This article and the articles to follow are intended for informational purposes only and should not be considered medical advice. Any concerns or questions you may have about steroids or any other aspect of your treatment should be discussed with your doctor.

Note: Although steroids are available in dozens of different forms and brands, for simplicity’s sake, I will refer to the oral form of steroids as Prednisone.

Prednisone: The History
After serving as the Chief of Medical Service and Director of the Army’s Rheumatism Centre during World War II, Philip Showalter Hench returned to work at the Mayo Clinic and continued his twenty year research in rheumatoid arthritis and other autoimmune disorders. By the late 1940’s, it had become clear to Hench and others that in order to bring autoimmune diseases under control, it was necessary to suppress inflammation and the immune system. However, finding an effective agent remained elusive.

It was during this search that Hench began to notice a certain phenomenon among his patients. During pregnancy and in the presence of jaundice, the severe pain of rheumatoid arthritis decreased and in some cases, even disappeared. Hench, along with his colleague, Edward Calvin Kendall, began to consider the steroids of the adrenal glands as the endogenous substance “X” by which RA might be controlled and even cured, saying:

“Substance X…probably was a biologic compound specific in nature and function, one which was normal to the human organism and of which, perhaps, the arthritis patient did not have enough. Since pregnancy alters the concentrations of hormones, we began to suspect that substance X might be a bisexual steroid hormone.”

In 1948, Hench and Kendall tested their theory on a middle-aged woman afflicted with severe RA. After receiving a series of corticosteroid injections over several weeks, the woman’s symptoms disappeared and she got up and walked away from the bed in which she had been confined for several years.

Amazed by the results, Hench and Kendall treated other similarly affected patients. After only a few days, people who were so badly crippled that they couldn’t rise from a chair, shave, open a door or even lift a cup were walking and even dancing. Medical experts throughout the world hailed cortisone as a “miracle drug” and a cure for rheumatoid arthritis. Not surprisingly, P.S. Hench and E.C. Kendall were awarded the 1950 Nobel Prize in Physiology and Medicine.

By then, however, steroids were beginning to show its dark side. Patients taking cortisone in doses high enough to reduce inflammation were experiencing the now well-known side effects: increased appetite and weight gain; fat deposits in chest, face, upper back and stomach; water and salt retention leading to swelling and edema; high blood pressure; diabetes; osteoporosis; cataracts; acne; muscle weakness; thinning of the skin; increased susceptibility to infection; stomach ulcers; psychological problems such as depression; and adrenal suppression and crisis. In some cases, the cure became worse than the disease.

Prednisone Today

Despite the risk of dangerous side effects, however, cortisone treatment is still very much in use, simply because it is often the only effective drug available. Prednisone is used to treat hundreds of disorders, many forms of cancer, including leukemia; lupus, vasculitis, asthma, meningitis, ulcerative colitis,  allergies, tuberculosis, Myasthenia Gravis, dozens of skin disorders, including psoriasis; eye disease, pneumonitis, vasculitis, organ transplants (to prevent the body’s normal inflammatory reaction to foreign tissue and infection), and even autism.

Unfortunately, many people (and in some cases, doctors) have become so leery of “scare-oids” that they have refused much-needed treatment. And, while it is true that long-term use of Prednisone at high doses can cause serious side effects, when used judiciously, Prednisone can literally be a life-saver, especially when inflammation in the heart, lung, eyes and blood vessels are involved. A severe flare can cause extensive damage to joints and cartilage over time, but even in the most severe cases, Prednisone can often provide immediate relief.

Really? Well, who would ever guess?

Apparently, not the researchers who conduct these very expensive, often taxpayer supported studies. Personally, I would like to use some of my wasted tax dollars to pay off some of my medical debts…or, here’s an idea: maybe I could use the money to get a couple of degrees so I, too, could afford to have arthritis.

Sorry. Guess that struck a nerve.

Still, if it weren’t for comments like that, the odious expression “Well, duh!” would have fallen the way of “far out” and “radical, dude!” into slang death. Of course, well-to-do people deal with RA better…they’re the few people in this country who can afford RA. Not only can they afford a rheumatologist, they can afford to go to Mayo or Duke or Johns Hopkins to get the full arthritis spa treatment: JAMA superstar rheumatologist, specially trained nurse, physical therapist, occupational therapist and even a psychiatrist to help with the transition. Afterwards, they can drive straight to their pharmacist with a prescription for Enbrel—absolutely secure in the fact that their insurance will cover it—and go back to their jobs which involve telling other people what they should build/design/type.

So, do I resent rich people? Hell, no. I resent that I can’t afford to be healthy. Without a doubt, America offers the finest medical training, technology and treatment in the world and yet we are ranked 12th in health care. (Italy, if you are interested, ranks number one). Sin is not a word that I frequently use, but I truly believe that it is a sin for anyone to be denied adequate medical care because they lack money…and as much as I love this great country of ours (and who isn’t patriotic, these days?), I believe that this have/have not system of health care is one of its greatest shortcomings.

Often, while on this subject, someone will say to me, “Yes, and look at the animals in prison. All of their medical treatment is paid for by you and me…” usually followed by the suggestion that bad people be put in a dungeon/ on a deserted island/ to death. My beliefs are even more radical: I believe that all members of the species Homo sapiens—even those of the slimy, single-cell variety—are entitled to health care. I honestly believe that it is our right as human beings to be treated when we are sick, no matter what our financial situation.

Don’t get me wrong: I may be a pinko, commie liberal, but I don’t have the first clue as to how to reform the health care system; I also respect that doctors, pharmaceutical companies and insurance companies would like to enjoy the fruits of a free market society as much as the next guy. (I also recognize that—given the times—it may be years before health care reform is even mentioned again).

I do, however, have an idea on how to get the lawmakers in this country to at least think about the high costs of health care: let’s take away their fancy health benefits. Why not? You and I pay for it, we should be able stop paying for it. Let these fat cats pay for their own colonoscopies and bypass surgeries. Maybe after shelling out $300-$1500 a month for prescriptions, they might decide it’s in their best interest to spend a little time studying solutions for an overlooked national crisis.

In the Meantime…

Some of the more astute readers out there may have detected that I am slightly bitter about this issue. You’re wrong…I’m very bitter. I’ve just concluded a two-year fight with my insurance company over Remicaide (they have finally conceded, if only to shut me up…but they still won’t pay for Enbrel), and while I am grateful to finally be able to use Remicaide, I can’t help but be angry for that wasted time, for all those flares, for the new deformities, and…for all those other people out there who are slowly being crippled because they, too, can’t afford to be healthy.

Or can they? Those who can afford to shell out $12,000 a year for Remicaide/Enbrel can afford the Cadillac-brand of health insurance that already pays 100% of prescription/hospitalization. And I’m not talking about the truly poor, who can qualify for Medicaid—which also pays out 100%. I’m talking about people whose insurance pays 70 or 80%. I’m talking about me (because when I really get angry, it’s usually because I’m mad at myself).

It wasn’t that my insurance company wouldn’t pay for Remicaide at all…it was that (and I won’t bore you with the details of why) they would only pay 70%. Well, by my calculations, 70% of $12,000=forget it. So I fought them and did without for two years, limping about the house and secretly resenting my husband for not saying, “Just go ahead and do it…we’ll manage somehow.”

And I’m the one who hates martyrs.

I know that I’ve used this analogy before, so bear with me: if I had cancer, I would do whatever it took to get well. If I had to hold fundraisers, collect cans by the side of the road, sell my body for pocket change…you name it, I would do it. So why didn’t I take my own treatment as seriously? Rheumatoid arthritis, if not treated, can ultimately be fatal. But, because it’s not fatal tomorrow, I think that many of us are shortchanging our health because we don’t want to add (more) financial strain on our families.

I’ve said it before and I’ll say it many times again: medicine is just as important as food. Just as you don’t need to ask permission to eat, you don’t need anybody’s permission to pay for proper medical treatment.

