JointHealth™ insight   October/November 2004

This issue of JointHealth™ monthly focuses on topics related to rheumatoid arthritis (RA), although some of it also applies to other forms of arthritis. Please let us know what you think and offer ideas for future issues by writing to Arthritis Consumer Experts or by sending us an email to We sincerely appreciate your help in making JointHealth™ as meaningful as possible to Canadians with arthritis.

Advocacy and Treatment

Rheumatoid arthritis should be considered a medical emergency

The research is becoming clearer: People with rheumatoid arthritis (RA) need a timely and accurate diagnosis to get the best treatment early in order to maintain their health, mobility and quality of life.

In last month's issue of JointHealth™, we reported that there is now a strong body of research suggesting that early treatment of RA results in better long-term health "outcomes" for persons with the disease - such as control of inflammation to prevent or minimize joint damage. But what does "timely treatment" look like? How is it "defined"?

Based on the research literature and the recommendations of the Canadian Rheumatology Association, the following is critical to getting the person with new RA timely treatment:
  • The family doctor must be able to recognize the hallmark signs and symptoms of RA - pain, swelling and stiffness in the joints, and fatigue
  • The family doctor must promptly refer the person with the above signs and symptoms to a rheumatologist
  • The family doctor's referral letter must highlight the reason for the referral - suspected diagnosis, list of signs and symptoms, how long the symptoms have been present, blood test results, and copies of X-ray reports and reports of any other diagnostic tests
  • The rheumatologist must try to get the person with new RA into their office within weeks.
Once a diagnosis is established and medication started, the next step is education and a plan to win against the disease. There are programs in Canada where a team of healthcare professionals provide support and education for people recently diagnosed with RA. An example is The Arthritis Program (TAP) in Newmarket, Ontario. Teams of seven professionals (that includes a pharmacist, physical and occupational therapists, dietitian, rehabilitation assistant, kinesiologist and rheumatologist) provide three weeks of treatment, education and specialized and focused therapy. For more information, contact Southlake Regional Health Centre at 905 895 4521 or at

As well as establishing a treatment plan with a health care team, here is a list of things a person with newly diagnosed RA can do for them self to get started on an effective treatment plan:
  • Learn about RA and what a good treatment plan consists of - education, support, medication, exercise, are just a few of the components
  • Develop a support system made up of family and friends and educate them about RA and what a good treatment plan consists of
  • Learn to work with the rheumatologist to reach agreement on the diagnosis and develop an early, aggressive treatment plan - ideally within the first three months of diagnosis
  • Access physiotherapy and/or occupational therapy services, as needed
  • Use evidence-based complimentary therapies like massage and nutritional supplements, as needed. Remember to discuss these therapies with your doctor and only try one therapy at a time in order to know what works and what does not.
What else can you do to access timely RA treatment for yourself or your family member?

The above ideas are key to getting good and timely treatment. However, it may take some doing on your part to get these things, such as clearly expressing your needs to your health care team, or, by writing letters to your local government representative.

For example, if you are facing a long wait list for joint replacement surgery or have having trouble getting reimbursement coverage for your RA medications (such as biologic response modifiers and others), it is important to write to your MLA or MPP to tell them about how these challenges are affecting you or your family member. The bottom line is this: You, your family and friends can make a difference in the kind and quality of health care you receive, but it takes being an active participant in "the system" to get it. And remember, ACE and other arthritis groups across Canada are there to help you.

To learn more about how to make your voice heard by the health care system and the government, visit the ACE web site at and click on "Arthritis and the Health Care System". There, you will find helpful letter writing tips, sample letters, and information on how to link up with arthritis advocacy and self-help groups in Canada.


Physiotherapy for rheumatoid arthritis

Physiotherapy is used as part of a treatment plan to deal with the physical symptoms of rheumatoid arthritis (RA). Physiotherapists are trained to diagnose problems with body movement and to help the person with RA develop a plan, with achievable goals, aimed at gaining back physical mobility and well-being. Regular visits can help maintain joint function and prevent joint damage.

The first step of a physiotherapist's work is to do a physical assessment, including:
  • A functional assessment (things like walking and other daily activities, including posture)
  • Evaluation of muscle strength and joint range of motion
  • Evaluation of pain and swelling.
Your first step is finding the right physiotherapist, preferably one with training specific to arthritis. Here are a few tips on how to find a physiotherapist:
  • Ask your doctor for a referral to a physiotherapist trained in arthritis care
  • Contact The Arthritis Society office nearest you;
  • Look in the yellow pages under physiotherapists and look for "arthritis" listed in the ads.
Note: Insurance coverage for physiotherapy treatment varies both by province and the many private extended health plans.

Following is a brief description on the types of physiotherapy and rehabilitative treatment used in rheumatoid arthritis.

Heat and cold therapies are probably the most common techniques used for people with arthritis. If a person with RA is having a flare, cold is generally applied, while heat used at other times, particularly before exercise. Physiotherapists use various techniques from traditional hot and cold packs to infrared radiation or paraffin (for heat) and nitrogen spray or cryotherapy (for cold).

Electrical stimulation is used to provide temporary relief for joint pain. The most common method is called TENS (transcutaneous electrical nerve stimulation).

