What is Arthritis?
Arthritis explained by Denver, Golden, Aurora, Boulder, Broomfield, Jefferson, and Littleton Colorado’s top pain doctors
Arthritis is an often painful disorder that can reduce normal movement and function. It can impact some or all of the bones, joints, and muscles in the body, and also tissues that support or connect these, such as cartilage. Arthritis is a term covering a multitude of conditions with similar symptoms and causes that can affect people of all ages. Some types of arthritis are associated with certain age groups, but others can affect people of any age. Many kinds of arthritis may result in the significant loss of mobility or normal function, due to the pain and other symptoms they may cause. This disorder in all its forms is an increasingly prevalent healthcare and economic concern, affecting ever-growing numbers of people by the year.
Types of Arthritis
Osteoarthritis is the most prevalent type of arthritis. Approximately 9% of the U.S. population is thought to suffer from this condition. This disorder causes the degeneration or breakdown of cartilage, a material that acts as a buffer and shock protector within joints. This erosion of cartilage becomes worse over time unless treated. Eventually, so much cartilage disappears that the inner bony surfaces normally protected by it are exposed and come into direct contact with each other. This is often associated with pain. The full etiology of osteoarthritis is not currently defined, but may be affected by factors including genetic predisposition, advancing age, very high BMI, muscle weakness, and joint strain. Strain on joints can be caused (or exacerbated) by injuries or very high levels of movement. Osteoarthritis can develop in joints almost anywhere in the body, including the neck, hips, toes, and fingers. Signs and symptoms of this condition include discomfort, pain, and stiffness. The latter is associated with inactivity and abates during movement. Symptoms are often mild at first and then intensify over time. Pain associated with osteoarthritis is often initially tolerable and does not affect normal movement or function. However, if the condition progresses into its later stages, pain may interfere significantly with mobility or functional status. Patients with advanced osteoarthritis may find that their symptoms seriously affect their abilities to exercise, perform normal tasks, or even sleep.
Rheumatoid arthritis is a condition involving the inflammation of tissues that function as linings of the various structures that make up a single joint. This common form of arthritis is associated with severe joint damage. It also has the symptoms of osteoarthritis, in addition to swelling around the joint and high temperature of the skin surrounding it. If one joint in a pair (e.g. one hip joint) is affected by rheumatoid arthritis, it is highly probable that the condition will spread to the other. Many studies indicate that the severity and symptoms can vary from day to day, based on patient reports and observations. The condition can also manifest in “flares,” which are abrupt intensifications of symptoms with durations of several days to several months.
Rheumatoid arthritis is associated with immune dysfunction, in which the immune system of the body attacks its own tissues rather than acting to eradicate bacteria, viruses, and other foreign bodies. Therefore, the condition is regarded as an autoimmune disorder of joint tissue. Autoimmune conditions involve the release of inflammatory molecules into the body tissues or organs affected. This is associated with pain and damage in the affected areas. There are nearly two million rheumatoid arthritis patients in the U.S. Women are at much higher risk of developing the condition than men. It generally has an onset in women of between 30 and 60 years. This time is less well defined in men, but tends to occur later compared to women. Early detection of rheumatoid arthritis is important, as the inflammation involved can cause severe joint damage, and even affect organs, if left untreated from the start.
There are also a range of autoimmune and inflammatory disorders that affect younger people, and are thus generally referred to as juvenile arthritis. These usually target the joints of children or adolescents, but can also affect the gastrointestinal tract, skin, or eyes of members of these age groups. Juvenile idiopathic arthritis is the most common form of these, in which an individual aged 16 years or less may experience joint swelling. This must occur for at least six weeks to satisfy the diagnostic criteria for the illness. The cause of arthritis in adolescents or children is not well understood. There are theories that implicate certain foods, toxins, or allergens as risk factors for juvenile arthritis, but not much high-quality evidence to support these. There are some studies that conclusively link genetic factors to the conditions, however.