Are you sure you can’t afford your medical care? Do you have cable? Do you drive a late-model car? Do you cave when your children insist on labels instead of clothes? Most of us could cut expenses if we had to….and guess what, we have to.

And, because I am psychic (a lie…if I were psychic, I would be rich and this article probably wouldn’t even occur to me), I know what many of you are probably saying by now: haven’t I sacrificed enough? Hasn’t my family? Yes, of course you have…it’s obscene how much many of us have sacrificed and I doubt that any of us have unaffected families, either. But suppose the treatment you are denying yourself really worked! Perhaps you would even feel well enough to get/retain a job. In other words, denying yourself adequate medical treatment may actually be an exercise in false economy.

Please do not get me wrong. Smile warrior that I am, I am also deeply in debt. Even with insurance grudgingly picking up 90% of the tab, my medical expenses run roughly $300-$500 a month…and that’s not including treatment for my son’s asthma or my daughter’s chronic—and very debilitating—migraines. Every month, I scheme and scramble—through eBay or making and selling this and that—to come up with a hundred here and there to at least put a dent in our debt and keep my already-resentful husband from going on one of his tirades.

It has occurred to me that not only will some people remain silent in the face of need, they will sleep well at night if you are crippled because of it…and to hell with that. Even I’m not that much of a martyr.

So, though I scheme and scramble, I also remain resolute: I will get proper treatment…if I have to sell my soul to the hospital, I will not go without proper medical care again, nor will I ask permission to do so. And neither should you.

Apparently, not the researchers who conduct these very expensive, often taxpayer supported studies. Personally, I would like to use some of my wasted tax dollars to pay off some of my medical debts…or, here’s an idea: maybe I could use the money to get a couple of degrees so I, too, could afford to have arthritis.

Sorry. Guess that struck a nerve.

Still, if it weren’t for comments like that, the odious expression “Well, duh!” would have fallen the way of “far out” and “radical, dude!” into slang death. Of course, well-to-do people deal with RA better…they’re the few people in this country who can afford RA. Not only can they afford a rheumatologist, they can afford to go to Mayo or Duke or Johns Hopkins to get the full arthritis spa treatment: JAMA superstar rheumatologist, specially trained nurse, physical therapist, occupational therapist and even a psychiatrist to help with the transition. Afterwards, they can drive straight to their pharmacist with a prescription for Enbrel—absolutely secure in the fact that their insurance will cover it—and go back to their jobs which involve telling other people what they should build/design/type.

So, do I resent rich people? Hell, no. I resent that I can’t afford to be healthy. Without a doubt, America offers the finest medical training, technology and treatment in the world and yet we are ranked 12th in health care. (Italy, if you are interested, ranks number one). Sin is not a word that I frequently use, but I truly believe that it is a sin for anyone to be denied adequate medical care because they lack money…and as much as I love this great country of ours (and who isn’t patriotic, these days?), I believe that this have/have not system of health care is one of its greatest shortcomings.

Often, while on this subject, someone will say to me, “Yes, and look at the animals in prison. All of their medical treatment is paid for by you and me…” usually followed by the suggestion that bad people be put in a dungeon/ on a deserted island/ to death. My beliefs are even more radical: I believe that all members of the species Homo sapiens—even those of the slimy, single-cell variety—are entitled to health care. I honestly believe that it is our right as human beings to be treated when we are sick, no matter what our financial situation.

Don’t get me wrong: I may be a pinko, commie liberal, but I don’t have the first clue as to how to reform the health care system; I also respect that doctors, pharmaceutical companies and insurance companies would like to enjoy the fruits of a free market society as much as the next guy. (I also recognize that—given the times—it may be years before health care reform is even mentioned again).

I do, however, have an idea on how to get the lawmakers in this country to at least think about the high costs of health care: let’s take away their fancy health benefits. Why not? You and I pay for it, we should be able stop paying for it. Let these fat cats pay for their own colonoscopies and bypass surgeries. Maybe after shelling out $300-$1500 a month for prescriptions, they might decide it’s in their best interest to spend a little time studying solutions for an overlooked national crisis.

In the Meantime…

Some of the more astute readers out there may have detected that I am slightly bitter about this issue. You’re wrong…I’m very bitter. I’ve just concluded a two-year fight with my insurance company over Remicaide (they have finally conceded, if only to shut me up…but they still won’t pay for Enbrel), and while I am grateful to finally be able to use Remicaide, I can’t help but be angry for that wasted time, for all those flares, for the new deformities, and…for all those other people out there who are slowly being crippled because they, too, can’t afford to be healthy.

Or can they? Those who can afford to shell out $12,000 a year for Remicaide/Enbrel can afford the Cadillac-brand of health insurance that already pays 100% of prescription/hospitalization. And I’m not talking about the truly poor, who can qualify for Medicaid—which also pays out 100%. I’m talking about people whose insurance pays 70 or 80%. I’m talking about me (because when I really get angry, it’s usually because I’m mad at myself).

It wasn’t that my insurance company wouldn’t pay for Remicaide at all…it was that (and I won’t bore you with the details of why) they would only pay 70%. Well, by my calculations, 70% of $12,000=forget it. So I fought them and did without for two years, limping about the house and secretly resenting my husband for not saying, “Just go ahead and do it…we’ll manage somehow.”

And I’m the one who hates martyrs.

I know that I’ve used this analogy before, so bear with me: if I had cancer, I would do whatever it took to get well. If I had to hold fundraisers, collect cans by the side of the road, sell my body for pocket change…you name it, I would do it. So why didn’t I take my own treatment as seriously? Rheumatoid arthritis, if not treated, can ultimately be fatal. But, because it’s not fatal tomorrow, I think that many of us are shortchanging our health because we don’t want to add (more) financial strain on our families.

I’ve said it before and I’ll say it many times again: medicine is just as important as food. Just as you don’t need to ask permission to eat, you don’t need anybody’s permission to pay for proper medical treatment.

Are you sure you can’t afford your medical care? Do you have cable? Do you drive a late-model car? Do you cave when your children insist on labels instead of clothes? Most of us could cut expenses if we had to….and guess what, we have to.

And, because I am psychic (a lie…if I were psychic, I would be rich and this article probably wouldn’t even occur to me), I know what many of you are probably saying by now: haven’t I sacrificed enough? Hasn’t my family? Yes, of course you have…it’s obscene how much many of us have sacrificed and I doubt that any of us have unaffected families, either. But suppose the treatment you are denying yourself really worked! Perhaps you would even feel well enough to get/retain a job. In other words, denying yourself adequate medical treatment may actually be an exercise in false economy.

Please do not get me wrong. Smile warrior that I am, I am also deeply in debt. Even with insurance grudgingly picking up 90% of the tab, my medical expenses run roughly $300-$500 a month…and that’s not including treatment for my son’s asthma or my daughter’s chronic—and very debilitating—migraines. Every month, I scheme and scramble—through eBay or making and selling this and that—to come up with a hundred here and there to at least put a dent in our debt and keep my already-resentful husband from going on one of his tirades.

It has occurred to me that not only will some people remain silent in the face of need, they will sleep well at night if you are crippled because of it…and to hell with that. Even I’m not that much of a martyr.

So, though I scheme and scramble, I also remain resolute: I will get proper treatment…if I have to sell my soul to the hospital, I will not go without proper medical care again, nor will I ask permission to do so. And neither should you.

Sick Anyway

Okay, so what if you overcame your needle phobia and got the flu shot, alienated all of the shunned sick people in your life, scrubbed your hands scaly, lived like a well-nourished hermit and you get sick anyway?

Hey, it happens. None of us are bulletproof, especially those of us with ignorant immune systems.

And those of us with the aforementioned immune systems need to take extra care when we do get sick. Many felonious bugs elude scientists and refused to be identified, so for practical purposes, I’ll divide the next section into caring for colds and flus. First of all, which do you have?

