RheumaGuide ENG

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understanding
age
Rheumatism
• Early detection
• Current therapeutic options
• Recommended by sufferers and support groups
Understanding Rheuma-
tism PAGE
EDITORIAL 5, 7
LIVING WITH RHEUMATISM10
INFLAMMATORY RHEUMATIC
ILLNESSES 20
HEUMATOID ARTHRITIS
R
(CHRONIC POLYARTHRITIS) 21
JUVENILE IDIOPATHIC ARTHRITIS (JIA) 27
MORBUS BECHTEREW 32
PSORIATIC ARTHRITIS 40
GOUT 45
MEDICINAL THERAPY 48
NON-MEDICINAL THERAPY 56
GENDER-SPECIFIC DIFFERENCES 62
REGULAR MONITORING AND

THERAPEUTIC ADJUSTMENTS 63
2 Rheuma verstehen 2014

CONTENTS
PAGE
DEGENERATIVE RHEUMATISM64
ARTHROSIS 65
OSTEOPEROSIS 72
SOFT-TISSUE RHEUMATISM78
FIBROMYALGIA 79
POLYMYALGIA RHEUMATICA (PMR) 82
AUTOIMMUNE ILLNESSES86
SYSTEMIC LUPUS ERYTHEMATOSUS 87
PAIN: CAUSES & TREATMENTS94
SUPPORT FROM YOUR PHARMACY102
PHYSICAL ACTIVITY & SPORTS110
SELF-TESTS113
SELF-HELP GROUPS114
CONTACTS:
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„Understand rheumatism“ All text in has been researched to the best of our knowledge. Errors are excepted. Despite careful scrutiny, Publisher and media owner not
responsible for typographical and substantive errors. For the sake of readability, often only the masculine form of the name of persons (e.g. the patient) is used, respectively,
but that both the female and the male form meant. No part of this publication may be reproduced in any form (photocopy, microfilm or any other process) without the written
permission of the publisher or electronically stored, processed, copied, used or distributed.
Rheuma verstehen 2014 3

CONTRIBUTORS
SCIENTIFIC ADVISORS FOR THIS EDITION:

Prim. Dr. Gabriele Eberl, MBA Univ.-Prof. Dr. Winfried Graninger
Ärztliche Direktorin des Klinikums Malcherhof Baden, Leiter der Klinischen Abteilung für Rheumatologie,
Baden bei Wien LKH-Universitätsklinikum Graz
Prim. Univ.-Prof. Dr. Ludwig Erlacher Prim. Doz. Dr. Günter Höfle
Leiter der 2. Medizinischen Abteilung, SMZ-Süd, Wien Leiter der Abteilung für Innere Medizin,
LKH Hohenems
CONTRIBUTORS TO THIS EDITION:

Dr. Georg Rüdiger Barisani Prim. Univ.-Doz. Dr. Burkhard Leeb
Facharzt für Unfallchirurgie und Sporttraumatologie Vorstand der 2. Medizinischen Abteilung,
Leiter der Abteilung für Unfallchirurgie, Niederösterreichisches Kompetenzzentrum für
Sanatorium Hera, Wien Rheumatologie, Landesklinikum Stockerau
Univ.-Prof. Dr. Hans Peter Dimai Prim. Dr. Monika Mustak-Blagusz

Präsident der Österreichischen Gesellschaft für Knochen und Fachärztin für Innere Medizin und Rheumatologie
Mineralstoffwechsel SKA-RZ Gröbming, Pensionsversicherungsanstalt
Vizerektor für Studium und Lehre
Prim. Univ.-Prof. Dr. Michael Quittan, MSc
Universitätsklinik für Innere Medizin,
Vorstand des Instituts für Physikalische Medizin und
Klinische Abteilung für Endokrinologie und Stoffwechsel,
Rehabilitation, SMZ-Süd und SMZ-Floridsdorf, Wien
Medizinische Universität Graz
OÄ Dr. Andrea Studnicka-Benke
Univ.-Doz. Dr. Johann Gruber
Fachärztin für Innere Medizin und Rheumatologie
Universitätsklinik für Innere Medizin VI,
Universitätsklinik für Innere Medizin III, Salzburg
Rheumatologie, Innsbruck
Prim. Univ.-Prof. Dr. Franz Trautinger
Prim. Univ.-Prof. Dr. Burkhard Gustorff, DEAA Universitätsklinik für Haut- und Geschlechtskrankheiten,
Vorstand der Abteilungen für Anästhesie, Intensiv- und Karl-Landsteiner-Privatuniversität für Gesundheitswissen-
Schmerzmedizin schaften, St. Pölten
Wilhelminenspital der Stadt Wien & Kaiserin-Elisabeth-Spital,
Wien OÄ Dr. Maria-Christina Walter
2. Medizinische Abteilung, SMZ-Süd, Wien
Prim. Univ.-Doz. Dr. Christian Huemer
Leiter der Abteilung für Kinder- und Jugendheilkunde,
LKH Bregenz
We thank all contributors and scientific consultants

for their support and effort.

EDITORIAL
Univ.-Prof. Dr. Winfried Graninger,

Graz
Prim. Univ.-Prof. Dr. Ludwig Erlacher,

Wien
Dear Readers,
You are now holding the 5th revised and updated edition of the “Understanding Rheuma-
tism“ patient advisor in your hands.
The great amount of feedback from sufferers highlights the need for understandable
information for patients. We are convinced that better knowledge of rheumatic illnesses
is of great importance, and that sufferers profit from knowing more about their illness.
Modern Rheumatology places a common goal, a common basis for decision-making by
Rheumatologists and patients, at the center of treatment – and achieving this, “knowl-
edge“ is a key requirement.
We have therefore joined together with medical journalists and experts to create this
comprehensive collection of articles. Here you will find a wealth of clearly-structured,
understandable information. You will find numerous answers to common questions,
subdivided according to the individual illnesses that are important to you.
In closing, we would like to point out that the pages 103 through 106, as well as the
advertisements in this edition, do not represent content disputed among scientists.
This compendium is a collection of many individual expert opinions. It can therefore
not be considered a basis for matters of medical controversy. Mainly, it is intended to
provide you with assistance – even for consultations with your doctor – as it conveys
important basic knowledge concerning the various Rheumatoid illnesses.
We wish you an enjoyable reading experience!
Univ.-Prof. Dr. Winfried Graninger Prim. Univ.-Prof. Dr. Ludwig Erlacher

ADVERTISEMENTS
Paid advertising in this edition:
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MOBIFLEX116

EDITORIAL
Mag. pharm. Dr. Christian Müller-Uri,

Vice President of the Austrian
Chamber of Pharmacists
Dear readers,
Informative guides like this one from the “Understanding Health“ series enjoy great
popularity among pharmacy customers. The demand is so great that some editions
have already sold out, such as “Understanding Rheumatism,” the 4th Edition of which
was published in 2012. Therefore, due to the obvious need by those suffering from
rheumatism, this 5th revised edition is now available.
Chronically ill persons often seek competent, reliable answers to their questions.
Health guides such as “Understanding Rheumatism” provide valuable information.
Our scientific advisors, with the support of whom all articles in this edition have
been written, ensure that the content is up-to-date.
The most important rheumatic illnesses, such as Rheumatoid Arthritis, Psoriatic Ar-
thritis, Morbus Bechterew, Arthrosis and Osteoporosis have been illustrated here in
a clear, comprehensive manner. In addition to therapeutic options, tips for patients
for dealing with their illness can be found in this guide. The dedicated “Help from
the Pharmacy“ chapter offers an overview of the support and products provided by
pharmaceutical professionals.
I hope you find this information helpful!
Mag. pharm. Dr. Christian Müller-Uri,

Living with Rheumatism
Real-Life Success:
A Sufferer Reports
Interview with Hans Spitzauer, five-time
Olympic medalist and European sailing
champion.
Editor: Mr. Spitzauer, you are one of around

two million Austrians diagnosed with Rheu-
matism. How and when did this occur?
Spitzauer: It all started with back pain in
September, 2010. Two weeks of injections Hans Spitzauer (right): full speed ahead.
and physical therapy later, I stepped out of
the car and due to the pain I couldn‘t even
walk. I also noticed that my knuckles were What was your highest priority following the
swollen, and my wrist was sensitive to diagnosis?
pressure. I was not able to train anymore The quick, confident action taken by th ex-
because of the great pain I was experienc- perts was key. As soon as the diagnosis
ing! My homeopathic doctor recommend- was in, I was in the hospital for 10 days to
ed that I have my blood tested, and thank- get control of my pain and get the medi-
fully he recognized right away that this was cation schedule in order. I learned how
likely something serious. So, he referred important early, proper treatment and
me to a Rheumatologist. consistent therapy are for success, and
how this improves your chances for re-
What was going through your head in the covery. The pain quickly resided, and af-
minutes following the diagnosis? ter a while I was again able to begin train-
The diagnosis was a shock. I thought ing.
Rheumatism was an “old person‘s illness“
– so why was it affecting me? Then my Is there anything you would like to pass on
Rheumatologist gave me the “Rheuma- to other sufferers?
tism Reader“ (Editor‘s note: “Understand- Yes. If you ever experience unusual pain,
ing Rheumatism,” 2nd Edition). It was go to a doctor! Get multiple opinions if
very helpful! I found that it was easy to necessary. Don‘t suffer unnecessarily – it
read and this is important since I had won‘t go away on its own. It is a shock
never had anything to do with Rheuma- for anyone to get this diagnosis, but if
tism before. Slowly but surely I began to you work with it and do the proper ther-
gain confidence. I didn‘t want to surren- apy, you can have a happy, normal life
der - I wanted to win. again.