Epidemiology And Impact Of Arthritis
Arthritis is an increasingly significant source of healthcare burden in the United States. Nearly 16% of all people in the U.S. suffer from one type of arthritis or another (many of whom are not seniors, as is the popular misconception). Research indicates that approximately 66% of all patients are 65 or younger, and 300,000 are aged 16 or younger. Approximately 72% of people in the U.S. with the condition are of Caucasian origin, 9.2% are African American, and 5.8% are Hispanic. All forms of the disorder combine to take the form of the most prevalent cause of disability and reduced mobility. Estimates suggest that the rate of arthritis development will increase over the next two decades. Based on this, the number of arthritis patients in the year 2030 has been projected as being as high as 67 million, unless the condition is better controlled.
Arthritis is also responsible for significant economic issues, as well as hospital resource problems. Reports estimate that the condition causes approximately 900,000 hospital stays per year, and 44 million outpatient consultations. In addition, surgical procedures that address arthritis or its symptoms are associated with longer hospital stays, according to a study of patients treated between 2003 and 2010. These stays tend to be extended even further if the patient is at an advanced stage of arthritis. The length a patient will avoid or delay seeking treatment for their case, and the type of arthritis in question, are factors that particularly affect the duration of hospitalization. On the other hand, timely diagnosis and treatment tends to result in shorter stays, requiring as little as one day for the procedure and hospital-based recovery combined. More lengthy stays obviously increase the strain on hospital and economic resources.
In addition, some reports suggest that the cost of rheumatoid arthritis treatments (for patients aged 18-64 years) have gone up dramatically (based on figures recorded between the years 2002 and 2011). This is thought to be associated with an increase in medication prescribed, contributed to by a lack of relevant hospital resources, and other economic effects such as disability leave or cover. The cost of drug therapy for rheumatoid arthritis has also been increasing since 2009. The overall costs to patients and healthcare providers are steadily rising and may continue to do so unless improved therapies or preventatives for arthritis are developed.
Causes of Arthritis
As there is no one discrete type of arthritis, there is no one prominent causative factor associated with the condition. On the other hand, since the disorder mainly targets the joints, the anatomy of these structures may contribute to an understanding of how arthritis develops. Joints are areas of the body where two bones meet, usually for the purposes of normal gait and movement. They are held in place by tissues (mainly ligaments) that hold them in roughly the same position in relation to each other, yet allow a wide range of movement. Ligaments are composed of pliable, stretchy, elastic material. They are located inside joints (mostly) to attach one bone to another, whereas muscles allow the bones to move.
Cartilage, as outlined above, coats the bony surfaces, to provide protection and cushioning, and to prevent friction between bones. There is a small amount of space between the interfacing surfaces of the bones that is filled with a material called synovial fluid. This is present to provide nutrients to the cartilage and bones, and also accords some additional shock absorption in the joint. All of these are subject to daily mechanical wear and to external sources of damage, such as injury or disease. In the event of an onset of arthritic symptoms, it may be attributed to a problem with the synovial fluid, cartilage, or immune responses in or near the joint. Arthritis may be thus diagnosed as a loss of cartilage, synovial fluid, normal immune function, certain infectious diseases, or a combination of these. For example, osteoarthritis is a progressive loss of cartilage from a joint (as outlined above). This can occur due to progressive mechanical damage that erodes the cartilage away over time, or more immediately, e.g. as a result of an accident. In either case, this results in a lack of protection from impacts and friction in the joint. Advanced osteoarthritis causes bones to rub against each other directly. This can cause severe pain and the inability to properly move or flex the joint.
Rheumatoid arthritis is an autoimmune disorder of one or more joints in the body. In this case, there is an abnormal immune response to the body’s own synovial membrane (a bag-like structure that contains synovial fluid in place). The membrane may swell up and be subject to inflammation. The autoimmune attack can spread from joints to organs over time, if left untreated.
Many cases of arthritis are caused or exacerbated by a number of additional factors, as mentioned above. These may influence the probability of developing or advancing a case of arthritis, and include:
- Age (e.g. the risk of osteoarthritis increases with age)
- Genetic factors
- High or very high BMI as there is some basis for the theory that increased bodyweight may increase susceptibility to arthritis, mainly through joint stress
- Injury as a history of direct joint damage may be associated with a risk of future arthritis
- Infection or immune responses to other external agents, e.g. pollen
- Foods as there is evidence that ingesting certain foods may be associated with an increased risk of arthritis in some people
- Repetitive strain or occupational hazard
- Repeated heavy lifting, especially if done in such a way as to put strain on joints
- Diseases with an autoimmune component
- Consistent use of the joint, e.g. through high-volume athletic or sports training
- Muscle weakness
Symptoms of Arthritis
Arthritis patients tend to experience high levels of stiffness and discomfort that often increase with age or disease progression.