Colds
May include some or all of the following symptoms:

* lasts 2-14 days
* nasal congestion/sneezing
* sore throat
* dry cough
* mild fatigue
* slight fever

Flu
May include some or all of the following symptoms:

* can last up to 2 weeks; fatigue can last for several weeks
* nasal congestion
* sneezing
* sore throat
* dry cough (more severe than with cold)
* aching muscles
* severe headaches
* extreme fatigue

There is a commercial that illustrates the difference between a cold and a flu with images of a gentle rainstorm (cold) to a hurricane (flu). Even so, medical advice is pretty much the same for both:

* Drink plenty of clear fluids.

Dehydration can occur more quickly than you think, especially if you have a fever. Drink more water than you think you need and avoid caffeine.
# Rest.
Rest is an ambiguous term (there was a time when I would interpret that to mean cutting back on one of my three jobs), so I’ll let the medical establishment spell it out: STAY IN BED AT LEAST ONE FULL DAY. Those of you still living in the real world with troglodyte bosses and mortgages to pay are sneering, so I’ll amend that to: AT LEAST GO STRAIGHT TO BED AFTER WORK. There…is that better?

# Use OTC meds for comfort…carefully.
Tylenol and its ilk are a godsend for various aches and pains, but please be careful. Even the most benign-sounding drug is still, in fact, a drug and should be respected as such. If you are taking prescription medication for your arthritis do not take anything without your doctor’s permission! Think I’m being paranoid? Okay, how about this: there is some evidence that ibuprofen should not be combined with methotrexate. Apparently, ibuprofen can raise the level of methotrexate to toxic extremes. Make friends with your doctor’s nurse and call before you take anything not approved by your doctor.

Inhale hot steam.
A nice hot bath or, better yet, a steamy shower will relieve your nose and head congestion, which may accelerate the healing process. Humidifiers and vaporizers work, too, but there is some controversy that bacteria can become trapped within, which could actually make you sicker. Ask your doctor.
# Avoid tobacco.
All of you smug (albeit, smart) folks who have never smoked are probably saying, “Jeez, this chick has a gift for the obvious.” True. But as non-practicing tobacco junky (I won’t say ex-tobacco junky because I still want to smoke. Sheer willpower and blackmailing children prevent me), I understand what it is like to crawl on my hands and knees from the sick bed to an ashtray. If you can’t stop completely, at least try to keep it down to 5 or less a day.
Okay…Real Sick, Now

There is some controversy as to whether methotrexate leaves you more vulnerable to colds and flus (of course it does, you scientific nitwits!); however, there is no question about the dangers of Prednisone, Remicaide and other cytotoxic drugs. If you are taking any drug that suppresses your immune system, never ignore persistent symptoms. You are more susceptible to infections—especially of the lung—and the same drugs that help you function can impair your ability to heal. Don’t ever be afraid to “bother” the doctor with seemingly minor symptoms. Studies show that “good patients” (friendly, compliant, hesitant to speak up or complain) have poorer prognoses than pain-in-the-butt patients who advocate for their rights and their health. Don’t be an arthritis wimp…raising a little hell may keep you out of the hospital.

(Note: the following advice is intended for healthy people…those with dysfunctional immune systems should report troublesome symptoms even sooner).

When to Call the Doctor

Cold

* if it lasts longer than 2 weeks
* if you have an earache
* if you have sinus pressure
* if you have a fever over 100 degrees Fahrenheit (could be an indication of infection)

Flu

* high fever
* chills
* yellow-green mucus
* difficulty breathing
Please, please don’t ignore this symptom, particularly if you are taking methotrexate and Remicaide. Both drugs make you more vulnerable to pulmonary disease…and people still die from pneumonia in this country. To illustrate my point, my doctor (after chiding me for not reporting a month-long bout of the flu) told me about another “good patient” of his who ignored a persistent cough for a few days because she didn’t want to use up her sick leave at work. She ended up having a nice, long vacation under an oxygen tent. It was months before she was well enough to take care of herself and she may have breathing difficulties for the rest of her life. You’re not being silly, you’re not a hypochondriac and it’s not your imagination: if you are having persistent symptoms—especially any type of chest pain or impaired breathing—call your doctor.

The Tao of Dealing With a Recalcitrant Immune System: A Modern Metaphor

I’ve noticed many similarities between my wayward immune system and my teenage daughter. They’re both moody, capricious and cause me a great deal of anxiety–and yet, they are not without their good days. As with raising teenagers, we of the weak immune systems have to perform a balancing act of knowing when to restrain and when to let go.

Let’s just hope that my immune system makes better grades and doesn’t try to date Goth stoners with bad personalities.

The difference was, however, that while everyone else seemed to bounce back after a couple of days, I was down for ten: every time I thought the saga was over, I would get sucker-punched by a nasty little sequel.

It’s just a plain, sad fact that those of us with rheumatoid arthritis are more vulnerable to bugs. Perversely, that confused, overactive immune system of ours is so busy beating the crap out of us that it takes awhile for it to notice our legitimate illnesses. And, until scientists can develop a drug that instructs rather than suppresses, many of us will be stuck with damn ineffective defenses.

An Ounce of Prevention…

If only we were as sensible as the Japanese. During the cold and flu season, it is not unusual to see dozens of businessman/women sniffling behind surgical masks. In fact, it is considered the height of rudeness not to wear a sterile mask; after all, the Japanese are as overworked as Americans, their sick leave just as meager. Quite frankly, they just don’t have time to be exposed to your germs. Here in America, however, wearing a mask is a culturally silly thing to do. John Wayne would never wear a surgical mask; neither would Clint Eastwood. Michael Jackson would and frequently does, which is probably the number one reason why Americans refuse to don the mask.

Despite our refusal to resemble Michael Jackson or other alien life forms, we are apparently no more resistant to germs than the Japanese. Every year, 62 million people catch a cold; 100 million will be struck down with the flu. Big deal, right? It is, actually: 20,000 Americans die from the flu every year; it’s unclear how many die from a cold turned into pneumonia.

Yet, even those of us with weenie immune systems can prevent many illnesses, just by taking care of ourselves, i.e. taking the time to use good hygiene. Taking the following steps will not guarantee good health, but it is likely to prevent nasty little bugs from abducting your body and holding you hostage.

Avoid Children

Okay, I’m being a little facetious, here. Anyone who knows me for longer than 30 minutes know that my entire raison d’etre is my children. Had arthritis not struck (along with accompanying fetus-hating drugs), I would have had five. Nevertheless, it cannot be denied that children are seething cauldrons of bacteria. They touch foul things, pick at rude places, share things with dogs and turtles and slide their infested little hands over every possible surface. If you have a child—and especially a school-age child—you will have to resign yourself to sharing at least some of their many illnesses. Take the following advice (below) and square it.

Avoid Sick People

This isn’t as simple as it sounds, especially if you work in an environment with stingy sick leave. The American workplace has rather stupid policies regarding sick leave, which forces walking microbes (formerly known as your coworkers) to hover in the cubicle nearby. Be sympathetic from a distance and—as soon as they turn their heads—wipe all surfaces (and yourself) with antibacterial wipes.

Avoid Indoor Crowds

The reason so many people get sick in the winter is not because of the cold but because we cram ourselves into overheated buildings, like malls, schools and home. Statistically speaking, there is bound to be at least one sick person there, politely sneezing into their hands and then using those hands to touch everything in your path.

Whenever your are confronted with the above situations, take the Howard Hughes approach and become a bit obsessive. If it seems silly or a waste of time, just remember the year before when that cold turned into an infection that wouldn’t go away or that flu that lasted for 6 weeks. That oughta do it.

* Do not kiss, hug, shake hands with or sleep next to an obviously sick person.

If the sick person is a reasonable individual, tell them the truth about your sissy immune system. If the person is a narcissistic jerk, tell them you are sick as well and you don’t want to make them any sicker.
# Assume all surfaces are contaminated.
Assume doorknobs, phones, counters, and coins/cash (I guess there is some truth to the phrase “filthy lucre”) are infested and act accordingly. Open push doors with your arm instead of your hand; bring along your own handkerchief for doorknobs and phones. For other situations, bring along some antibacterial wipes or gel. And keep your hands away from your face; like it or not, you’re germy, too.