LIVING WITH
RHEUMATISM
The various rheumatic illnesses are best controlled
with early detection and maintaining the right therapy.
What does “Rheumatism“ actually addition to the pain, the illness also
mean? causes massive psychological pressure
The term “Rheumatism“ can be translat- for the involved parties.
ed as “pain in the musculoskelatal sys-
tem.“ This term applies to all longer- Isn‘t Rheumatism a problem experi-
term functional disturbances in the enced only by older people?
musculoskelatal system (this includes No. Rheumatism is not necessarily linked
bones, joints and muscles). Rheumatism to advancing age. The typical patient that
– otherwise known as the “illness with suffers from chronic inflammatory
many faces“ – therefore serves as ge- rheumatic systemic disease (e.g. Rheu-
neric term for over 400 illnesses, behind matoid Arthritis) is 40 years young and
which lies a seemingly endless multi- female. Patients who suffer from Fibro-
tude of afflictions and causes. myalgia are only 35 years old on average.
The first symptoms of Morbus
Do I have Rheumatism – and will it Bechterew, another inflammatory rheu-
heal by itself? matoid illness, appear around the 23rd
Every third person is, in the course of his year of age. Arthrosis is not necessarily a
or her life, affected by rheumatic ail- sign of old age.
ments. Early detection, in particular
early diagnosis, is especially important. What illnesses are considered
Unfortunately, many sufferers realize ”Rheumatism”?
too late that the possibility exists that A classification of rheumatic illnesses
they could be ill with Rheumatism. can be carried out respective to the rheu-
This, however, is valuable lost time for matic disorder, according to the causes:
the health of the joints. Therefore, as
soon as the first warning signs appear 1. Inflammatory Rheumatism: Inflam-
(joint pain and swelling, stiffness in the mable rheumatic joint affliction (e.g.
mornings, etc.) then go see a doctor Rheumatoid Arthritis, Juvenile Idio-
right away! pathic Arthritis, Psoriatic Arthritis).
What applies to all types of Rheuma- 2. Degenerative Rheumatism: Erosive
tism is the fact that those who have fall- joint and spinal changes (e.g. Arthro-
en ill to Rheumatism once in thier lives sis)
often needs long-term therapy. If not 3. Soft-Tissue Rheumatism: Extra-artic-
properly treated, inflammatory Rheuma- ular Rheumatism (e.g. Fibromyalgia),
tism progresses in any case, leading to as well as abrasion and overloading of
impairment of the musculoskeletal sys- tendons or bursa in the case of local
tem and causes irreversible joint damage. pain in only one joint (e.g. calcific ten-
If not given enough attention, debilita- donitis)
tion, disability and, in the worst cases, 4. Joint diseases caused by metabolic is-
early retirement can be the results. In sues (e.g. Gout)

In the case of inflammatory rheuma- Soft-Tissue Rheumatism is character-

tism, various joints of the body suffer ised by local afflictions of the tendons,
from recurring or constant (chronic) in- synovial sheath, muscles, ligaments and
flammation of a joint (Arthritis) or mul- bursa. These are best handled by an or-
tiple joints (Polyarthritis). The reason is thopedic surgeon. A special type is Fi-
an overflowing reaction by the im- bromyalgia (chronic, widely-distributed
mune system which attacks its own pain).
body...therefore the term Autoimmune About 5% of the population suffers
Disease. from Fibromyalgia.
Between 70,000 and 80,000 people in
Austria suffer from Rheumatoid Arthri- Gout is one of the afflictions caused by
tis. problematic metabolism; namely, an
accumulation of uric acid crystals in the
In the case of Degenerative Rheuma- joints.
tism, the joint cartilage can wear down
to the point that the bones actually What are the initial symptoms when it
grate on one another. Loose pieces of comes to Rheumatism?
cartilage can irritate the joint mucous The discomfort is often described by pa-
membrane, leading to severe pain. tients as distributed and difficult to lo-
Around 1.3 million people in Austria cate. Most people assume they have sim-
suffer from Arthrosis. ply slept uncomfortably or overworked
their body. As sometimes becomes ap-
parent after months of pain, these were
merely the precursors of a rheumatic ill-
ness.
Important note: Especially when it
comes to Rheumatic illnesses, the earlier
it is diagnosed and a suitable therapy can
be started, the better are the chances for
successful therapy! This means perma-
nent damage can be avoided.
What role does the immune system

play regarding Rheumatism?
Our immune system is responsible for ef-
fectively deactivating impurities that have
forced their way into our bodies. In the
case of inflammatory rheumatoid illness-
es, however, the immune system is dys-
Joint pain is typical for inflammatory Rheumatism. functional. It is no longer able to tell the

difference between foreign and innate sub-

stances and tissues, and the body attacks Possible First Symptoms
its own structures such as the synovium in
the case of Rheumatoid Arthritis. The in- 1. J oint pain and swelling for no appa-
flammatory response runs its course, the rent reason, sweating at night, fatigue,
afflicted joint swells and sometimes be- morning stiffness; fingers and toes are
comes warm, and affects the entire body. usually affected first, then the large
This is what makes it an inflammatory- joints; often, symmetrical swelling of the
rheumatic systemic illness. same joints on both sides of the body:
The changes to the joint during Arthro- A chronic inflammatory rheumatic illness
sis are prodominantly not inflammatory, is suspected.
as the immune system is not involved.
2. P ains that occur at the beginning of bo-
What causes inflammatory dily activity, then fade after a short time
rheumatism? (startup pains) as well as a feeling of
A distinct trigger for the aggressive reac- tension in the joints, in particular during
tion of the immune system in inflammato- changes in weather to wet-cold periods:
ry-rheumatic illnesses has not yet been In this case, a degenerative illness can
identified. In some cases, however, familial be expected.
and gender-related tendencies can be iden-
3. P ain in specifiic muscles, tendons and
joints; the pain attacks can also be felt
in one or another bodily region: this
is most likely soft-tissue (travelling)
Another symptom of Rheumatism.
Rheumatism is
fatigue. 4. P ain, pressure sensitivity and joint
swelling overnight; sometimes following
intensive alcohol consumption: Gout.
tified. The influence of genetics has been

proven, however this does not mean that a
corresponding rheumatic illness is inherit-
ed. Children of inflammatory Rheumatism
sufferers show only a very small increase
in probability to develop inflammatory
rheumatic illnesses (genetic pre-disposi-
tion; risk of Rheumatoid Arthritis rises
from 0,001 to 0,002).

Can another inflammation be the testine) is responsible as the trigger for a

cause of Arthritis? joint infection. In the process, in the af-
In principle, yes, however a clear distinc- fected joints themselves no pathogens
tion must be made here: In the case of could be detected; however, they could
bacterial arthritis, for example, an infec- be in a urine or stool sample.
tion can evoke a bacterial supperation –
detectable in the joint fluid. This acute What causes Degenerative Rheuma-
illness can usually be cleaned out with tism?
antibiotics and joint flushing. It can be The causes of degenerative illnesses can
distinguished from the reactive arthritis, be malposition, overloading of the joints
by which an infection of other organs due to occupation, excess weight or com-
(urinary tract, respiratory passages, in- petitive sports.
Answer the “WH“ Question before seeing a doctor.