There are more typical symptoms, including:
- Decreased flexibility or range of motion
- Joint tenderness
- A sense of “grating” in the joint (or even audible grating)
- Joint redness
- Swollen joint(s)
- High skin temperature (indicates an immune component)
- Joint stiffness or pain during or just after movement
- Joint stiffness or pain while rising after sitting or lying down
- Joint stiffness on waking
- Reductions in BMI
Osteoarthritis also has some characteristic signs, including:
- Soreness or stiffness in affected joints, particularly in the lower back, knee, and hips joints
- Soreness or stiffness magnified by either over- or under-use of the joint
- Stiffness following rest that decreases gradually in response to movement
- An increase in pain after or during activity, or at night
Some symptoms are particularly associated with rheumatoid arthritis, including:
- Extended stiffness in the morning
- Consistent pain
- Red and/or swollen joints
- High skin temperature
- Inflammation of the wrists or finger joints
Patients with juvenile arthritis may experience the following:
- Pain, often chronic
- Stiff joints, particularly associated with the start of the day
- Swollen joints
- Joint tenderness
- Irritable mood
- Red or painful eyes, blurry vision
- Recurrent fever
- Sudden drops in body weight
- Problems with normal walking or movement
- Apparent motor or short-term memory problems
The manifestation of arthritis differs from patient to patient, and some may have all of these symptoms while others may have only a few. Arthritis symptoms can be chronic or acute. The severity of all symptoms, including pain, can be mild or significantly debilitating. In addition, the intensity of symptoms may vary over time for the patient, present in “flares,” or be more consistent. Patients may observe that their condition improves one day to return to a typical level the next.
Diagnosis of Arthritis
Many forms of arthritis can be diagnosed through analysis of a patient’s medical history or self-reporting of symptoms. This may also require a physical examination or observation of certain signs, such as swelling or redness. The joints may also be evaluated more directly by using imaging techniques such as X-rays or magnetic resonance imaging. Some cases may be caused by more than one type of arthritis, e.g. rheumatoid in addition to the juvenile form. To diagnose this, lab testing of synovial fluid, urine, and blood may be carried out. Tests may also reveal the type of arthritis contracted and to distinguish it from other conditions with similar symptoms.
Blood tests, for example, can now detect biological markers associated with arthritis. These include specific antibodies that are present in up to 90% of arthritis patients. These may be present in normal healthy individuals, but elevated in the blood of those affected. Some types of arthritis do not have one particular genetic marker, however. In the case of juvenile arthritis, blood tests may confirm high concentrations of inflammatory molecules, but not much more. Therefore, juvenile patients may have to undergo more rigorous diagnostic methods, such as MRIs or physical examination.
The consensus among medical professionals in this field is that early detection and treatment of arthritis contributes profoundly to adequate control of the disease and its symptoms, and is associated with avoidance of serious interventions such as surgical procedures. Untreated arthritis may result in ligament, cartilage, and joint damage, and may as mentioned lead to spreading of inflammation to other tissues, including organs. Severe cartilage loss or bone damage may lead to posture defects or disability due to pain or impaired mobility. Timely diagnoses may also avoid increased medical costs and economic insecurity.
Treatment for Arthritis
There are no treatments available that can conclusively stop or reverse the progress of arthritis. The best outcomes of arthritis therapies include the reduction of pain and the conservation of mobility, usually through conditioning of muscles and joints to promote the retention of motion and flexibility. When arthritis is diagnosed, medical personnel may advise steps such as courses of analgesics and other drugs, joint support devices (e.g. braces or bands), the application of either heat or ice to the affected area, and strength training. Patients may be discouraged from exercise due to the pain experienced, but there are many studies that show its benefits, especially in the initial stages of osteoarthritis and rheumatoid arthritis.