# Wash your hands!
The number one way to avoid contagion is by washing your hands frequently and well. That means using plenty of soap and warm/hot water, taking off your rings and scrubbing all surfaces of your hands and fingers for at least one minute. Nurses time themselves by singing the alphabet song. Don’t use communal towels, either. Either assign a hand towel for every member of the house or use paper towels. Finally, you should probably finish up with a little bit of lotion. Chapped hands can crack and lead to infection, especially for those of us on Prednisone.

# Eat and sleep well.
Get at least 5 servings of fruit and vegetables a day; get at least 6-8 hours of sleep a day. Yeah, yeah, yeah, you’ve heard it all before, but how many of you are actually doing it?

# Exercise—when you are well.
Exercise boosts the immune system and makes you stronger, but exercising while sick can accelerate a minor illness into something serious. Exercise when you are well, rest when you are sick. And, no, your thighs don’t look fat.

# Take Vitamins…within reason.
So far, there is no replicated evidence that vitamins C, zinc or any other vitamin can prevent a cold…but taking a daily multivitamin certainly can’t hurt. What can hurt are mega doses of vitamins. A recent study (to be fair, I don’t believe that the results of this study have been replicated, either) that large doses of vitamin C actually caused gene mutations. Certain vitamins, like vitamin A, can become toxic at relatively low doses, so follow the directions of your doctor, not your guru.

# Reduce stress.
Yeah, well…good luck. After all, life is stress. However, many people—especially nice, suburban mom-types—suffer from self-inflicted stress by currying to everybody’s expectations except their own. Learn how to say NO.

# Getting a flu shot.
Ah, the gentle influenza vaccine, much maligned and quite benevolent. And yet, that silly myth persists that getting the flu vaccine will give you the flu. Impossible. The flu vaccine is made from a killed virus, which is incapable of causing disease. Still not convinced? Okay, how about this: the flu vaccine can prevent up to 70% of hospitalizations due to flu complications and 85% of flu-related pneumonia. The flu vaccine is widely available, relatively inexpensive and perfectly safe (check with your doctor, anyway). It’s not too late to get it, so what are you waiting for?
to beontinued…

Think Pilates is just another Hollywood fad like that sudden yoga/Buddhism trend (which is, like, soooo ’98)? Well, don’t take Julia’s word for it…how about the great dancer/choreographer George Balanchine? Both he and the late Martha Graham were early pioneers of the Pilates method. Dancers have known for years—more than seventy years—about the benefits of this method of body conditioning.

Mr. Pilates

Joseph Pilates was born in Germany in 1880, a frail child who grew to become obsessed with fitness. Devoted to the idea of transforming his health, Pilates became an accomplished gymnast, boxer and circus performer, as well as a student of yoga and karate. Students of the Pilates method claim that he incorporated elements from each of these fitness regimens, but it was while interned in a prison camp during World War I that he began to develop his method in earnest.

During his stay at the prison camp, Pilates used whatever props were available—his bunk, the bedsprings, a chair—along with the core of his work, which he referred to as “the mat work”. While other prisoners grew sick and weakened, Pilates thrived. After teaching his method to the other prisoners, the guards were so impressed that it became a mandatory exercise for the entire camp. This was during the worst pandemic influenza of the twentieth century and yet not a single prisoner died. Later, he was hired to train the most elite cadres of British troops.

Over the years, many athletes—including boxer Max Schmelling—included this method into their training, while choreographer George Balanchine was so enamored of the Pilates method that he incorporated its mat routine into the dance piece, “Seven Deadly Sins”. Dancers, always vulnerable to injury, discovered that using Pilates led to quicker recovery time and have consistently used this method from its inception to this day Alas, Pilates did not catch on with the general public. Earlier in the century, Pilates predicted it would be fifty years before the importance of his work was recognized. Apparently, he was right. It is probably to his credit that he lived to be a healthy 87.

So, What is Pilates?

Although Pilates is usually shown being performed on huge, complicated-looking machinery, Pilates first defined his series of 34 specific exercises to be performed individually, on a mat, without aid or assistance from any machinery or equipment. In the Introduction to his 1945 book of exercises, Return to Life Through Contrology (guess he decided to change the name!), Pilates says: “Contrology is complete coordination of body, mind, and spirit. Through Contrology you first purposefully acquire complete control of your own body and then through proper repetition of its exercises you gradually and progressively acquire that natural rhythm and coordination associated with all your subconscious activities.”

In other words, this isn’t the exercise to do while watching the soaps. This method requires full participation, as it focuses on the whole body. There is no flailing about; huffing and puffing is not necessary nor is it desired. Instead, the upper and lower muscle systems are coordinated within the body’s center, working very specific areas with careful, fluid movements. All movements are extremely slow and rhythmic, allowing weaker muscles to be located, which leads to better support for the joints.

“Girdle of Strength”

Joseph Pilates often referred to the “girdle of strength”—the area including the abdominal muscles, extending out to the buttocks and the latissimus dorsi (the muscles in the back that control shoulder and arm movements)—claiming that the strength needed for the exercises originates in the abdominal muscles. If these muscles are not in control, then other muscles such as those in the back, neck or shoulders can be damaged. It is by using the abdominals and learning correct breathing that leads to strength and improved posture.

Breathing

Open any book on Pilates (and there are dozens, at least) and proper breathing will be emphasized, over and over again. Each movement is tied to a specific manner of breathing and the way that you breathe is just as important as the movements themselves…especially since most of us breathe “wrong”, expanding only the top part of our lungs. Instead, you should breathe from the diaphragm so that your stomach rises and falls, rather than your chest. Practice this way of breathing for five minutes and you should actually feel yourself relaxing.

Concentration

Often, we become so distracted by our various responsibilities that we are complete unaware of our movements. In Pilates, the movements focus on a very specific area of the body; concentration is essential.

Control

One of the reasons that Pilates is an ideal ROM exercise for arthritis is that the movements are very controlled; chances for injury are minimal. In the beginning, these movements may feel clumsy, but once you have a grasp of the move, you will be able to execute the movements with grace and control.

Fluidity

Each exercise leads to the next, moving seamlessly from one to the other. Even though each movement has a beginning and ending, you blend the movements into each other, stretching and continuing, so that the end of one movement gracefully becomes the beginning of another.

Are Those Exercise Machines or Torture Chambers?
Many people shy away from Pilates because they’ve seen it performed on huge, complicated machinery. Repeat after me: you do not have to use the resistance machines. Joseph Pilates designed 500 different movements, but they all evolved from the 34 core movements, what he called “mat work”. So if money is a problem or you live in a small town where even the fitness instructors say, “Pi-who?”, rest assured, you can still benefit from Pilates.

However, if you live near a Pilates studio, using the resistance machines helps you become more aware of how the movement works each muscle, which can also help you improve your mat work. Also, it creates an intensity which is hard to achieve on your own. If at all possible, at least try to find a qualified “mat work” instructor who can guide you, adjust your posture, demonstrate breathing and correct movements and add new exercises as you become stronger. Even in little ol’ Radford, Virginia, pop. 15,000 (with students; more like 12,000 without), we have a certified Pilates “mat instructor”.

Pilates and Arthritis

So, is Pilates safe for arthritis? Sure. Not only has Pilates been used (in conjunction with medical treatment) to treat rheumatoid arthritis, it has also been used for back and neck pain, osteoarthritis, mastectomies, joint replacements, scoliosis, lupus, fibromyalgia, chronic fatigue syndrome, and joint and muscle injuries. In fact, many physical therapists, orthopedists, and chiropractors have integrated the Pilates method of body conditioning into their rehabilitative programs. The slow, controlled movements are ideal for protecting joints and improving alignment. Even so, consult your doctor and/or physical therapist before starting any exercise program, especially if you’ve been sedentary for an extended period of time.