• When – at what time of day, in what kind of weather does pain occur?
• Where – in what small/large joints does the pain occur?
• How – is swelling apparent - warmth, morning stiffness, etc.?
WANN
WO
WIE

What is an anamnesis, and what cal history on suspicion of Rheumatic

purpose does it serve? illness, and send the patient to laborato-
An anamnesis is a person‘s medical histo- ries to have x-rays and blood tests done.
ry and it can provide clues for proper iden- If the blood tests and x-rays confirm
tification of illness and diagnosis. It makes suspicion, then the patient should be re-
sense that the patient has already answered ferred to a Rheumatologist so that phar-
the first so-called “WH“ question before maceutical therapy can be started im-
the first visit to the doctor (see box). mediately. If the laboratory results are
too ambiguous to provide the basis for a
Who do I go to if I have joint pain? clear decision (which happens about
The general practitioner or family doctor is 80% of the time in the early stages) but
the first point of contact, and who should joint pain persists, then a more precise
properly guide patients. If test results show analysis which can detect the inflamma-
possible rheumatic illness, then the patient tion, such as MRI using contrast medi-
should be referred to the proper specialist, um, or high-definition joint ultrasound,
in this case a Rheumatologist. should be carried out.
Orthopedists are medical specialists
who, on the one hand, perform surgical What is “modern” rheumatic therapy?
procedures, and on the other hand, treat The key element in this therapy is the
pain using injections and manual therapy understanding between doctor and pa-
(so-called conservative orthopedics), and tient concerning the targets of the thera-
also correct malposition. Orthopedic spe- py. The patient must feel well understood
cialists might have additional specialisa- by the doctor taking care of him/her. The
tion in Rheumatology. therapeutic concept should be properly
A Rheumatologist is a specialist doctor tailored, chemically synthetic and bio-
for internal medicine with 3 years of ad- logically produced medicines and treat-
ditional training in the areas of Rheuma- ments are combined together. The selec-
tology and Immunology. He has special tion of medication essentially has to do
skills in diagnosis and therapy of patients with the cause and the history of the
with inflammatory and degenerative skel- rheumatic illness.
etal, soft-tissue and autoimmune illness- In a first step, it is naturally also impor-
es. Rheumatologists are trained to carry tant to get the pain under control. At
out or order targeted physical, laboratory the same time, these days the progres-
and radiological examinations. Based on sion of the illness can be slowed, and
the results, they present their findings to sometimes even stopped altogether.
the patient and discuss suitable forms of The goal of timely, proper therapy is to
treatment and activities with the patient. prevent damage to the joint and to
preserve functionality. If treatment is
How should the diagnosis proceed? not provided, or inadequately, for the
The first place to go is to the general patient this means a life of pain and
practitioner, who will record the medi- progressive bodily disability.

What role does the mind play to no illness activity, and following pri-
throughout the course of the illness? or consultation with a doctor. Indepen-
For sufferers, the illness also brings about dent of the exact rheumatic illness di-
a great deal of mental stress, since it has agnosis, an increase in the mother‘s
to do with a chronic – lifelong – illness. illness activity means a minimally-in-
Much self-discipline is often required for creased risk of miscarriage, premature
the years of pharmaceutical therapy. Pain birth and impaired growth of the child.
and stress management also play an im-
portant role. Psychological help, such as Does illness activity change during or
stress training, autogenous training and after birth?
behavior therapy, can have positive ef- The prognosis for the mother depends on
fects on the course of the disease. the exact diagnosis: In the case of Rheu-
matoid arthritis and Morbus Bechterew,
Why are so many people with Rheu- an improvement in illness activity dur-
matism not in therapy? ing the pregnancy is to be expected; how-
The patient care in Austria, with suitable ever, in about a third of patients, illness
medication, physiotherapy and other sup- activity could actually increase. The re-
port is anywhere betwen very good and duced illness activity is traced to the
excellent. The problem lies elsewhere: ev- changed immune situation during preg-
ery second sufferer of Rheumatism has nancy...in other words, how a “foreign
never been to see a doctor, and often only body“ is tolerated. In the case of collage-
suspect a rheumatic condition very late. nosis, such as Systemic Lupus Erythema-
Consequently, the doctor can‘t even refer tosus, a worsening can be expected, espe-
the patient to a laboratory examination or cially if the kidneys are involved.
Rheumatologist. Therefore, cooperation with organ spe-
cialists, such as for Nephrology (special-
Can children also become ill with ists for kidney, hemodialysis and organ
Rheumatism? transplantation), D ermatology (skin) or
Yes. This form of Rheumatism is called Neurology (chronic neuritis).
“Juvenile idiopathische Arthritis” (JIA).
It is an autoimmune illness and can What should an expectant mother
even affect newborns. The reasons why look out for?
the immune system fails to regulate it- In addition to the usual pregnancy pre-
self have not all been discovered at this cautions, closely-monitored rheumato-
point in time. logical examinations should be carried
out. It makes good sense for involved
Is it not advisable to carry out a preg- doctors, such as rheumatologists, gyn-
nancy with Rheumatism? ocologists and pediatricians, to discuss
As a matter or principle, a pregnancy is among themselves the best possible
always possible. However, it should re- course of action for the pregnant pa-
ally only be planned in phases of little tient.

What effect does a pregnancy have This should be discussed during prepara-
on taking medicine? tion in order to more quickly begin proper
The package insert for almost all medi- therapy.
cations contains the following advice:
“Do not take if pregnant.” This refers to Will my child also have a tendency to
the fact that no medication has been develop Rheumatism?
tested to the point of being able to be The genetic, hereditary tendency to devel-
called “harmless“ if taken during pre- op Rheumatism does exist. However, this
gancy. Experience, however, shows is only very slightly responsible for the ac-
that medication - even those for which tual breakout of the illness, as has been
a warning is printed on the package in- shown by studies on identical twins. Cur-
sert - can certainly be taken during preg- rently, the only known preventative mea-
nancy. In any case, before taking any sure for every type of rheumatic illness is
medication, it is necessary to consult to stop smoking!
with a medical doctor! In summary, one can say: A pregnancy is
Support centers are available for human a wonderful event. For women who suffer
genetics, which deal with precisely this from a rheumatic ill-
question, and also generate expert re- ness, planning
ports covering the risks of taking medi- should be carried
cations during pregnancy and breast- out together with
feeding. the rheumatolo-
A bit of advice to male Rheumatism gist so that this
patients: The subject of medication ap- special time,
plies not only to women. Men suffering which is so im-
from rheumatic illness with a desire for a portant for
child should not simply stop taking their both mother
medication, but rather discuss this sub- and child, can
ject with their doctor. also take its
course in rela-
Can complications arise during preg- tive security.
nancy?
Yes, and for this reason, regular consulta-
tion with your doctor is so important! If
problems begin to emerge, then monotir-
ing at a high-risk clinic is recommended.
Birth should be carried out in a depart-
ment with an adjacent neonatol care unit
(premature birth station). In general,
pregnancy and birth occur without any
problems. However, often enough, imme-
diately following birth a surge can occur.
Overview Symptoms
1. Chronic Inflammatory Illnesses
a. Rheumatoid Arthritis, RA Joint pain or swelling, pressure pain, morning stiffness
(CP; Chronic Polyarthritis) for at least half an hour
b. Juvenile Idiopathic Arthritis Pain/Swelling, joint overheating, morning stiffness,

(JIA) fatigue, whining
c. M
orbus Bechterew Deep back pain, morning stiffness in the spine, chest
or back pain, hip pain in der upper groin area, spine
stiffness
d. Psoriatic Arthritis Radiant inflammation of the joints of the hands and feet,
PsA; skin psoriasis with joint illness) accompanied by skin problems, tendon inflammation
with swelling
2. Non-Inflammatory Rheumatic Illnesses

a. Arthrosis Pain at the beginning of a movement, restricted move-
(Abrasion of the joints) ment, muscle tension, joint deformation
b. Fibromyalgia Pain over large areas, from head to tow, sleep or fear
(“Soft-Tissue Rheumatism”) disorders, chronic fatigue, depression, in some cases
the feeling of swelling in the hands, feet and face,
sensitivity to sounds, light and cold.

Pharmaceutical Therapy Non-Pharmaceutical Therapy Page
NSAIDs (non-steroidal anti-inflammatory Remedial gymnastics, ergotherapy, thermo- 21

drugs), DMARDs (Disease-Modifying therapy, electrotherapy, ultrasound
Antirheumatic Drugs, such as Methotrexa-
te, Sulfasalazine, Leflunomide), Cortisone,
Biopharmaceuticals (TNF-alpha, T- cell,
Interleukin-1 and Interleukin-6 inhibitors,
B-Cell antibodies)
NSAIDs, Cortisone, DMARDs (Methotre- Physiotherapy, ergotherapy, joint-friendly 27

xate), and TNF-alpha, Interleukin-6 and sports
T-Cell inhibitors
NSAIDs, TNF-alpha Inhibitors Daily gymnastics, heat and cryo-therapy, 32

massages
, NSAIDs, Cortisone for surges, DMARDs, Physiotherapy 40

and TNF-alpha and Interleukin-12/23
inhibitors
Anti-inflammatory creams/gels, NSAIDs, Sufficient activity, joint protection, weight 65

Cortisone for acute Arthrosis (injected reduction and ergonomic, heat and cryro-
into the joints), and possibly Hyaluronan therapy, electrotherapy, aqu training, everyday
assistance (cane, sturdy shoes)
Antidepressives, analgesics, muscle- Psychological support, activity and training 79

relaxing compounds, substances against therapy
neuropathic pain

INFLAMMATORY
RHEUMATIC
ILLNESSES
Rheumatoid Arthritis is the
most common and well-known
inflammatory rheumatic illness

Rheumatoid Arthritis
RHEUMATOID ARTHRITIS
(CHRONIC POLYARTHRITIS)
What is Rheumatoid Arthritis? What happens in the body?

