend you make an appointment to see a rheumatologist or orthopaedist. One of these specialists will be able to rule out other problems that could cause the pain in your knees and legs.

If your leg pain is indeed caused by your flat feet, your doctor should refer you to a specialist called an orthotist, who will custom make special shoe inserts to help support your arch and realign your foot into a more ideal weight-bearing position.

Unfortunately, because this is a ligament/bone problem, performing exercises to strengthen the muscles is not going to help.

Judy Piette, PT, Physical Therapist

A. Intermittent hydrarthrosis is a rare condition in which patients generally experience swelling of one knee -- or occasionally both knees -- at regular intervals. This condition most often begins at adolescence and may last until middle age.

While the cause of intermittent hydrarthrosis is unknown, fluid drawn from the affected joint does not demonstrate features of inflammation (such as the infiltration of white blood cells) that are seen in diseases such as rheumatoid arthritis.

Attacks generally last from two to four days. During that time, there is really nothing that can be done to stop them, nor is there any treatment to prevent future episodes.

Other than being a nuisance, the condition appears to be harmless. It generally isn't painful and doesn't cause damage to the bone or cartilage. With time, you may find your intermittent hydrarthrosis improves on its own, perhaps often disappearing completely.

Jeffrey Nugent, MD, Orthopaedic Surgeon

A. It's true that massage can help reduce the pain, swelling and muscle spasms common with arthritis, but you're right to be concerned about having massage following joint replacement surgery.

In general, I recommend that people avoid massage on a new surgery site. After the incision has healed (about two weeks) and rehabilitation exercises are under way, massage by a physical therapist using even pressure and large strokes toward the heart can help increase circulation while decreasing tissue swelling. Also, I teach my patients to massage their scars. It promotes good mobility of the incision after stitches/staples are removed.

I recommend that people not use massage over a joint that is acutely inflamed – red, swollen and tender. In that situation, I would apply ice to it for a few days to reduce the pain and swelling. Once the inflammation has calmed, a massage using large strokes as described above is helpful. A deeper kneading-type massage can relax muscles and ease spasms. Massage therapy will not ease pain from swollen or inflamed joints.

Judy Piette, PT, Physical Therapist

A: Unfortunately, there is no single laboratory test that can definitely diagnose arthritis; nor is there a single form of arthritis that's accompanied by a rash. A variety of lab tests are used in conjunction with a physical exam and medical history to help a doctor confirm a diagnosis. In fact, there are many things that can cause an abnormal arthritis test in someone who does not have arthritis -- medications, viruses, chronic infections, scar tissue of liver or lung, or even advanced age, to name a few. Interestingly, it is not uncommon for abnormal test results to be seen among healthy young people. However, the reasons for this are not known.

A: It's true that massage can help reduce the pain, swelling and muscle spasms common with arthritis, but you're right to be concerned about having massage following joint replacement surgery.

In general, I recommend that people avoid massage on a new surgery site. After the incision has healed (about two weeks) and rehabilitation exercises are under way, massage by a physical therapist using even pressure and large strokes toward the heart can help increase circulation while decreasing tissue swelling. Also, I teach my patients to massage their scars. It promotes good mobility of the incision after stitches/staples are removed.

I recommend that people not use massage over a joint that is acutely inflamed – red, swollen and tender. In that situation, I would apply ice to it for a few days to reduce the pain and swelling. Once the inflammation has calmed, a massage using large strokes as described above is helpful. A deeper kneading-type massage can relax muscles and ease spasms. Massage therapy will not ease pain from swollen or inflamed joints.

Judy Piette, PT, Physical Therapist

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A: As you suspected, the term inflammatory arthritis is often used when a doctor is unable to make a definitive diagnosis. Arthritis by definition means inflammation of the joints, although there are, in fact, many different forms of the disease. Most forms do show evidence of inflammation, such as redness, heat, swelling, tenderness and difficulty with movement.

Generally a doctor can make a more specific diagnosis on the basis of laboratory tests, including the rheumatoid factor; X-ray findings; and the occurrence of other signs.

However, when joint inflammation is present without other findings to pinpoint the diagnosis, the term inflammatory arthritis is used. This term can be helpful to distinguish the condition from osteoarthritis, which is usually considered non-inflammatory in origin.

Just because your doctor is calling your condition “inflammatory arthritis” now doesn't mean that will always be your diagnosis. Sometimes, it takes a while for findings to appear that enable a doctor to make a specific diagnosis.

David S. Pisetsky, MD, PhD, Rheumatologist

A: There is a very interesting relationship between arthritis and disorders of the thyroid gland: Thyroid disease can lead to a type of arthritis, and certain forms of arthritis can increase the risk of thyroid disease.

Arthritis can occur with either hypothyroidism (too little thyroid hormone) and hyperthyroidism (too much thyroid hormone). In fact, it is not uncommon for people with thyroid disease to first seek medical attention for musculoskeletal problems.

People with hypothyroidism commonly develop profound fatigue and a fibromyalgia-like syndrome with diffuse muscle aches and tender points. In addition, they may develop arthritis in the hands and knees that resembles rheumatoid arthritis (RA). Musculoskeletal complications are much less common in people with hyperthyroidism, but can include severe osteoporosis, as well as an unusual swelling of the fingers and legs called “thyroid achropachy.” In general, rheumatic complaints resolve as the thyroid disease is treated.

When thyroid disease occurs as a complication of an inflammatory disease, such as RA, lupus, scleroderma or polymyositis, treatment of both the underlying arthritis and the thyroid disease is generally needed.