Rheumatoid arthritis is a maddening disease.
Despite all of the exciting breakthroughs in the field of immunology, the cause and cure of RA remains elusive. And then there’s the temperamental nature of RA—waxing and waning, virtually impossible to predict. It is understandable how many people—including some respected researchers—believe that a person’s personality determines who contracts RA and who doesn’t…that there is an actual “arthritis personality”.
Personality=Arthritis

The Mind/Body Connection

The idea that the mind influences one health is not a new concept. Hippocrates, the father of modern medicine said:

“The patient was the real thing, the disease not an entity but a fluctuating condition of the patient’s body, a battle between the substance of disease and the natural self-healing tendency of the body.”

And there is some rationale for the link between personality and illness. Nowadays, even the most conservative doctors will admit that an aggressive, “Type A” personality can lead to hypertension, heart attacks or strokes. There is rising credence to the idea of a “Cancer Personality” (e.g. repressed anger, excessive need for approval) although it should be emphasized this has not been clinically proven. And then there is rheumatoid arthritis—capricious and temperamental, illogical and cruel—a sort of Freudian symbol for women…and, of course, women are usually its’ victim.

In fact, in some of the early research on arthritis and personality, you can find Freud’s indelible mark. Only women were tested, the arthritic personality said to be:

* self-conscious
* rigid
* inhibited
* shy
* conforming
* frigid

Later researchers concluded that the study was flawed by faulty research methods in that there was an inadequate definition of arthritis and that the personality information gathered during the interviews were inconsistent. Still, the idea of an “arthritis personality” was established.

The Birth of Psychoneuroimmunology

In 1964, psychiatrist George Solomon started the field of “psychoneuroimmunology”—the science that explores connections between personality and the immune system. He and Rudolf Moos of Stanford University conducted a study on women with RA and their non-arthritic sisters. He found that certain personality traits of the arthritic women were not found in the non-arthritic sisters. This time, the arthritic personality was said to be:

* passive
* self-sacrificing
* overly sensitive to the anger of others
* compliant
* anxious
* depressed
* unable to express anger

Solomon and Moos then concluded that people who are genetically predisposed to RA but are emotionally healthy could actually prevent the disease.

It must be kept in mind that these women were tested after contracting RA; it did not seem to occur to Solomon and Moos that their personalities could have changed in response to the disease. It is also interesting that—again—only women were tested. As a psychiatrist, it is possible that Dr. Solomon could have given credence to the Freudian idea of the “hysterical woman”, i.e. women being so swayed by their emotions that they could actually cause themselves to become ill and disabled.

This tendency for doctors to disregard women’s complaints as “being in their head” still occurs today. In a recent study, women were found to be twice as likely to die from a heart attack than men. Apparently, when men complain of chest pain, they are immediately hooked up to an ECG but when women complain of chest pain, doctors tend to attribute it to stress. Many women leave their doctors with a prescription for antidepressants—if anything at all

The Granola Effect

Psychiatrists aren’t the only people who blame RA on personality. Naturopaths, homeopaths, holistic “healers” and the like, also believe that a person’s personality can result in chronic disease, including RA. According to naturopath David Hoffman, the arthritic personality consists of:

* static anxiety
* rationalization
* dependency
* reduced ability to express emotions openly
* infantile aggression

Hoffman also believes that “friction in the joints” is directly attributable to the patient’s “friction with other people”. Since there has not been a single replicated study in which holistic medicine produced a measurable effect on RA, one is tempted to believe that the reason naturopaths blame the patient’s personality is to provide a ready-made excuse when their treatments fail (i.e. the patient doesn’t improve because she refuses to “change her personality”).

Arthritis=Personality

“Learned Helplessness”

The chronic pain, stiffness and malaise of RA can produce incredible stress. In a now infamous study, dogs were placed in cages with electrified bottoms. Intermittently, the researchers would shock the dogs. At first, the dogs would struggle and try to escape. After realizing that there was no escape, however, the dogs stopped struggling, and simply huddled on the floor…even when there was a means of escape. This rather cruel experiment lead to the theory of “learned helplessness”.

Other studies have confirmed that if there is a repeated inability to do something about stress, a pattern of behavior develops that is characterized by “giving up”. Eventually, the victim is unable to clearly assess the causes of stress or to formulate solutions for dealing with them. The relentless, seemingly inescapable pain of RA is a perfect example of a persistent stressor; its victims can easily conclude that any action on their part is futile.

While “learned helplessness” may be too generalized a term, depression is a common problem with RA patients; it has been estimated that at least 40% will experience a period of severe depression. Many of the personality traits espoused by Solomon and others: difficulty in expressing emotion, overly sensitive, inhibition—even “infantile aggression”—are likely the effects of depression.

Self-Conception and RA

If these traits are the result of arthritis-induced depression, can one’s personality be altered for a healthier outcome? Probably not. In a recent study in Sweden, researchers tested two groups. The first group had what was considered a “positive” personality, showing traits such as a “fighting spirit”, acceptance (as opposed to giving in), and revaluation. The second group demonstrated “negative” personality traits: they were reserved, tended to “protest” their fate and felt there was a significant deprivation of life. It was believed that there would be a correlation between the “positive” thinkers and lesser symptoms. However, disease indicators correlated only weakly with self-conceptions; there was little if any difference in the severity of the “positive” thinkers and the “negative” thinkers.

The Efficacy of Coping

In the same study, however, researchers noted that while personality had little to do with severity, it could make a significant difference in coping. The attitudes demonstrated by the “positive” thinkers helped them to deal with RA in a way that allowed them to function as normally as possible. In yet another study on personality traits, it was found that certain traits helped patients cope with RA more effectively than others. The traits—both “positive” and “negative” are:

* Neuroticism
Anxious, self-pitying, tense, touchy, unstable, worrying

* Extraversion
Active, assertive, energetic, enthusiastic, outgoing, talkative.

* Openness to Experience
Curious, imaginative, insightful, having wide interests.

* Agreeableness
Appreciative, forgiving, generous, kind, sympathetic, trusting.

* Conscientiousness
Efficient, organized, reliable, responsible.

It was found that the subjects who exhibited “positive” traits—extraversion, openness to experience, agreeableness and conscientiousness—managed their RA much better than those who exhibited neuroticism; that, while there was no difference in the severity of their symptoms, they were able to live their lives more freely. It also found that the more perceived control the subject had over RA, the more effectively he or she coped with pain.

Should we then conclude that there is no such thing as an “arthritis personality”? Yes and no. As of yet, there is no replicated clinical evidence that personality traits can trigger RA. However, many people with RA report that a major stressor (death in the family, divorce etc ) in their lives occurred just before onset of the disease. Even though there is no convincing evidence of a link between stress and severity of symptoms, it is known that stress can alter the immune system. Also, a link has been found between RA patients who have a history of depression or anxiety disorders and increased fatigue.

So far, psychoneuroimmunology and the treatment of RA has a fairly dismal record. The concept of an “arthritis personality” is not a harmless one, either. Many people with RA are beset with guilt—they do not need the added stress of believing that they “caused” their arthritis—nor do they need their families, friends and coworkers believing that RA is simply neurotic behavior, that, if they would just “think positive”, they would be cured. As far as studying the links between personality and RA, most patients with RA would probably prefer already-scarce funding to go towards finding a genuine cure.

If you are occasionally irritated by my aerobics teacher tone, here is my confession: I hate to work out. In fact, not only do I hate to work out, I will—at any given excuse—duck out of exercise the way a sinner skips Sunday school.

“I’m too busy,” is my excuse of choice and it’s true—this holiday season was more hectic than usual. At any rate, New Year’s Day came with all of its requisite guilt and I realized that I had not really exercised in nearly two months. Full of resolve, I pulled out one of my exercise tapes and some of my hand weights and set to work. Realizing that I was probably not up to my usual level, I did only half of the tape and used my lightest weights. True, I sort of glossed over the cool-down, but I got through the workout easily. In fact, I even felt a little cocky, knowing that I could have completed the entire workout, if I had wanted.