Rheumatoide Arthritis (RA) or Chronic Usually, the synovium (or membrane in-
Polyarthritis (CP) is a form of inflamma- side the joint) produces the synovial fluid
tory rheumatic illness. It often pro- which is responsible for reducing friction
gresses in phases, whereby inflamma- between the articular cartilage of synovial
tory swelling of the synovium (tissue joints, and nourishes the cartilage tissue.
inside the joint) and associated struc- RA occurs when the immune system
tures (e.g. bursa) are characteristic. overflows, causing the synovium to
Rheumatoid Arthritis affects three becomme inflamed. The so-called pro-
times more women than men, with a inflammatory cytokines play a key role
peak age of 40. Around 70,000 – 80,000 in this cascade of inflammation. These are
people suffer from rheumatoid arthri- proteins and semiochemicals that boost
tis. Every year, there are between 2,400 the body‘s own defences, causing or in-
and 4,800 incident cases. creasing inflammation. Some of the most
well-known pro-inflammatory cytokines
Does a trigger exist which is known to are TNF-alpha (Tumor necrosis factor al-
be responsible for RA? pha), Interleukin-1 and Interleukin-6. Un-
According to the current state of knowl- der the influence of these pro-inflamma-
edge, medical science cannot identify an tory cytokines, the production of now
individual trigger for the onset of RA. changed, inflammatory joint fluid is stim-
Given genetic disposition and due to ex- ulated. The result is painful swelling of
ternal factors, an interplay of multiple the joints and, in some cases, hematoma.
aspects leads to a defficiency in the im- Later, the synovium grows into the joint
mune system. This means that the im- like a benign tumor. Cartilage and the
mune system attacks its own body, in bone beneath are attacked and the joint
this case the joints. Studying animal becomes deformed.
models over the past several years, sci-
entists have come to the realization that How can I tell if I have RA?
retroviruses are likely involved in the on- RA differs from case to case. It can break
set of RA. However, when it comes to out all of a sudden, or stealthily show
humans, no such evidence has yet come signs of its existence via unspecific
to light in research. This means that no symptoms. The most common is the
causal treatment currently exists. classic course of development:

Rheumatoide Arthritis
• Joint pain or swelling, at first usually What happens if therapy is not

symmetrical, whereby both wrists, initiated?
knuckles and finger joints are affected, If the misdirected immune system is not
and later on larger joints. slowed down, then the destruction of the
• Swelling, overheating and pressure joint inexorably progresses within a few
pain in several joints. months and years. Inflammations partially
• Painful restriction of movement. regress after a few weeks, only to return in
• Uncharacteristic signs like loss of ap- surges to continue damaging the joint
petite, weight loss, profuse sweating, structure. And, since Rheumatoid Arthritis
increased temperature and exhaus- is a systemic illness, in the case of a more
tion. protracted illness, inflammation of inner
• Morning stiffness (for at least an hour) organs is also possible - the veins, heart,
that makes bathing and dressing diffi- kidneys, liver and lungs. The illness carries
cult; the symptoms disappear accord- per se an increased risk of infection. The
ing to illness severity and activity risk of contracting lymphatic cancer is also
throughout the course of the day. greater. Given progressive destruction of
•Years later: Occurrence of rheumatic the joints, the illness can lead to joint stiff-
knots, which are small, rough knots un- ness, deformation and even invalidity.
der the skin, often on the extensor side
of the elbow. What can cause a surge?
The opinion that psychological aspects
can often play a role is unanimous, since
stress, worry and unsolved problems can
have a bearing on the immune system.
For someone who has fallen ill to RA,
this can result in a surge. Sufferers no-
tice a surge due to an increase in joint
pain and swelling, growing fatigue and
noticeably more severe pain while mov-
ing or at rest.
Which examinations are necessary

for proper clarification?
Once again, the doctor‘s inquiry (medi-
cal history) is very important. However,
the patient‘s descriptions are usually
enough for the general practitioner
only to suspect that the problem could
be RA. To get a certain diagnosis, imag-
If you experience joint pain or swelling, see a ing and laboratory examination are
doctor immediately! available by which the doctor can con-

firm his suspicions. When the results their illness, up to 85% of RA patients
are in and suspiction has been con- show Rheumatoid factors in their
firmed, the patient should definitely blood serum. This does not provide
seek the advice of a Rheumatologist clear proof of the existence of RA, since
who can set the optimal therapeutic there are also patients with RA who
course of action. have no Rheuma factor (negative, sero-
negative). The converse argument is
What do the findings show? also false, because those persons who
Laboratory findings alone cannot pro- show this factor in their blood are not
vide proof of the existence of RA with necessarily ill with RA. Up to 20% of all
absolute certainty. However, in addition healthy elderly people exhibit higher
to the clinical findings (e.g., the patient Rheumatoid factor levels.
is experiencing pain and joint swelling), The most modern laboratory tech-
findings can often be confirmed. Fur- nique for certain diagnosis is the ACPA
thermore, they are useful for the current Test, which can prove the existence of
diagnosis because they can help to judge Anti–citrullinated protein antibodies
the activity of the illness. llike Anti-CCP or Anti-MCV antibodies.
During inflammation, blood tests often This is in fact very meaningful for the
show an increased erythrocyte sedi- existence of RA.
mentation rate and an increased C-re- If blood tests reveal no clear results,
active protein (CRP). The value of the but if clinical symptoms persist, then
ESR and the CRP, however, merely next steps should most certainly be
shows that an inflammation is present in taken to secure a clear diagnosis.
the body, but provides no evidence of
whether or not the issue is an inflamed What imaging methods are available,
joint and therefore definitely RA. and why are they important?
The changes typical for RA can be prov-
What are Rheumatoid factors? en and the condition of the joints can be
Rheumatoid factors (RF) are the body‘s made visible via x-ray. It is these joint
own defenses that bind to the body‘s proximity erosions (defects in the area of
own immunglobulins (antibodies), and the cartilage-bone junction). X-ray, how-
hence turn on their own kind. They can ever, can only reveal already-existing
be detected in the blood. The RF can destruction to the knee.
confirm the suspicion of the presence In the early stages of RA where no signs
of RA, but is on its own not proof of a are visible via x-ray, an MRI (magnetic
rheumatic illness. The Rheumatoid fac- resonance imaging) is very helpful. An
tor is a building block that is, in addi- MRI allows the early detection of joint
tion to the discomforts described by inflammation without radiation, and
patients and the results of bodily ex- before serious damage has been done
amination by the doctor, important for to the cartilate and bone. To this end, a
diagnosis. Throughout the course of magnetic contrast agent is injected.

al facts and provide confirmation of a

rheumatoid illness. The Rheumatolo-
gist is specially trained to analyze these
very individual factors like swelling,
functional restrictions, changes in tis-
sue, etc.
What is the goal of the therapy for RA?

Reduction of pain and eliminating swell-
ing clearly have priority during therapy.
Anti-inflammatory rheumatoid pain kill-
ers (NSAIDs) work very well to achieve
these goals. The Rheumatologist will try,
immediately following diagnosis, with
the help of a so-called disease-modify-
ing antirheumatic drug (DMARD) to get
control of the swelling and the mis-
guided immune system. In addition,
taking this medication for the rest of
your life is often necessary. The most
commonly-used active ingredient is
Methotrexate (MTX). The results of the
DMARD treatment are often only seen
Typical changes in the joint are visible with an MRI.
after the first two months, though not
all patients see benefits right away. As a
The advantage of a high-resolution joint general rule, 40% of sufferers see an
ultrasound is, on the one hand, the ab- improvement in regards to inflamma-
sence of exposure to radiation, and on tion. In 15% of the cases, even remis-
the other, that movements can be ob- sion (total disappearance of the illness
served. Using ultrasound, inflammations symptoms) is the result.
in the synovial tissue can be detected, Due to the delayed start of positive ef-
proven and affected areas can be precise- fects, the Rheumatologist often recom-
ly located. mends the use of the body‘s own adrenal
Ultrasound exams are especially useful hormone, Cortisone, to bridge the gap
for hand and finger joints as well as until the DMARD treatment can take ef-
forefoot, tarsal and shoulder joints. fect. One should remember that, if Cor-
tisone and an NSAID are taken at the
At what point is RA diagnosed? same time, something for the stomach
When a patient with clinical afflictions should be taken as well to reduce the risk
visits a Rheumatologist, due to special of stomach and duodenum ulcurs. Al-
training the doctor can clarify addition- though many patients initially see the

use of cortisone with some degree of age, resulting in a pain-free existence.