Other factors that are associated with control of arthritis symptoms include weight reduction and education in the prevention of further joint damage (i.e. through injury). This may be supported by observation that obese individuals involved in weight loss programs achieve a reduction of four pounds of pressure off their knee joints for every pound of bodyweight lost. This may contribute to a reduced risk of joint damage or inflammation. Physical therapy may also be recommended for the early stages of arthritis. A combination of two or more of the treatments mentioned above may result in effective remission of symptoms. In treatment-resistant cases, however, more invasive options such as surgery may become necessary.
Physical therapy can contribute significantly to the treatment of some arthritis patients. The condition tends to cause a reduction of physical activity below levels associated with a healthy lifestyle. As a result, therapists may attempt to combat this using techniques derived from behavioral and psychological sciences. This includes education of patients in the beneficial effects of increasing or maintaining activity levels on their arthritis symptoms. Some recent studies indicate that the uptake of this type of therapy is associated with older patients in receipt of disability benefits with more advanced stages of arthritis who have access to a reliable panel of community and personal support structures.
In addition to exercise and education, there is evidence that diet may play a role in the control of arthritis. There are many studies that indicate the association between the promotion of inflammation and certain dietary fats including trans fats; therefore, avoiding these may reduce symptoms or risk of the condition. Other foods are also linked to the up-regulation of inflammatory molecules.
These types of foods, which patients may benefit from the reduction or elimination of, include:
- Palm oil, palm kernel oil, or foods with these as a listed ingredient
- Pastries or other baked goods containing white flour
- Commercially-produced white rice
- Commercially-produced white bread
- Fat-rich pork or beef
- Cooked skin of chicken, duck, turkey, etc.
- Fat-rich dairy or foods containing these
- Foods high in sugar, particularly refined sugar
These types of foods may be substituted with lean pork or beef, skinless poultry, and low-fat or non-fat dairy. There are foods that may be more beneficial to arthritis patients, including:
- Vegetables rich in vitamins A and C (e.g., yams, spinach, kale, broccoli, butternut squash, Brussels sprouts, sweet red peppers, and carrots)
- Fruits and vegetables with vitamin C (e.g., oranges, lemons, grapefruits, pineapples, strawberries, guava, and potatoes)
- Nuts (e.g. walnuts and pistachios)
- Ground flaxseeds
- Chia seeds
- Soy beans
- Fish (e.g., salmon, herring, mackerel, sardines, anchovies, and rainbow trout)
The types of nuts, seeds, and fish listed are high in omega-3 fatty acids. These are oil molecules that have been shown to significantly ameliorate arthritis symptoms, particularly those related to rheumatoid arthritis. Omega-3s are also found in healthier oils such as olive oil. Olive oil also contains a natural compound called oleocanthal that may have a negative effect on the concentrations of the inflammatory molecules associated with rheumatoid arthritis. Oleocanthal may also have similar, inflammation-inhibiting properties to established drugs, such as ibuprofen. Vitamin C is an antioxidant found in many fruits and vegetables, as are carotenes and bioflavonoids, that may also have an inhibitory or down-regulatory effect on inflammation. These may contribute to pain relief, symptom remission, and a slowing down of the progression of arthritis.
Guided imagery and the practice of relaxation techniques are alternative treatment options that may be recommended to arthritis patients. Mental imagery, or visualization, is a technique involving the projection or imagination of completing a specific task or action. The term guided imagery is also used as a therapist or technician is employed to instruct or help a patient fully complete the projection to full effect. Research suggests that this visualization of an activity before execution enhances the necessary motor skills associated with the real actions involved, and thus improves the completion of the actual task. Some studies show the benefit to motor activity with prior visualization compared to similar motor function without practice. Studies on exercise or training activities conducted with visualization demonstrate benefits over analogous activity without. Research investigating visualization indicates the beneficial effects of prior guided imagery on physical actions.
Treatment With Medication
Over-the-counter medication may address either mild or moderate symptoms of early-stage arthritis, including pain. Significant chronic or episodic pain can be reduced by conventional analgesics (painkillers). There are many choices of drug therapies currently available that can be prescribed to treat arthritis-related pain. The initial steps of recommended painkillers for many physicians will most often be a non-steroidal anti-inflammatory drug (NSAID), e.g. aspirin or ibuprofen. These types of drug inhibit or reduce inflammation in the target area, thus increasing the probability of easing arthritis symptoms.