At 3 AM, I awoke in pain. At first, I thought that I had been slammed with a five-alarm flare—which was true—but it was more than that. It was my muscles. Gingerly, I made my way downstairs, taking a full minute and a half to reach the bottom. I increased the dreaded Prednisone, I iced, I heated, I rested…and still, I could barely even lift my arms, much less function like a human being.

The only thing that hurt more than my muscles (and, of course, my joints) was my pride. I couldn’t believe that such a baby workout could crip me out for three days. Then I remembered about muscle atrophy, another one of those fun components of rheumatoid arthritis. When you have RA, you must exercise, not only to keep your joints limber, keep your weight down, keep the circulation going, but also to keep your muscles from literally wasting away. True, by a certain age (which I passed, a while back) everyone has to exercise to avoid muscle atrophy. But when you have RA, the process is accelerated. It’s as if you have to exercise—not to get ahead, but just to keep up with your own body.

Realistically speaking, however, there will probably be periods of time in which you don’t or can’t exercise. If you’re getting over a flare, maybe you’re even a little gun-shy. So how do you get back into the exercise groove? Very carefully, of course…

Easing Back into Exercise
See your doctor.

Overkill? Maybe. But if it’s been awhile, it can’t hurt to get checked out by your rheumatologist. Not only can he/she check on your general well-being (blood pressure, heart, lungs, etc), he/she can best determined your level of severity and make appropriate suggestions for getting back into shape.

If you RA is extremely active, if you haven’t exercised in years or if your general health is poor, you may be referred to a physical therapist. Don’t be embarrassed! There is no shame in having a problem, only in doing nothing about it. A physical therapist is specially trained to work your weakest muscles and joints. It’s hard and even painful, but a good physical therapist can work wonders for even the wheelchair bound and can certainly help you develop a realistic exercise plan.

Underestimate your exercise level.

Let’s say that—miracles of miracles—you wake up feeling almost normal on a coincidentally gorgeous day. You blow the dust off of your walking shoes, step out into the sunshine and tell yourself, “I feel like I could walk a mile!”

Terrific! Walk half a mile.

Chances are that on a good day, you probably could walk that mile without any major problems. But your body still benefits from that half a mile and you can always build up to a mile or two or even 5. Building up, however, is the key. If you’re feeling truly impatient, look at it this way: how many miles are you going to be walking if you are knocked back with a flare? In this case, the tortoise truly does win the race.

Choose your exercise carefully.

Speaking of walking, I would like to take this opportunity to state that, contrary to what the “experts” claim, walking is not for everyone. Some of us have severe deformities in the metatarsals, which leaves very little cushioning…even with good shoes and orthotics. This is just one example of comparing your exercise needs with your arthritic limitations. For someone whose feet are severely afflicted, swimming or rollerblading would be a better option.

Another example might be someone whose neck is affected. While walking might not present a problem, many yoga poses would be out of the question and might even be dangerous. This is why it is important to discuss your exercise options with your doctor before starting. Not only can he/she offer suggestions he/she can also discuss which exercises should not be attempted.

Study beforehand

Again, this probably sounds like overkill, but if you’ve been out of the game for awhile, it can’t hurt to watch others before attempting a workout yourself, especially if you are planning on taking a class. While aerobics/aquatics/yoga/tai chi/pilates teachers may be very knowledgeable in their field, chances are that they don’t know squat about arthritis. Ask an instructor if you can watch an actual class before signing up. Watch carefully and take notes about possible problems. Afterwards, approach the instructor and ask if certain poses, steps, etc can be modified (and they almost always can); you may even decide that this particular class is not for you. Most instructors will be happy to work with you. If not, that is a red flag that you may not be dealing with a professional. Avoid any instructor who seems unsure of him/herself, is unable/unwilling to answer your questions or who seems threatened by the idea of adapting any part of the routine.

This is also an excellent way to “review” an exercise tape. Most exercise videos can be rented from the local video store; if not, the more reputable exercise programs offer a money-back guarantee. Either way, try to watch the tape more than once before attempting to follow the routine. The terrific thing about workout videos is that you can stop them. If there is a part you don’t understand or a move that you feel you should modify (and even Tae Bo can be modified!), stop the tape and write a note to yourself. Later, after you have warmed up, you might want to try out the adapted form before you start the actual workout.

Plan your exercise time and keep it sacred.

Morning stiffness makes exercise nearly impossible for some of us; evening fatigue for others. Pay attention to your body and decide when the best time is for you. If you are a procrastinator or if you really, really hate exercise, you might even consider “scheduling” exercise time on your calendar. Writing anything down as an appointment somehow makes it seem more important…

Exercise Time!
You must warm up before any type of exercise…

That includes yoga, tai chi, pilates, swimming or any other kind of “soft” exercise. Some of you are probably saying, “You mean, I gotta stretch before I stretch?”—which is a common misconception. Warming up is not stretching; it is the light exercise you do to warm you muscles before you even stretch. A few minutes on the treadmill (or around the block), marching in place, or easy dancing are all excellent ways to warm up. Five minutes is fine for non-arthies, but I feel that arthritic folk should probably aim for ten. Since our muscles are stiffer, they are more prone to injury.

Still not convinced? Okay, well here’s what the experts at AskMen.comhave to say:

“The theory behind warm-ups is that muscular contractions are dependant on temperature. Because increased muscle temperature improves work capacity and a warm-up increases muscle temperature, it is assumed that one is necessary.

“The amount of knee fluid also increases with a warm-up, oxygen intake improves, and the amount of oxygen needed for exercise is reduced. This is why performance improves after warming-up. Nerve messages also travel faster at high temperatures. Your reflexes will be faster and so will your muscular reactions, therefore you will reduce the potential risk of injuries.”

And, as an infamous lover of the hard way, let me share what happened to me—pre-arthritis—when I didn’t warm up properly. I was late for ballet class, and instead of warming up properly, I jumped in with the rest of the class who were in the middle of the barre (a series of advanced leg stretches performed on a chest-high bar). Since the teacher didn’t notice me sneak in, I thought I was pretty slick; in fact, I was winking at one of my classmates when something popped in my left hamstring, sending me and my smartass grin to the floor. That was 7 years ago, and I still have problems with that hamstring. Please…it’s only ten minutes. Take the time to warm up.

then stretch.

Even so, it’s not enough to just warm up your muscles. They must also be stretched to avoid injury. Any reputable class or video will have both a warm up and a stretch incorporated into their routine; if you are on your own, and are unsure about what to stretch and how, Carol Dickman offers 21 different stretches on her website Stretch.com.

Don’t go for the burn.

The “burn” is for Jane Fonda and millions of other non-arthies; we have built-in burns that don’t need to get worse. If you are following an instructor, stay well below his/her pace; there will be time enough to catch up as you build up your strength. In fact, for the first few times, stay well below the level that feels challenging. This may seem frustrating, but it will help you prevent flares and muscle blowouts, which will ultimately help you attain the level that is best for you.

Cooling down.

Okay…everybody makes mistakes. Perhaps kickboxing wasn’t such a great idea. If the exercise you chose truly hurts you, by all means, stop—gradually. During any aerobic activity, blood is sent to the extremities and, of course, the heart rate is increased. If you stop suddenly without cooling down, it puts extra stress on the heart, causes the blood to pool in your legs and can lead to muscle stiffness and tenderness…and who needs that?

Cooling down is much like warming up except that you are gradually slowing rather than quickening your pace. Walking in place or on the treadmill, taking a couple of slow laps in the pool, or even just lifting your knees to waist level until your heart rate normalizes are all ways of cooling down. By finishing up with a five-minute stretch, you further decrease your chances of next-day muscle aches.

Afterwards…
Hit the water.

Warm water seems to have restorative powers for arthritic folk. Five minutes in a Jacuzzi is heaven, but even a hot shower or bath is a nice way to finish up a workout and prevent stiffness. Make it a bubble bath and you’ve rewarded yourself for a job well done!

Schedule lightly.