skepticism, the effect - especially on
pronounced joint swelling is usually so What is decisive for successful treat-
liberating that the concerned person is ment?
glad to take it for up to several weeks. Success depends on when treatment
starts: In the case of early treatment, op-
What happens if the disease-modify- timal results can already be expected
ing antirheumatic drugs are unsuc- within 12–16 weeks. The development
cessful? of the illness depends on the assistance
If the DMARD treatment does not bring of the patient, meaning consistent taking
the desired results - a hinderance of the of medicine and regular checkups. The
inflammation - then it is typical to ei- Rheumatologist will modify the treat-
ther switch to another basic therapeu- ment as long as the illness at least dis-
tic treatment or begin with another plays lower levels of activity or full re-
parallel (combination therapy). mission (disappearance of symptoms);
Another promising option is biophar- in medical circles, this approach is com-
maceuticals. These are the TNF alpha monly refered to as “Treat to Target”.
blockers (Adalimumab, Certolizumab,
Etanercept, Golimumab, Infliximab) What additional treatments are
Abatacept to restrict the activation of available for RA?
T cells, and the Interleukin-6 blocker. The muscles need to be strengthened
These are used when treatment with con- with physiotherapy and targeted reme-
ventional chemical DMARD treatment dial gymnastics. Massaging helps to im-
or a combination thereof hasn‘t been prove circulation and muscle relaxation,
successful. Biopharmaceuticals are most since patients with RA often suffer from
effective when used in combination with massive muscle tension. Apart from the
conventional DMARDs. Within only a medicinal therapy, additional types of
few weeks, it becomes clear whether or therapy, especially in pain reduction, al-
not the desired effect can be achieved ways make sense if the patient can real-
with biopharmaceuticals. If this is not ize subjective improvements in well-be-
the case, then the option exists to switch ing and quallity of life.
to another biopharmaceutical. As a matter of principle, for RA the use
If the inflammation cannot be perma- of very hot compresses or submer-
nently reduced or stopped, then the gence in hot water (over 32°C) should
Rheumatologist can take advantage of be avoided. Especially during times of
other immuno-therapeutic and also high illness activity, cryotherapy is rec-
biopharmaceutical options: Inhibition ommended when the patients realizes
of the B cells using Rituximab. a subjective benefit from it.
In the long term, a reduction in inflam- Please note: During acute levels of ill-
matory activity should be the result. This ness activity, remedial gymnastics and
in turn curtails or even stops joint dam- electrotherapy are contraindicated!

Special devices support movements that have become too difficult.
What ergonomic assistance is avail- out the affected joint (see page 56). After
able for day-to-day living? only a few weeks, the synovial tissue
This is the domain of the occupational grows back (regenerates).
therapist. When day-to-day activities,
such as holding a coffee cup, cutting
bread or buttoning a shirt become im-
Tips for better living
possible, it‘s time to start looking at as-
sistive devices available in well-stocked • Carry heavier loads by backpack for
specialty shops. Finger and arm slings even weight distribution.
can be very helpful, as can so-called but-
tonhole und swan neck splints or meta- • Avoid shock to the joints (vibrating
carpal brace. Special knives (the handle machines, joint agitation).
is bent back 90 degrees from the blade) • Do not exceed your weight limit; don‘t
and bottle openers can also offer assis- overdo it.
tance.
• Wear wrist supports when doing activities
When is an operation inevitable? involving heavy loads.
Operations are only carried out when • Pay closer attention to your posture when
other forms of therapy have not brought sitting and standing.
about the expected results. In a proce-
dure known as a Synovectomy – for pres- • Make sure to engage in fun activities to
ervation of the joint – the inflamed syno- realize happy moments.
vial membrane is removed by stripping

Juvenile idiopathic arthritis
JUVENILE IDIOPATHIC ARTHRITIS (JIA)
What is Juvenile idiopathic arthritis?

Juvenile refers to youth and children, id-
iopathic means illnesses of unknown or-
igins and arthritis refers to joint inflam-
mation.
Can Rheumatism in children disap-

pear as they grow older?
Certainly not on its own. Rheumatism in
children must be treated! Indeed, in
many cases it is possible that, with the
right therapy, the illness can be
stopped in its tracks or slowed down so
much that it‘s possible to live with it. It
is important that, during a phase of ac-
tive joint inflammation, in particular
with pharmaceutical therapy, to pre-
vent permanent joint damage as this
cannot be reversed.
How often does JIA occur?

In Austria alone there are about 140 new not the same for all children. In some
incidences per year, with a nationwide cases the joints become inflamed time
total of about 1,700 children and adoles- and time again, in other cases only sel-
cents who suffer from chronic arthritis. dom. Often, only one joint is affected.
Rheumatism is therefore found as fre- Doctors speak of JIA when the joint in-
quently in children as Diabetes mellitus. flammation lasts for at least six weeks
and the illness begins before the age of
How does JIA manifest itself? 16.
Rheumatism in children is noticeable in
various ways, and shows itself - when What are the indications?
compared with chronic arthritides in As diverse as the progression of JIA can
grown-ups - in various ways as well: be, all cases have joint swelling in com-
The number of affected joints may mon. Pain and swollen, overheated
vary, skin, ligaments and tendons may joints can be the first symptoms. Joint
also be involved in the inflammation stiffness can also be apparent in the
process. Also, the course of the illness is mornings.

swelling of entire fingers and toes be-

What other afflictions can also occur come apparent.
along with joint illness? • Enthesitis-Related Arthritis: In addi-
Impaired growth, inflammation of the tion to joint pain, ligaments and ten-
eyes or adverse affects on the stages of dons, and expecially the heel, are af-
development. fected by swelling. This form of JIA
usually begins in school age and is
What are the way in which JIA can more common in boys. The joints are
progress? usually affected asymmetrically, par-
How JIA develops and whether it be- ticularly the knee and ankle joints.
comes noticeable in older age is difficult
to predict. The progression often de- Where can I find medical help tailored
pends on the exact form of illness. to the needs of children?
Due to the distinctive characteristics of
Doctors distinguish among the follow- child rheumatic illnesses, therapy must
ing forms of JIA: be carried out by a team made up of
• Oligoarthritis: One to four joints are child rheumatologists, child physio-
affected, most commonly the knee therapists and ergotherapists, child or-
joint. The illness often does not affect thopedic specialists, child psycholo-
both sides of the body in the same way, gists and pediatric eye specialists. In
but rather asymmetrically. Eye infec- Austria there are eleven hospitals
tions are common. The illness begins whose children‘s wards have a child re-
when the child is very young. heumatology clinic. During especially
• Polyarthritis: At least five joints are af- difficult phases of the illness, inpatient
fected; most commonly the hand, finger, treatment might be necessary.
elbow, knee and ankle – usually on one
half of the body – are inflamed. How is Rheumatism detected in a
• Systemic Arthritis: In addition to the child?
joints, with this form of Rheumatism First of all, a detailed discussion with the
also organs such as the heart, lymph child rheumatologist is necessary. Some
nodes, spleen, liver, kidneys or lungs typical questions are:
are affected. It usually begins with high • Do other family members suffer from
fever and skin rashes in toddler age. rheumatoid arthritis?
• Psoriatic Arthritis: The knee joint and • When did the pain begin?
the smaller joints (hands, feet) can also • How often does pain occur?
appear together with Psoriasis. These • Has any change been noticed on the
are strongly confined, reddish areas on skin or on the eyes?
the skin covered with silvery-white
scales. Before Psoriasis appears, how- These questions serve to collect as
ever, changes in the nails and also much information as possible from the

For kids, going to the hospital is often not easy.
young patient‘s medical history and to es- avoiding lasting damage to the joints.
tablish connections with his/her current The therapy schedule differs according
affliction. In addition to the thorough ex- to patient, and is made up of a combina-
amination of the inflamed joints, another tion of pharmaceutical drugs, physio-
assessment of the illness follows using therapy, ergotherapy, psychosocial sup-
imaging procedures such as ultrasound, port and, rarely, operations.
x-ray, MRI and, rarely, CAT scan. A he-
mogram (bloodwork) is also important Which medicines are applied?
for the diagnosis. By way of the enthro- Usually, multiple kinds of pharmaceuti-
cyte sedimentation rate, the behavior of cal medicine are necessary in order to
red blood cells is observed - allowing one get control over the inflammation and
to draw conclusions concerning an infec- the pain:
tion in the body. The level of C-reactive • Non-steroidal antirheumatic drugs
proteins (CRP) – one of the proteins in are anti-inflammatory and partially re-
the blood – also rises when an infection is lieve pain.
present in the body: the higher the value, • Cortikoids inhibit the inflammation
the more active the instance of inflamma- and are administered to children and
tion. adolescents not only in tablet form or
via infusion, but also as an injection. It
How is child rheumatism treated? is carefully dosed and the duration of
The main goal of the treatment is to stop treatment is as short as possible. A sin-
the inflammation altogether, thereby gle high dose is administered only in