General harmful side-effects at the site of inflammation include the release of pain-inducing enzymes into the affected area. NSAIDs regulate these enzymes and prevent their accumulation. Some NSAIDs also inhibit the release of these enzymes, thus preventing their contribution to the pain associated with arthritis. NSAIDs usually come in pill form, in various formulations and concentrations, that can be swallowed or chewed. Other classic analgesics (such as paracetamol) are also prescribed for arthritis pain. This type of drug does not have properties that reduce or inhibit inflammation, however.
Arthritis symptoms can be chronic and resistant to these treatment options, however. Patients with consistent, severe pain may opt for more direct (i.e. surgically invasive) options in the hope of relieving symptoms. This may take the form of injections of corticosteroids into the affected joint. Corticosteroids, such as cortisone and prednisone, are known to effectively inhibit inflammation, and are also associated with immune system suppression. This may be relevant to cases with an immune component such as arthritis caused by infection or rheumatoid arthritis. There are several variations on the corticosteroid injection procedure available. If a physician or pain specialist comes to the conclusion that a patient will benefit from one, they may recommend a course of multiple injections over time to achieve optimal relief.
Joint injections are associated with significant relief from arthritis pain in many cases. The technique is very common and well-practiced among pain specialists and physicians. They usually involve the delivery of corticosteroids in addition to local anesthetics into the joint via a needle or catheter inserted through the skin. Corticosteroids act to inhibit inflammation, while the anesthetics temporarily block pain perception. Individual procedures are not time-consuming and achieve immediate pain relief in some patients. The injections may be repeated in short succession if necessary to provide maximal pain treatment. Research has demonstrated the ability of joint injections to significantly reduce pain and also improve life quality and the ability to move and function for a large number of patients.
Medial branch blocks are a similar procedure that may be recommended to some arthritis patients. In this process, local anesthetics or steroids are injected into the facet joints of the spinal cord (the joints between individual bones of the spine or vertebrae) in order to block the pain emanating from affected joints from perception, which is mediated by the brain. Neural tissue called medial branch nerves serve facet joints, and also contribute to the transmission of information about damaged tissue to the brain, which is perceived as pain. Medial branch blocks are associated with the relief or absence of chronic arthritis symptoms as a result.The procedure may also reduce disability or reduced mobility caused by arthritis.
A physician preparing for surgery to address very severe or treatment-resistant arthritis symptoms may employ corticosteroid injections and medial branch blocks in order to predict the effect of this serious intervention on the joints and nervous tissue in question. The blocking injections in these cases target major spinal nerves that may incur damage or be otherwise affected in the course of the surgery planned. Spinal nerves are major sources of sensory or painful impulses associated with joints commonly affected by arthritis. The needle insertion and placement are monitored using imaging technology (e.g., MRI or fluoroscopy). When accurate placement is assured, a catheter will be inserted in place of the first needle, and a continuous supply of anesthetic and/or steroids will be delivered. A compound that destroys nervous tissue (in cases where this tissue may send abnormally high or constant pain signals) may also be injected. This technique often results in the effective blocking of painful nervous impulses that may last for a number of weeks to a number of months.
The results of a diagnostic block may help a surgeon form a theory of how the tissues of a particular patient will respond to invasive treatment. Diagnostic blocks are usually performed at least twice. The analgesic response of the patient from these often correlates to the improvement of their arthritic symptoms gained from surgery. Surgeons may wait to see if positive responses are elicited from at least two diagnostic blocks before proceeding with a major intervention.
There is no known procedure that can totally eradicate osteoarthritis, although the concomitant pain may be managed by on-demand pharmacological therapy. If this does not seem to slow the progression, the physician may add other treatments such as physical therapy. If the pain becomes very severe or intractable, or the condition significantly affects normal movement and function, surgery may be considered as a last resort.