The first few days of a new workout—or an increase in level—is not the time to finish all those chores that you’ve put off for a week. Keep the errands and housework to a minimum. Order out. Give your kids the car keys or teach them the fine art of walking. Until you know how your body is going to react, allow yourself time to recover.

Re-evaluate.

Remember: the next morning is Judgement Day.

Ease out of bed slowly and assess your level of stiffness and pain. Some increased stiffness and soreness should be expected, but if you are truly in pain then you need to re-assess your workout. Could you reduce the intensity or adapt some of the movements? Would it be possible to perform the same exercise at a slower pace or at half the duration? Chances are good that by adjusting the tempo or time, you will be able to continue your workout. If, however, you don’t feel that an adjustment is possible, then it’s time to look for a different way of exercising.

Fortunately or unfortunately, exercise is not an option for folks with RA. We must exercise regularly to protect our bodies from further degeneration. If care is taken, if we are ready and prepared to adapt, there are many types of exercise that are still open to us. And, whether or not you truly like exercise, when you work out, it feels as if you have broken a barrier…and isn’t feeling less limited, even by a small degree, worth all of the sweat and soreness?

Generally speaking, we Americans are viewed as being fairly happy-go-lucky people (we are also viewed as being fat, vulgar, arrogant and violent…but then, that’s another article). Even Henry Miller—and I don’t think anyone ever accused him of being a Pollyanna—confessed that he sometimes irritated his French companions with his chronic cheerfulness, admitting, “I’m just as retarded as any American.”

With the skyrocketing popularity of Prozac, however, I believe we are showing some cracks in our rugged individualism. True, we don’t make depression a national pastime as they do in Sweden, but in America, I believe that depression is finally coming out of the closet.

So if the average American can confess to being depressed, then we in the arthritic community might as well admit it: depression and rheumatoid arthritis go hand-in-hand. Why? Because we have been slapped down by a disease that robs us of our mobility, our independence, our jobs, our social lives and—to a lesser or greater extent—our dignity. We are financially devastated, frightened about the future, lonely, angry and defenseless against the ultimate betrayal: being attacked by our own bodies.

Most of us could adapt to even these changes within time, though. We can survive death and divorce, eventually. So why is it that 90% of people with RA will experience occasional depression and 40% will be treated for severe depression? The number one reason for depression—and as my father-in-law says, this ain’t rocket science, folks—is pain. Pain—that great malefic god—is constant, relentless, capricious and, worst of all, greedy. Pain doesn’t want to share you with anybody; he wants you all to himself.

And only those in pain understand the loneliness that comes with pain.

Okay, now that we’re being honest, I’ll even be more frank: recently, I asked my doctor for antidepressants. Yes, me: the Joan of Arc of arthritis, smile warrior, exercise ninny and happy Heidi. I had a rough summer, arthritis-wise, one of the worst I’ve had. That, combined with some family/financial issues, sank me into deep dark hole. I guess you could say that I lost some of my infamous “adaptive techniques”.

So am I suggesting that we all go on antidepressants? No, of course not. I’m just giving an example how even the most positive of us can get worn down occasionally. And, while there is no evidence that depression exacerbates pain, it does diminish your coping skills which can lead to increased severity of symptoms. It can be argued that in some cases, depression can be more debilitating that arthritis itself…and arthritis and depression can be indescribably miserable.

So what do we do about it?

Well, first of all, roll out of bed, rub the cobwebs out of those unblinking eyes and take a test from the folks at the National Institute for Mental Health. This will help determine whether you are just in an inflammation funk or if you are clinically depressed. If you are experiencing four or more of the following symptoms for more than two weeks, you should seek help immediately.

* Persistent sad, anxious or “empty” feeling
* Feelings of hopelessness and/or pessimism
* Feelings of guilt, worthlessness and/or helplessness
* Loss of interest or pleasure in ordinary activities, including sex
* Sleep disturbances (including insomnia, early-morning waking and/or oversleeping)
* Eating disturbances (changes in appetite and/or weight loss or gain)
* Decreased energy, fatigue and/or a feeling of being “slowed down”
* Thoughts of death or suicide, or suicide attempts
* Restlessness and/or irritability
* Difficulty in concentrating, remembering and/or making decisions

If, however, you are not experiencing four or more of these symptoms, or if you believe that this is a temporary case of the arthritis blues, read on for tips to feel better.
Depression Busters
Will any of these tips “cure” your depression? Probably not. But as easy as it is to get mired in depression, distraction can sometimes be surprisingly effective. Try any or all of these ideas…most of them are free.

Give in to it
You heard me. Sometimes the best thing to do is just…go with it. Allow yourself 24 hours of self-pity. Stay on the couch. Eat ice cream. Watch Gilligan’s Island and the Late, Late, Late show. Cry. After wallowing for a day or two, you just might be ready to take a shower and rejoin life.

Get Outside
Get out of the house. It doesn’t matter where you go or what you do…just get out and stop staring at those same four walls. Who knows? Even the fresh air could revive you.

Exercise
(I can actually hear all those eyeballs rolling in their sockets). I know, I know…exercising is the last thing you want to do. But endorphins and adrenaline are powerful drugs…some studies suggest that vigorous exercise is as effective as Prozac. In any case—provided the exercise is arthritis-friendly—it can’t hurt.

Keep a Journal
There’s something about writing that stops all those dark thoughts from circling in your head.

Listen to Music
Choose songs that have strong, positive meaning for you. And who doesn’t feel better after a rousing chorus of R-E-S-P-E-C-T?

Go for a Long Walk
True, I could have put this under either “Get out of the House” or “Exercise”, but I think that long, meandering walks have a way of “wearing out” bad feelings.

Sing
It doesn’t matter if you’re Beverly Sills or if you torture dogs…throw your head back and sing. I don’t know why this works, but try it: I guarantee that you’ll feel a little better.

Seek Out Other People
This one is tricky. Being depressed causes you to withdraw but the more you withdraw, the more depressed you’re likely to become. Call one of your friends…especially if they’re troubled too. It might sound a little sadistic, but sometimes listening to other people’s problems helps you keep your own in perspective. As a corollary:

Participate
In your own small way, rejoin the human race. Drag yourself to your support group, book club, coffee circle…whatever you usually do, keep doing. Sometimes if you pretend that you feel alright, you start feeling alright.

Check your Medication
We all have our own unique chemistry; some of us react more strongly to certain drugs. Corticosteroids (Prednisone and the like), in particular, are notorious for causing depression and anxiety.

Distract Yourself with Something Boring
Clean out one drawer. Pay your bills. Organize anything. Not only will it distract you from your problems, it will give a (small) sense of accomplishment, which always makes you feel better. When you’re through being practical:

Do Something Frivolous
Buy flowers. Read a comic book. Eat a banana split. Challenge your kids to a bubble-blowing contest. Buy something useless. Pour an entire bottle of Mr. Bubble into your bath. Remember what it is like to have fun.

Invest in Comedy
Read A Confederacy of Dunces. Or, if you don’t have the energy to read, rent five comedies from the video store. My pick for impossible-not-to-laugh videos? Raising Arizona, Funnybones, After Hours (the one by Martin Scorcese), Being John Malkovich and anything by Monty Python.

Do Unto Others
It’s corny, but true…doing something nice for someone else just makes us feel all warm and fuzzy inside. Volunteer—community agencies are always short of volunteers and are not picky about abilities. Or buy something for a friend for no reason. Cook a fancy dinner and take it over to an elderly person. It doesn’t matter what you do, as long as you are doing for someone else…which takes the focus off of yourself.

Try to put Things into Perspective
Chronic pain is so overwhelming that it can take over our thoughts. Sometimes we need to take a step back and truly examine our lives. Take an inventory of what is good, helpful or positive in yourself and in the people around you. You might discover happiness that you hadn’t recognized before.

Now, Here’s a few “Don’ts”…
Do Not Make any Major Life Decisions
You are literally not in your right mind. Don’t sign any papers, pack any bags or kick anyone or anything out of your house just yet…wait until you are feeling better.