rare cases, such as when the inflamma- der to maintain and promote mobility, only
tion is especially strong and must be after proper instruction by a therapist.
curtailed quickly. With the help of ergotherapy, joint-
• Disease-modifying antirheumatic friendly movements are practiced which
drugs (DMARDs) are used in the case are meant to assist in day-to-day life. As-
of more severe forms of JIA. They di- sistive devices such as individually-tai-
rectly influence the process and there- lored splints, grips for pens or special
fore the progression of the illness. three wheelers can be useful. Having the
Methotrexate is one of the most com- bed at the correct sitting height eases
monly-used DMARDs. standing up, and a vertically-adjustible
• Biopharmaceuticals also directly influ- desk and an ergonomic desk chair are
ence the illness process. Biopharmaceu- also important for healthier day-to-day
ticals like Etanercept or Adalimumab living.
block the body‘s own Tumor-Necrosis- Since the bodies of children and adoles-
Factor alpha (TNF-alpha) messenger, cents are still in the growing phase, a bal-
and are then used when other medicines aced diet of fresh fruits and vegetables,
appear to have no results or have nega- milk and whole wheat products, fish and
tive side effects. Biopharmaceuticals vegetable oil are essential. Unbalanced
(e.g. Abatacept), are often combined diets are to be avoided!
with DMARDs to target and influence
the inflammation process. The Interleu- When is it time for an operation?
kin-6 inhibitor Tocilizumab is also im- If damage has already occurred to the
plemented to handle child rheumatism. musculoskeletal system, operations on
In contrast to DMARDs, the effects of rheumatically-deformed joints can help
Biopharmaceuticals are already appar- to re-establish functionality or to avoid
ent within only a few weeks. further restriction. A commonly-applied
• Pain therapy: Serious cases of JIA can invasive measure is the intra-artikular
result in severe pain. This is when, in steroid injection. This is a very effective
addition to pharmaceutical therapy, means for suppressing joint inflamma-
physical therapy can make sense. The tion by way of a one-time administra-
pharmaceutical pain therapy when ap- tion of anti-inflammatory medicine via
plied to children requires a great deal injection.
of experience in regards to proper dos-
age and tolerance. How should a family deal with such
an illness?
What supportive therapy options The first thing to do is inform everyone
exist? within the child‘s immediate circle of
Physiotherapy helps to prevent or correct family and friends - teachers, class-
malposition and stiffness of joints arising mates, playmates, etc. - about the ill-
due to protective posture. It is important to ness. Visits to the doctor and therapy
carry out exercises regularly at home in or- must be integrated into every-day life.

Apart from that, the child should main- tients themselves to get to know others
tain as normal a life as possible. It is who suffer from the same illness.
therefore important not to conceal the
illness, but rather to accept it and Is it alright if my child engages in
thereby encourage the child to make sports activities?
the best out of the situation. Don‘t al- Yes, absolutely! Sports have a positive
ways take it easy, either. Rather, be con- effect on mobility. Even if some types of
sciously aware of which hobbies or sports such as tennis or football are not
types of movements are possible de- recommended due to the severety of the
spite bodily constraints! Exchanging illness, there are alternatives which al-
experiences with other parents of afflict- low one to keep moving: swimming,
ed children via the Austrian Rheuma horseback riding, dancing, bicycling or
League or a self-help group (www. table tennis are types of sports that are
rheumaliga.at, www.rheumalis.org) can easy on the joints. Get your child to keep
be comforting and be a source of many moving, and encourage happy moments
valuable and practical tips for parents. It by engaging in fun, recreational activ-
can also be helpful to the young JIA pa- ites!
Suitable sports activities for my child

with Juvenile Idiopathic Arthritis:
...almost always:
Swimming
Attention: correct water temperature! Bicycling
...depending on severity of illness:
Careful preparation can reduce the risk

of injury.
Complementary physiotherapy is usually
Table tennis Gymnastics Skiing
advisable.

Morbus Bechterew
MORBUS BECHTEREW
Spondylitis, but also inflammation in

other joints.
What is a Spondyloarthritis?
Spondyloarthritis is an inflammation of
the vertebrae and the small joints in the
spine. In its most advanced form, it is
also referred to as Morbus Bechterew
(lat.: Spondylitis ankylosans).
Other forms of this illness are:

• Undifferentiated Spondyloarthritis
• Non-Radiographic Axial Spondyloar-
thritis
• Reactive Arthritis
•Arthritis associated with Psoriasis
Vulgrais (Arthritis psoriatica)
•Arthritis associated with chronic in-
flammatory bowel disease (Colitis ul-
cerosa or Morbus Crohn)
What happens to the body in the When is undifferentiated spondyloar-

case of Morbus Bechterew? thritis diagnosed?
Morbus Bechterew, or Ankylosing Undifferentiated Spondyloarthritis is di-
Spondylitis (AS), is a chronic inflamma- agnosed when individual symptoms of a
tory illness that causes pain in the spinal-associated illness become appar-
spine, backside and extremities. It ent, but the complete picture of an ill-
should be treated by a doctor special- ness like AS, reactive arthritis, psoriatic
izing in Rheumatology. arthritis or arthritis due to chronic in-
The spine is made up of vertebrae. flammatory bowel disease cannot be de-
When these vertebrae grow together termined. It is predominantly apparent
in a bony manner, the vertebrae lose in the spine or joints. Otherwise, the ill-
their mobility. “Ankylosierend” means: ness is examined and treated exactly like
bony fusion; “Spondylitis” means: in- AS. When the symptoms are mainly
flammation of the vertebrae. found in the spinal area, then this illness
Spondyloarthritis refers to a family of is also determined by the doctor to be
illnesses by which the result is often non-radiographic spondyloarthritis.

When it comes to undifferentiated spon-
dyloarthritis or non-radiographic spon-
dyloarthritis, additional medical con-
trols can be deemed necessary. Over
time, additional symptoms (signs of ill-
ness) can develop which make a more
precise assignment to a specific form of
spondyloarthritis possible.
What is non-radiographic axial Genetic fingerprint: A certain gene increases the

spondyloarthritis? risk of illness.
Patients with a non-radiographic axial
spondyloarthritis have an illness very
similar to AS, except that on an x-ray What symptoms occur in the case
the sacroiliac joints are without patho- of Morbus Bechterew (Ankylosing
logical findings. Some patients do, spondylitis)?
however, exhibit typical changes on an The most common symptom is pain in
MRI. the lowest part of the spine, the lumbar
spine. Additional typical symptoms re-
What is the difference between “axial” duce mobility, a feeling of stiffness in
and “peripheral”? the spine and, sometimes, in the back-
Spondyloarthritis can also be classified side.
as “axial” or “peripheral”, depending on More typical symptoms of the inflam-
whether mainly the spine or the arms/ mation of the vertebrae are: slow start,
legs – the extremities – are affected. worsening due to rest, pain in the sec-
Symptoms of axial Spondyloarthritis ond half of the night, improvement
occur mainly in the area of the spine. due to movement.
Patients with peripherer Spondyloar- In addition: Hip pain or even inflamma-
thritis suffer from symptom mainly in tion of the hip joint (Coxarthritis) with
the arms and legs. pain shooting in the groin or pain
Some of these illnesses need time to when walking; pain and restricted mo-
develop into their full-blown state, and bility in other joints (shoulders, knee,
sometimes one illness can carry over ankle); inflammation of a joint (Monar-
into the other. thritis) or a few joints (Oligoarthritis);
Enthesitis, or inflammation in the start-
Term: Spondyloarthritis: ing point of large tendons on the bones
(Enthese); mainly back and achilles
heel.
Spondyl = vertebrae; Arthros = joint; -itis General symptoms: Lethargy, malaise,
= inflammation sleep disorder, low fever, loss of weight,
increased inflammation factor rating.

Morbus Bechterew
How is the diagnosis reached?

The diagnosis is reached via a combina-
tion of symptoms, analysis and imaging
(x-ray, MRI, sometimes ultrasound). In
addition to symptoms of pain, the diag-
nosis is supported by evidence of HLA-
B27 in blood tests.
Imaging: Typical alterations are shown

in the sacroiliac joints (joints that con-
nect the vertebrae to the pelvis). These
changes are evident in late stages on
x-ray images, and in earlier stages with
magetic resonance imaging (MRI).
Other examinations: No laboratory test

exists which can neither definitively con-
firm nor exclude an AS diagnosis.
Which complications can occur?

Uveitis anterior: Apart from the joints, a
chronic inflammation of the sclera is the
primary affliction. It leads to pain in the
eyes, blurred vision and photosensitivity.
A redenning of the eyeball is apparent.
These complications should be treated An ex-ray image tells more about how far along
immediately in order to prevent perma- Morbus Bechterew is.
nent damage to the eye. If left untreated than in healthy persons. The most acute
long term, the result can be blindness. fractures affect the neck. The injury can
also be light. More than half of these
Osteoporosis: Osteoporosis is common fractures are not visible by x-ray; there-
for patients with Morbus Bechterew, fore, a CAT scan or MRI should be car-
therefore every patient should undergo a ried out. Patients with spinal marrow in-
bone density scan. juries often have only mild neurological
failures.
Vertebrae fractures and spinal marrow Important note: Every spinal injury re-
injuries: Fractures in the vertebrae and quires immobilization, medical supervi-
injury to the spinal marrow are four to sion and, possibly, an assessment in case
eleven times more common in patients of emergency.