Prevention of this last line of treatment is associated with the maintenance of healthy activity levels and lifestyle. It is recommended that this is implemented as soon as possible after the definitive diagnosis of a condition such as osteoarthritis, as this may limit its progression to end-stages (in which surgery may become nearly unavoidable). Reduction in movement and exercise is linked to an increase in progressive inflexibility and weakness of the affected joint, which in turn is associated with greater pain symptoms and disability. Exercising also conditions and strengthens muscles, which contributes to joint integrity. Managing weight to a healthy degree is also linked to the prevention of arthritis development. Other factors that may combat arthritis include a healthy diet, adequate (but not excessive) rest, recreational activities, and measures to prevent depression and stress.
Rheumatoid Arthritis Treatment
As with the management of other arthritis types, rheumatoid arthritis treatment focuses on reducing its progression rate and on fighting inflammation. NSAIDs and other conventional medications are again often very helpful when managing a case of rheumatoid arthritis. Drug therapy is associated with significant, and even near-total, eradication of inflammation in some instances of this condition. The consulting physician should still monitor levels of inflammation (i.e. through regular blood tests, physical exams, and patient monitoring) even if this appears to have been achieved. If the symptoms seem to re-establish themselves, the physician may respond with a trial of a different drug or a new dose-regimen of a current prescription.
The patient in question also plays an important role in the management of his or her own symptoms. Efforts to remain physically active can contribute to the reduction of pain and other effects of rheumatoid arthritis. Education and training with a physical therapist may be valuable in achieving this goal. Again, maintaining a healthy weight and sustaining beneficial eating patterns are also factors in reducing the intensity of this condition. Implementing this type of lifestyle may help with managing pain and in retaining mobility and functional status.
Juvenile Arthritis Treatment
Juvenile arthritis treatment should ideally maintain a child’s quality of life at normal levels, through the maximal reduction of inflammation and relief from pain. Effective plans to achieve this are available that usually include utilizing programs of appropriate physical activity, eye care, healthy meals, and medication. Plans may need to be tailored to each individual child, which may require the services of a full team of healthcare professionals who are equipped to adequately monitor and evaluate the progression and symptoms of the child. This team may include a dentist, rheumatologist, physical therapist, ophthalmologist, and nurse practitioner who specialize in pediatrics. Every child patient will respond in their own way to treatment, and often require very competent, specialized care.
There are two distinct groups of drugs in general use for the treatment of juvenile arthritis. The first group is anti-inflammatory drugs, both NSAIDs and corticosteroids, in addition to analgesics, in order to combat inflammation and pain. The other group is disease-modifying anti-rheumatic drugs (DMARDs) that are associated with possible remission and protection from joint damage. Some juvenile arthritis patients require experimentation with various types of both groups, with differential dosing, in order to elicit the most effective treatment possible. Some of either class may cause immune system responses or side effects, so frequent evaluation of the eventual regimen and any adverse reactions will be necessary.
Arthritis is an increasingly significant health issue. It affects nearly 9% of the U.S. population and ranks highly as a source of functional disability. Arthritis is a term that defines over 100 musculoskeletal conditions and diseases with similar symptoms and characteristics. Contrary to what may be popular opinion, about 66% of patients are not over 65. The three most common variations of the condition are rheumatoid arthritis, juvenile arthritis, and osteoarthritis. These all share some symptoms, including joint weakness, pain, stiffness, and swelling. Osteoarthritis is caused by degeneration of cartilage, a material normally present between two bones to provide protection and prevent joint friction. This may be associated with either wear and tear over time, or damage related to an injury. Rheumatoid arthritis is an abnormal immune reaction to the body’s own synovial membranes (which holds the synovial fluid of many joints in place). Juvenile arthritis is a form of the condition seen in people of 16 years or younger who experience symptoms for a period of six weeks or more.
No conclusive cures for arthritis are known. Treatment options for the condition are confined to the management of inflammation and pain. Techniques and therapies that are non- or minimally-invasive are pursued for as long as possible before serious interventions such as surgery become necessary. These may begin with physical therapy, the promotion of exercise and conditioning, pharmacological therapies, and the application of ice or heat to the affected area. Arthritis pain that is or becomes consistent and renders these options ineffective may be addressed by joint injections. These contain local anesthetics and corticosteroids (which inhibit inflammation) and may give medium-term relief from pain. Multiple injections may be necessary for maximal effect, if the consulting physician deems this necessary.