Don’t Lash Out
Depression often leads to irritability. Lashing out at others—and receiving a tongue-lashing in kind—will only make you feel worse, and could damage important relationships.

Leave Your Credit Card at Home
There’s nothing wrong with buying yourself a small gift, if it makes you feel better…but save the sprees for after you win the lottery. There’s nothing like an unpaid stack of bills to send you spiraling back into depression.

Padlock the Refrigerator
Go ahead and have that indulgent treat…and then give your waistline a break. Obesity, like bankruptcy, will not help your condition.

Now it’s your Turn
Talk to me…what causes you to become depressed and what do you do about it? Tell me about it in Feedback. This is your time to vent, rage, cry or offer hope…and you may remain anonymous. Depression is something that we all experience from time to time…let’s share our experiences—not only to help each other, but to remove the stigma that keeps some of us from getting help when we need it.

Is your doctor a board certified rheumatologist? If not, you might be cheating yourself out of the care you deserve. Ask yourself this question: if you had cancer, would you see a family practitioner or an oncologist? That may sound extreme, but if not treated properly, RA can potentially be fatal. So, while your PCP may the ideal doctor to maintain your general health, a disease as complex as rheumatoid arthritis needs to be treated by a specialist.

A Rheuma-who?

According to the American College of Rheumatology (ACR), a rheumatologist is “an internist or pediatrician who is qualified by additional training and experience in the diagnosis and treatment of arthritis and other diseases of the joints, muscles and bones. Furthermore, many rheumatologists also conduct research to determine the cause and better treatments for these disabling and sometimes fatal diseases.” And if you have experienced persistent pain in your joints, muscles or connective tissues—especially if symptoms persist for six weeks or longer—a rheumatologist is the doctor you should see.

It is estimated that there are over 100 different types of arthritic diseases (some say as many as 175). Anything ranging from infection to cancer can look like or be involved with joint pain. While all doctors study rheumatic conditions, it would be impossible for the average PCP to stay current on all the different types of diseases and treatments. Even if your PCP is a top-notch physician, he/she can not measure up to the educational standards of a rheumatologist:

* Four years medical school (internal medicine or pediatrics)
* 2-3 years specialized rheumatology training in the rheumatology department of a working hospital
* Since most rheumatologists choose to become certified, they must pass a rigorous exam conducted by the American Board of Internal Medicine
* Many rheumatologists also participate in regular continuing education programs

And rheumatologists aren’t limited to treating the more than 100 different types of arthritis. They also treat certain autoimmune diseases such as lupus, back pain, osteoporosis, musculoskeletal pain disorders such as fibromyalgia, and tendonitis. Their education and experience allow them to accurately evaluate symptoms and determine the correct diagnosis. The importance of early diagnosis in arthritic conditions (particularly RA) has been proven, but often symptoms are difficult for the average doctor to diagnose.

For example, if a patient is suspected of having RA, most doctors will routinely test their blood for presence of the rheumatoid factor. However, it is estimated that 25% of people with rheumatoid arthritis are known as seronegative and will never develop the rheumatoid factor. Moreover, the rheumatoid factor has also been found in people with other autoimmune diseases, such as lupus, mononucleosis and even leukemia. So how can a doctor really know whether a patient has RA or some other condition?

A rheumatologist will be able to tell because he/she has been specially trained to correctly analyze specific blood tests. He has also been trained to take a complete medical history, to give the patient a comprehensive physical exam, and what to look for when viewing diagnostic x-rays. After carefully listening to the patient and analyzing the data, a rheumatologist will be able to pinpoint certain patterns of symptoms that another doctor might overlook. Once he/she diagnoses the disease, an individualized treatment plan will be prescribed.

Brave New World

We are fortunate that—if we must have arthritis—this is the time to have it. In the past few decades, many RA patients were treated with little more than aspirin and Prednisone. We still have aspirin and Prednisone, but now we also have NSAIDS, COX-II inhibitors like Celebrex, disease-modifying anti-rheumatic drugs (DMARDs) like methotrexate and Arava and the new biologic agents, Enbrel and Remicaide. Yet recently, I met a woman who had been diagnosed with rheumatoid arthritis and her family practitioner had prescribed only naproxen. She was in a great deal of pain, but accepted it because her doctor had told her, “You’re just going to have to learn to live with pain.”

Since rheumatologists recognize that treatments of arthritic conditions are changing (and improving) rapidly, many of them participate in ongoing educational programs to be as current as possible. Just a few years ago, even rheumatologists began treating new patients with only NSAIDs and maybe Plaquenil. If his or her symptoms did not improve, then they might try corticosteroids and DMARDs. Now, however, many rheumatologists believe in more aggressive treatment, often starting a patient on a DMARD like methotrexate and then escalating to “combination therapy” (e.g. biologic agent such as Remicaide in combination with a DMARD) if they don’t respond. This new, “aggressive” approach minimizes the chance for deformity, disability and lessens the severity of the symptoms. In rare cases, it could possibly bring about spontaneous remission.

These drugs are not without risks, however, and your rheumatologist is the most qualified doctor to monitor these drugs for possible side effects or drug interactions. He or she is also well versed in other forms of treatment, such as the use of heat/ice, exercises and orthotics and can provide referrals to appropriate professionals or agencies. If asked, he/she can even refer some patients to clinical trials. Often, patients don’t mind being a “guinea pig” if there is a chance of lessening their symptoms.

Someone once told me, “You have completed successful rheumatology training when you can look patients in the eye and say ‘I don’t know’”.

Steven S. Overman, M.D.

“I Can’t See a Rheumatologist Because…

Still, only a minority of RA patients see a rheumatologist. Many people are under the misconception that they can’t afford a rheumatologist. And it’s true—a specialist does charge more money than a family practitioner. In the long run, however, a rheumatologist could actually help you save money. A rheumatologist saves you money by:

* Diagnosing your condition more quickly
By diagnosing your condition/disease more quickly than a PCP, you are able to avoid unnecessary blood tests, office visits and second or third opinions.
* Specially tailoring your treatment
By pinpointing which treatment is best for you, you save money on unnecessary and possibly ineffective treatments.
* Reducing the severity of your symptoms
Which could lead to you keeping or attaining employment; it also prevents the kind of deformities that could lead to permanent disability.

But sometimes seeing a rheumatologist is easier said than done. Unfortunately, there are thousands more people with arthritis than there are rheumatologists and the rheumatologists out there are spread pretty thin. I drive 90 miles round-trip to see my rheumatologist…and consider myself lucky. Often, people (especially in rural areas) live hundreds of miles away from a qualified rheumatologist…and if they felt well enough to drive hundreds of miles, they probably wouldn’t need a rheumatologist. Still, one might be closer than you think. If you would like help in locating a certified rheumatologist, ACR offers a Geographic Membership Directory.

So, you found a rheumatologist, but your insurance won’t pay for a specialist? Fight. You heard me—fight them and don’t give up until you get a satisfactory answer. You are entitled to appeal any decision that you feel is unfair. If you have exhausted all of your appeals and you still haven’t found satisfaction, contact you state insurance commissioner. You’d be surprised how a call from the insurance commissioner can lead to results. In the meantime, there are other sources of financial aid. ACR lists several sources of Assistance . Don’t let pride stand in the way of your health!

But My Doctor’s So Nice!

Sure he is…but he is also a professional and should be able to recognize his limitations. According to a study published by the Journal of American Medical Association (JAMA), 1355 patients with RA were followed for 3.9 years. 45%-60% were treated by a family practitioner, while rheumatologists treated the remaining patients. Researchers found that the quality of care for those patients without rheumatologists was insufficient. However, the family practitioners were superior to the rheumatologists in providing basic health maintenance.

In other words, this isn’t about firing your doctor. Ideally, your rheumatologist and your PCP should work as a team, consulting each other whenever there is a question or a problem. Nowadays, most PCPs will automatically refer any patient with an arthritic condition to a rheumatologist, anyway (assuming availability). And if he/she is offended by the suggestion, you not only need a rheumatologist, you need a new PCP…someone with a sounder self-esteem.