Morbus Bechterew
Neurological problems – Cauda equina What are some additional risk factors
syndrome: Following a long period of ill- for AS?
ness with severe stiffness of the spine, the The risk of illness is higher in some fam-
result can be nerve damage in the area ilies, especially for immediate blood
under the lumbar spine. The symptoms relatives (parents, sisters, brothers, chil-
are numbness, weakness, difficulty uri- dren). AS occurs more often in men
nating and involuntary defecation. It can than in women. It is commonly diag-
also lead to erectile dysfunction and im- nosed between the ages of 20 and 30.
potence in men.
Does AS affect everyday life?
Cardiovascular disease: Rarely it in- AS can affect everyday life in the fol-
volves the aortic valve, which no longer lowing areas: getting dressed, grabbing,
closes all the way, the results being heart standing up from the chair, getting up
failure, signs of leg edema and shortness from the floor, standing straight, ascend-
of breath under stress. ing stairs, looking to the side or over the
shoulder, doing household chores. These
Lung disease: Due to a stiffening of the limitations can occur due to a lessening
joints in the chest, many patients can no of joint and spinal mobility and have ef-
longer fully extend their lungs. The re- fects on the patients and their families.
sult is a change in the function of the Sometimes it is necessary to have assis-
lungs. A special form of breathing ther- tance.
apy can also help to reach the inade-
quately-ventilated areas of the lungs, How is AS treated?
thereby reducing the risk of infection. Treatment is adapted to the specific
manifestations and the severity of the ill-
Enteritis: Some patients with AS devel- ness. The following elements can/should
op infections in their intestines, which be part of the treatment:
normally do not produce any symptoms.
Remedial gymnastics exercises:
What is HLA-B27? “Bechterew Gymnastics“ should be part
The HLA-B27 antigen is an innate char- of the treatment for all patients with AS.
acteristic of white blood cells. It does not The exercises are comprised of daily
change throughout one’s lifetime. Proof home exercises, single or group therapy
that one carries this characteristic means with a physiotherapist or even physio-
a higher chance that a Spondyloarthritis therapeutic applications such as heat/
diagnosis can be reached, but only when electricity/ultrasound/massages. The
pain is clearly present. The HLA-B27 an- home exercises should include posture
tigen can also occur in totally healthy per- training, breathing exercises, back
sons – in which case it means nothing. strength training and stretching.

Morbus Bechterew
Important safety note: Falls should be

avoided as much as possible due to the
higher risk of severe osteoporosis (loss
of bone density). Some additional, im-
portant things to keep in mind are:
• Keep alcohol consumption low.
• Be very careful when taking certain
painkillers such as opiates or muscle
relaxers (and only after consulting a
doctor).
• Contact sports like football or ice
hockey, and high-impact sports such
as parachuting, should be avoided.
• At home, the following can reduce the
danger of falling: shower and bathtub
handles, night lights, anti-slip pads,
getting rid of slippery rugs.
• A panoramic mirror can help improve
visibility for car drivers who are not
able to turn their head very well.
• To avoid malposition of the neck and
back, when sleeping, only thin pillows
should be used.
What medicine is used? Targeted physiotherapy helps reduce loads.

Non-steroidal anti-inflammatory drugs
(NSAIDs): NSAIDs are commonly used
to reduce pain and stiffness. This medi- Sulfasalazine: This medicine is a dis-
cation should be taken regularly for sev- ease-modifying antirheumatic drug
eral weeks before their full effectiveness (DMARD), taken to slow the progress of
can be appreciated. Unfortunately, they the illness. It helps if other joints are also
are sometimes not compatible with the affected, but it has no effect on the spine
body and can lead to serious side-ef- itself. It can be taken parallel to NSAIDs.
fects. Therefore, the daily highest dose
should not be exceeded and various Anti tumor necrosis factor therapy:
NSAIDs should not be taken at the same These genetically-engineered medicines
time. are available as injections or infusions.

Morbus Bechterew
Operations: Hip joints or spinal opera-

tions can sometimes be necessary. In
particular, the following operations are
very common:
• Hip joint replacement: In the case of
permanent severe pain or immobility,
sometimes a prosthesis is necessary.
• Spinal operation: The stiffening of
neck vertebrae is seldom recommend-
ed for patients with certain malposi-
tions, in order to avoid a spinal marrow
contusion.
• Posture correction operation: In cases
of severely bad posture, an operation
can be carried out to correct the curva-
ture of the spine.
What else can I do to help achieve

better improvements?
There are several things patients can do
right away to realize benefits:
• Stop smoking: Smoking promotes in-
flammation throughout the body, es-
pecially in the lungs which can al-
ready be under attack by the illness.
Therefore, it is doubly important to
Breathing exercises improve the function of the
eliminate smoke, tar and nicotine
lungs.
from the body!
• Take care to have good posture and
When taken for AS, it often helps a great take part in an exercise programme.
deal for pain and inflammation. Examples • Be sure to get enough calcium and Vita-
are: Infliximab, Etanercept, Adalimumab, min D to reduce the risk of bone densi-
Certolizumab pegol and Golimumab. ty reduction (osteoporosis). Products
that contain calcium and Vitamin D are
Glucocorticoids: A cortisone injection milk products such as milk, cheese and
in an especially swollen or painful joint yoghurt.
can produce excellent results. Treatment • Drugs for the treatment of osteoperosis
with cortisone tablets is rarely necessary can be recommended when a reduction
for AS. in bone density is already apparent.

Morbus Bechterew
1A 1B 2A
Spinal mobility exercises Strengthening the back muscles
2B 3 4
Stomach and backside exercises Stomach strengthening
Daily gymnastics least five times in comfortable cloth-

for Morbus Bechterew ing on a floor mat. It is important to
In Morbus Bechterew therapy, regular hold the tension for 5 seconds. Should
(daily), targeted gymnastics is a must. you experience pain, then stop the exer-
The targeted muscle training helps to cise and speak with your doctor about
relieve pain and maintain spinal mobil- it. When exercising please remember
ity. In this way, early spinal stiffness and to consider your existing limitation of
malposition can also be prevented. As a movement.
general rule, it makes good sense to craft
, together with an experienced therapist, 1. Spine Mobilization
an exercise plan that suits the phase that Get down on your knee and support
the illness is in. yourself with your hands shoulder-width
apart. Now, alternate: first hump your
Below are several exercises cited as back – pulling your chin to your chest
examples which you can try at home. – and then arch your back, looking up
These exercises should be repeated at and outward

Morbus Bechterew
2. S
trengthening the upper back
muscles
Lay on your stomach and fold both hands
in front of your head, with the palms of
your hands on the floor, supporting your
forehead. Now, slowly raise the elbows
and pull your head up. Hold this posi-
tion. Then, lay yourself down flat on the
mat and relax, before repeating the exer-
cise again.
3. S
trengthening the stomach and
backside muscles
Get down on all fours and raise your left
arm and right leg horizontally. In the
process, strain your stomach and back-
side muscles without leaning out with
the hip (in other words, the hip should
remain positioned over the knee). After
you have returned to all fours, repeat the 5
motion, but this time with the right arm
and left leg. Strengthening the shoulder muscles
4. Strengthening the stomach muscles

Lie on your back and angle your right included in any Morbus Bechterew
leg so that it creates a right angle. Now, therapy programme since breathing is
push the left arm against the right knee restricted due to loss of movement of
and hold it with the leg against it. No- the spine and pain. These exercises can
tice how your stomach muscles are in can be included in the gymnastics pro-
tension. Repeat this movement with the gramme and performed regularly at
other arm and leg. home – with the approval of a special-
ist, of course. The function of your lungs
5. Strengthening the shoulder muscles will be demonstrably improved, as has
Sit straight on a hard surface (edge of a been shown in studies.
chair), push the shoulders downward and Rotation exercises for the chest and
make your neck long. Now, circle the gymnastics exercises for the neck verte-
shoulders – first toward the front, then brae are also recommended by physio-
the back – and try to hold the tension. therapists.
Targeted breathing exercises are rec- Speak with your doctor; he or she will
ommended throughout, and should be refer you to a specialist.

Psoriatic Arthritis
PSORIATIC ARTHRITIS
What is Psoriatic Arthritis? What are the causes of

Psoriasis vulgaris is a chronic skin ill- Psoriatic Arthritis?
ness that shows itself by reddened, usu- In the case of Psoriasis as well as of
ally very flaky changes in the skin, that Psoriatic Arthritis, the problem is an
are either only found on certain places auto-immune illness by which the im-
(e.g. elbows, knee, scalp, nails) or some- mune system attacks its own tissue as
times also all over the entire body. If a foreign body. A precondition for the
Psoriasis appears together with joint information of the illness is a genetic dis-
flammation, then the suspicion falls to position. This means that people with
Psoriatic Arthritis (PsA). certain hereditary dispositions have a
Around 2–3% of the Austrian population tendency to develop Psoriasis and
suffers from Psoriasis, and of these, Psoriatic Arthritis, under which - either
around 10–20% are afflicted by painful on its own or due to external triggers,
joint illnesses. Men and women are af- such as with infection illnesses – the
fected equally, and the discomfort usu- result is a malfunction of the immune
ally starts between the 35th and 45th system.
year of one‘s life.

Psoriatic Arthritis
How does it manifest itself?