John Klippel, MD, Rheumatologist

A: I guess it's possible that the feeling you describe could be arthritis in your back, but what you're experiencing is more likely to be heartburn, or more properly called gastroesophageal reflux, the backflow of stomach acid into the esophagus.

The symptoms of gastroesophageal reflux can be felt in the abdomen, back or chest. The reason is that sometimes pain or other sensations are perceived by our brains as originating from sites other than that from which they actually originate -- a phenomenon called referred pain. (An example of referred pain is the pain from a heart attack that is felt in the left arm or jaw.)

Although gastroesophageal reflux is my best guess as to what's causing your symptoms, I cannot say with certainty. To find the specific cause of your symptoms -- and to determine whether they have anything to do with arthritis -- you'll need to see your doctor.

C. Tim Lambert, MD, Family Physician

A: Not necessarily. In fact, your doctor probably has a good reason for not prescribing the drug you saw advertised, and he should be willing to explain that reason to you. Certainly, some doctors do prescribe drugs just because the drugs are new, their advertisements are enticing or because patients are demanding them – none of which are necessarily good reasons.

Of course the drug in the advertisement sounds perfect for you. That’s how advertisements work, regardless of the product they are selling. By making the product look appealing or better than what we have now, ads entice us to buy it. When the product is a new toothpaste, dish detergent, cat litter or even a new car, the decision to buy is ours alone. But when the product is a prescription drug, there’s more involved – namely, our doctor’s knowledge, experience and judgment influencing his willingness to write the prescription.

It used to be that doctors made their prescribing decisions with little if any influence from their patients. In fact, you may have never heard of a drug until your doctor prescribed it. My, how times have changed! Consumers have grown savvy and are interested in taking an increasingly large role in their own care.

Noting this interest, drug companies are increasingly advertising their products directly to consumers. In 1999, the pharmaceutical industry spent $1.53 billion on direct-to-consumer (DTC) advertising – up from an even $1 billion just two years earlier. And that’s just a fraction of their total advertising expenditures – an estimated $6.4 billion last year, according to IMS, a company that provides information to the pharmaceutical and health-care industries. The pharmaceutical industry still targets most of its advertising efforts and money on doctors.

The drugs you see advertised are typically, but not always, new drugs. Most have the potential to be used by large numbers of people, which translates into potentially large profits by pharmaceutical companies. As you consider a drug you have seen advertised, keep in mind that just because it sounds good doesn’t mean it is right for you. You could end up paying more for something that isn’t necessarily better than what you’re using now – particularly if your insurance doesn’t cover the new drug.

That’s not to say that ads are bad. They play an important role in our education. (One survey showed that 25 percent of people changed the way they treated their medical condition based on DTC advertisements, and 20 percent, like you, said they had asked their doctor to prescribe a drug they had seen advertised.) But drug advertisements should not be our only source of education.

If you want to know more about a product you see advertised, it’s best to go to publications and Web sites of non-commercial sources, such as the Arthritis Foundation, the National Institutes of Health or the Food and Drug Administration’s Center for Drug Evaluation and Research. It’s also a good idea to check with your pharmacist.

By law, DTC ads that appear in print media are required to run a disclaimer listing prescribing information, precautions and possible side effects. Reading this fine type provides you with important information about an advertised drug and can bring up points you might want to discuss with your doctor – which brings me to my final suggestion.

Talk with your doctor about the drug. Ask for specifics on why he doesn’t want to prescribe the drug. Do you have risk factors for problems that using this drug might aggravate? Have studies shown that this drug is no more effective than what you are taking for the particular problem you have? Is the drug more expensive or not covered by your insurance? Certainly, you can press your doctor to prescribe a new drug for you, but hear him out. It’s his best judgment about you, your disease and your situation that should determine if you get the prescription you are seeking.

Doyt Conn, MD, Rheumatologist

A: Most infections have the ability to disseminate, which means extend beyond the initial or usual site. This is what happens when gonorrhea causes arthritis - the infection extends beyond gonorrhea's usual site in the genital system and disseminates to joints.

Gonorrhea-related arthritis presents itself in one of two ways: as inflammation in the tendons and several joints accompanied by a skin rash or as an infection in a single joint. Treatment in either case involves antibiotics given by injection.

Gonorrhea-related arthritis usually affects young people and is considered when there is a sudden onset of arthritis in someone who is sexually active. Women may be more susceptible to dissemination than men because symptoms of gonorrheal infection in women are subtle and less likely to receive prompt medical treatment; only about half of women with gonorrhea experience any genital-related symptoms. In men, gonorrhea causes discharge from the urethra, which is difficult to miss or ignore. In women, symptoms may include the need to urinate frequently or painful urination.

DAVID PISETSKY, MD, PhD, Rheumatologist

A: Although joint pain is often the primary symptom of arthritis, muscles next to the affected joint certainly can be a source of pain. Because arthritis can restrict movement of the joints, the muscles that support the joints are not able to fully stretch and contract. As a consequence, they often become weakened and withered -- a condition called atrophy. Weakened muscles are more susceptible to injuries, such as sprains. A good example is the atrophy that occurs in the quadriceps muscle on top of the thigh. Within three weeks after a knee problem develops, weakness and withering can be seen in the quadriceps. This weakness, if not corrected, can lead to more pain and accelerate damage to the involved knee. Properly performing non-weight bearing exercises [- that is, exercises in which the body's weight are not borne by the legs -- for the quadriceps is important to reduce this source of pain and deterioration.

PAUL F. HOWARD, MD Rheumatologist