Effective pain management and retention of mobility is associated with timely diagnosis and treatment of arthritis. Avoidance or postponing of consultation may result in more serious consequences, such as disability or surgery. Rheumatoid arthritis may cause organ damage due to widespread inflammation without treatment in some cases. It is recommended to arrange a consultation if the signs or symptoms of any type of arthritis are experienced, just to ensure future wellbeing and functional status.
- Ayral X. Injections in the treatment of osteoarthritis. Best Pract Res Clin Rheumatol. 2001;15(4):609-626.
- Fleming A. Drug management of arthritis in the elderly. J R Soc Med. 1994; 87(Suppl 23):22-25.
- Huscher D, Mittendorf T, von Hinüber U, Kötter I, Hoese G, Pfäfflin A, Bischoff S, Zink A; for the German Collaborative Arthritis Centres. Evolution of cost structures in rheumatoid arthritis over the past decade. Ann Rheum Dis. 2014; in press.
- Messier SP, Mihaiko SL, Legault C, et al. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults eith knee osteoarthritis: The IDEA randomized clinical trial. JAMA. 2013;310(12):1263-1273.
- Mori M, Takei S, Imagawa T, Imanaka H, Nerome Y, Kurosawa R, Kawano Y, Yokota S, Sugiyama N, Yuasa H, Fletcher T, Wajdula JS. Treatment of disease-modifying anti-rheumatic drug (DMARD)-refractory polyarticular course juvenile idiopathic arthritis: experience from Japanese clinical trials. Mod Rheumatol. 2011;21(6):572-580.
- Nessen T, Opava CH, Martin C, Demmelmaier I. From clinical expert to guide: Experiences from coaching people with rheumatoid arthritis to increased physical activity. Phys Ther. 2014;in press.
- Pakzad H, Thevendran G, Penner MJ, Qian H, Younger A. Factors associated with longer length of hospital stay after primary elective ankle surgery for end-stage ankle arthritis. J Bone Joint Surg Am. 2014;96(1):32-39.
- Scott IC, Tan R, Stahl D, Steer S, Lewis CM, Cope AP. The protective effect of alcohol on developing rheumatoid arthritis: A systematic review and meta-analysis. Rheumatology. 2013;52(5):856-867.
- Superio-Cabuslay E, Ward MM, Lorig KR. Patient education interventions in osteoarthritis and rheumatoid arthritis: A meta-analytic comparison with nonsteroidal anti-inflammatory drug treatment. Arthritis & Rheumatism. 1996;9(4):292-301.
- Vitiello MV, McCurry SM, Shortreed SM, Balderson BH, Baker LD, Keefe FJ, Rybarczyk BD, Von Korff M. Cognitive-behavioral treatment for comorbid insomnia and osteoarthritis pain in primary care: The lifestyles randomized controlled trial. J Am Geriatr Soc. 2013;61(6):947-956.
- Erdem E. Prevalence of chronic conditions among medicare part a beneficiaries in 2008 and 2010: are medicare beneficiaries getting sicker? Prev Chronic Dis. 2014;11:E10.
- Gvozdenović E, Dirven L, van den Broek M, Han KH, Molenaar ET, Landewé RB, Lems WF, Allaart CF. Intra articular injection with corticosteroids in patients with recent onset rheumatoid arthritis: subanalyses from the BeSt study. Clin Rheumatol. 2014; in press.
- Iversen MD, Chhabriya RK, Shadick N. Phys Ther. Predictors of the use of physical therapy services among patients with rheumatoid arthritis. Phys Ther. 2011;91(1):65-76.
- Javadi S, Kan JH, Orth RC, Deguzman M. Wrist and ankle MRI of patients with juvenile idiopathic arthritis: identification of unsuspected multicompartmental tenosynovitis and arthritis. AJR Am J Roentgenol. 2014;202(2):413-417.
- Yates CM, Calder PC, Ed Rainger G. Pharmacology and therapeutics of omega-3 polyunsaturated fatty acids in chronic inflammatory disease. Pharmacol Ther. 2014;141(3):272-282.
- Zhang H, Xu L, Wang S, Xie B, Guo J, Long Z, Yao L. Behavioral improvements and brain functional alterations by motor imagery training. Brain Research. 2011;1407:38-46.