Water therapy (hydrotherapy) and water-based exercise have a long history in helping people with rheumatism relax. Body weight is reduced by 50% to 90% in water, making moving joints and exercising easier. At the same time, the body relaxes in water, bringing a sense of well-being.

Therapeutic Exercise plays an important role in helping people manage their RA. Maintaining muscle strength is important, not only for general function, but also to help protect and stabilize joints. A physiotherapist can develop a customized exercise program, taking into consideration the extent of the disease, a person's age and current level of fitness.

Range of Motion Exercises can be learned with a physiotherapist and continued at home on a daily basis. Note any pain during exercise should be reported to your physiotherapist immediately.

Strengthening Exercises are very important for people with arthritis. Work with a physiotherapist to set reasonable and achievable goals. There are two main types of strengthening exercises: Isometric and isotonic.

    Isometric Exercise involves contracting a muscle without any movement of joints. These exercises can be done daily, any place, and any time. The benefits of this type of exercise include:
    • Maintaining muscle size and improving muscle tone
    • Developing muscle strength needed for weight-bearing activities
    • Developing muscle strength in preparation for joint surgery or replacement.

    Isotonic exercise involves both muscle resistance and joint movement. This type of exercise increases endurance, improves blood flow, promotes strong bones and cartilage as well as maintains or improves muscle strength. Because the joints are involved, extra care is needed to perform these exercises correctly and to note how the body responds. Ask your physiotherapist to advise you on how often you should do the exercises and the number of repetitions of each exercise.

Assistive devices and adaptive equipment can help maintain stability, mobility and reduce the risk of falling. It may be difficult to think about using a cane, but this simple device can reduce pressure on the weight bearing joints as well as increase stability and maintain mobility. For more ideas on ways to make the home more "arthritis-friendly", please refer to the article on "Living Independently with Arthritis" in the September 2004 issue of JointHealth™ monthly.


TNF inhibitors and bone and joint surgery in rheumatoid arthritis

There are risks with every type of surgery, however, one of the most common is the risk of infection after surgery. People with rheumatoid arthritis (RA) are often at greater risk because their immune systems are weakened by the disease-modifying medications they are taking.

Because they are relatively new in the treatment of RA, it is not known what effect TNF inhibitors (a type of biologic response modifier), such as adalimumab (Humira®), etanercept (Enbrel®), and infliximab (Remicade®) have on the people who are on them and undergoing orthopaedic surgery.

A recent study conducted by researchers at Johns Hopkins University and presented at the American College of Rheumatology scientific meeting in October 2004, suggests that there is an increased risk of infection in the first 30 days following bone or joint surgery in those people on TNF inhibitors.

In the study, 10 out of 91 participants developed a serious infection within 30 days after surgery. Of the 10, 7 of the 35 (20%) that received TNF inhibitors before their surgery compared to 3 of the 56 (5%) that did not receive TNF inhibitors got an infection. This is a significant finding and one that warrants further study, as physicians and patients need more than one study to base their medical decisions on.

Two other very important questions the Johns Hopkins University research team intends to investigate are whether stopping TNF inhibitors before surgery will reduce the risk of infection after surgery and when is it safe to restart them after surgery.

In the meantime, for people with RA and on TNF inhibitors who need to have bone and joint surgery, so the researchers at Johns Hopkins University suggest the following:
  • adalimumab (Humira®) - stop one month before surgery
  • etanercept (Enbrel®) - stop two weeks before surgery
  • infliximab (Remicade®) - stop eight weeks before surgery.
For all TNF inhibitors, the researchers recommend restarting no sooner than two weeks following surgery, however, some Canadian rheumatologists recommend different restart times for each TNF inhibitor.

Another unknown is how RA disease flares affect a joint undergoing surgery. It may be that by stopping the TNF inhibitor, the joint may become inflamed and may worsen the post-surgery recovery. Also, if a medication was used to treat the disease flare such as glucocorticoids (prednisone), there may be problems with infection and post-surgery recovery.

Finally, what is known is that studies like the one reviewed in this article are important to both people with RA undergoing surgery and on TNF inhibitors and their health care team. The knowledge gained from a study like this is critical to developing "best practice" guidelines and helps physicians and patients use breakthrough medications like TNF inhibitors as safely as possible.


ACE Consumer/Patient Survey on NSAID Use in Canada

The research literature shows that patient-physician communication is key in making informed health care decisions, especially around medication usage. To help ACE understand what you think and know about your NSAID medication, we invite you to take the ACE Consumer/Patient Survey on NSAID Use in Canada.

This is an anonymous survey. No personal identification can be made based on the information you provide.

Over the past 12 months, ACE received unrestricted grants-in-aid from: Abbott Laboratories Ltd., Amgen Canada / Wyeth Pharmaceuticals, Bristol-Myers Squibb Canada, GlaxoSmithKline, Hoffman-La Roche Canada Ltd., Merck Frosst Canada, Pfizer Canada and Schering-Plough Canada, UCB Pharma Canada Inc. ACE also receives unsolicited donations from its community members (people with arthritis) across Canada.

ACE thanks these private and public organizations and individuals.