In many cases, years after the appear-
ance of the Psoriasis, the joints begin to
become painfully inflamed. Only about
every tenth sufferer experiences skin
problems following joint inflamma-
tion. In most cases, however, the skin
and joints become afflicted at the same
time.
Which parts of the body are mainly

affected?
Joints, bones and also ligaments are af-
fected to different degrees by the illness.
Psoriatic Arthritis is most common on
the small joints of the fingers and toes.
Important note: If Psoriatic Arthritis is
not treated early enough, as with other
rheumatic joint illnesses, this can lead to
irreparable damage of the joints!
Characteristic: swollen finger
What symptoms are typical for Psori-
atic Arthritis? are located, or the joint connection be-
• Radial inflammations of individual tween the pelvis and the sacrum, which
fingers or toes. The entire length of the are commonly affected. Sufferers often
affected body part is red, swollen and complain of pain in the gluteus.
very painful. • In contrast to rheumatoid arthritis, the
• It is very common for the middle and pattern of joint affliction in the case of
end finger joints to be affected (dacty- Psoriatic Arthritis is often symmetri-
litis). This distinguishes Psoriatic Ar- cal; that means, different joints are af-
thritis from other forms of inflamma- fected on the right or the left sides of
tory rheumatoid arthritis by which the body.
joints closer to the body are afflicted. • When the psoriasis has affected the
• Inflammation of the ligament where it toenails or fingernails, this is a clue
connects to the bone, accompanied by for the presence of Psoriatic Arthritis.
swelling and pain (frequently, for ex- For example, pits the size of needle
ample, on the heel bone where the heads can be seen on the nail, which
achilles tendon connects). can also be colored yellow (so-called
• The spine can also be affected, espe- oil stains). The nail can lift up from the
cially the lower third of the back. This toe and, sometimes, be totally de-
is where to so-called sacroiliac joints stroyed.

Psoriatic Arthritis
How does the illness progress? How can I recognize Psoriatic Arthritis
As a rule, Psoriasis as well as Psoriatic in my child?
Arthritis progresses in chronic phases. Psoriatic Arthritis in infancy is rare and
This means that phases of decline switch does not follow a uniform pattern. Re-
with phases of improvement or even free search shows that children are affected
of pain. Though the skin affliction in ev- mainly between the ages of 2 and 5 years
ery illness phase can be brought into full old. The little patients usually have to
remission, the joint inflammations lead deal with painful inflammation of the
to permanent damage, resulting in lim- finger or toe joints. The children wish to
ited movement of the affected joint. keep their weight off of the afflicted joint
and want to be carried. Older children
suffer from inflammationo of th liga-
ments and/or the spinal joints, which can
result in pain in the lumbar area. Also,
fever which appears with or without a
rash over a longer period of time, or an
inflammation of the iris can be a first in-
dication.
How does the doctor reach a diagno-

sis?
The doctor assesses the disease pattern
according to
• the pattern of joint affliction,
• the appearance of the skin,
• the progression,
• possible accompanying illnesses,
• the characteristics of the illness,
• the results of x-rays and laboratory
findings.
What is important about the findings?

In the case of Psoriatic Arthritis, it is im-
portant to differentiate the illness from
other rheumatic disease patterns such as
rheumatoid arthritis, Morbus Bechterew
or joint wear and tear (Arthrosis, Osteo-
arthritis). Skin and joints don‘t always
display the typical changes (see “What
Symptoms are typical for PsA?“) – so a

Psoriatic Arthritis
clear diagnosis is often difficult and can

often take more time. Through collabo-
ration between rheumatologists and skin
doctors, however, it is usually possible to
provide a speedy diagnosis.
What laboratory analyses are avail-

able?
Blood tests can be helpful, also if there
is no clear marker for the Psoriatic Ar-
thritis. In addition to general signs of
inflammation (erythrocyte sedimenta-
tion rate, CRP) the so-called rheumatic
factor is also ascertained, which - in re-
gards to Psoriatic Arthritis and in con-
trast to rheumatoid Arthritis - is usually
negative (e.g. unverifiable). Patients
with Psoriasis and Psoriatic Arthritis
have a higher risk of metabolic disor-
der, therefore also the analysis of blood
fats and uric acid with appropriate con-
sultation makes good sense.
Which imaging procedures help with

diagnosis? The MRI findings can substantiate suspicion of
The skeletal x-ray is an essential imag-
Psoriatic Arthritis.
ing procedure for the joints as well as the
spine, and by which asymmetrical
changes like wear and tear or prolifera- early detection of joint defects that have
tions (bony adsorptions). Ossification already appeared, and serious progres-
and calcium deposits can appear sive forms of Psoriatic Arthritis.
where ligaments are attached to bone,
for example on the hips (trochanter), How is the illness treated?
the knee cap (patella) and heel (calca- The administering of drugs to arrest in-
neus). In very advanced stages of the flammation and suppress the illness ac-
illness, severe bone malformation can tivity is the most important therapeutic
occur. measure that can be taken. Furthermore,
Occaisionally, ultrasound and magnet- physiotherapy represents an important
ic resonance imaging (MRI) are imple- additional form of therapy. It strengthens
mented for diagnostics. The MRI is an muscles, relieves the joints and helps
especially valuable examination for the sufferers to learn the right movement

Psoriatic Arthritis
patterns. Only very infrequently is surgi- substances are currently in development.

cal intervention absolutely necessary. Biopharmaceuticals are likewise suit-
able for the treatment of skin and other
What drugs are available? joint ailments and, as with the older
Pharmaceutical medication from the medications mentioned above, for
non-steroidal anti-inflammatory drug long-term therapy as well. Biopharma-
(NSAID) substance group effectively ceuticals are then used when Metho-
mitigate pain, but cannot influence the trexate is not effective enough or can-
course of Psoriatic Arthritis. NSAIDs are not be tolerated by the body.
most commonly used when the illness Important note: In order to ensure safe
is very mild. For acccute phases of Pso- long-term therapy with immunomodu-
riatic Arthritis, direct injections of corti- lating substances, before therapy can be-
sone can be used in the short term. gin, a comprehensive, informative con-
Over the long term, so-called immuno- sultation on necessary preliminary
therapeutic substances suitable for assessments and checkups, side-ef-
long-term therapy can be taken which fects and complications with an experi-
suppress the illness activity – usually on enced doctor is very important.
the skin as well as in the joints. These
drugs, which are usually taken in tablet Are any other illnesses associated
form, belong to a group of substances with Psoriatic Arthritis?
which are utilized for the treatment of Numerous studies have shown that other
other rheumatic illnesses, such as Meth- chronic illnesses occur especially fre-
otrexate, as well as Sulfasalazine and quently when it comes to persons with
Leflunomide. Psoriasis or Psoriatic Arthritis. These in-
A more targeted effect on the immune clude metabolic disorders like excess
system can be achieved by newer med- weight, Diabetes mellitus and coronary
ications which, altogether, are referred artery calcification. The reasons for the
to as Biopharmaceuticals. These have correlation have not yet been cleared be-
been used for years for Psoriasis thera- yond doubt, nor has the question of
py, and have been shown to achieve whether a successful therapy for Psori-
very good success in the treatment of atic Arthritis also leads to an improve-
Psoriatic Arthritis. With these substanc- ment in these associated illnesses. One
es, which are administered as infusions thing is for sure: Patients with severe
or subcutaneous injections, specific se- Psoriasis and Psoriatic Arthritis should
miochemicals produced by the body take extra care to achieve and maintain
itself and which help cause skin and healthy metabolism and lifestyle, while
joint inflammation are targeted and avoiding additional risk factors (e.g. cig-
blocked. Currently, so-called TNF al- arette smoke), and to get the right con-
pha blockers and Interleukin 12/23 sultation and information as part of a
blockers are available, and series of new comprehensive treatment programme.

Gout
GOUT
Other joints can also be affected, such

as the ankle or the joint at the base of
the thumb. In some cases, the general
condition is bad, and fever and head-
aches can also occur. The symptoms
usually subside after several days. The
next time gout occurs can be anywhere
from a few weeks to a few years.
If the symptoms persist, then one
speaks of Chronic Gout. It can attack
the kidneys (resulting in kidney insuffi-
ciency), lead to joint deformation and
even damage organs.
What causes the level of uric acid in

the blood to rise?
Uric acid rises due to the metabolic
breakdown of purine nucleotides which
make their way into our bodies through
What is Gout? the foods we eat. If the concentration of
Gout, or Arthritis urica, is the name for uric acid is too high, then there are too
an inflammatory illness of the joints, many purines and/or the kidneys are not
which is caused by too much uric acid able to extract enough of it. If laboratory
in the blood. The uric acid crystals ad- findings can show that uric acid is above
here to joints so firmly, that the joints the nominal value and you are starting to
become inflamed and very painful. show signs of affliction, then it is best to
speak with your doctor right away. The
What are the symptoms? higher the level of uric acid in your
The first acute attack of Gout occurs – bloodstream, the higher the chance is
usually at night or in the early morning that you are suffering from an illness as-
hours – with no warning at all. Typical sociated with Gout.
symptoms are fierce bouts of joint pain,
whereby usually the base joint of the How is Gout diagnosed?
large toe is affected. It swells and is of- Higher levels of uric acid can be present
ten so plump, that the skin literally in the bloodstream already many years
gleams. It is highly painful; the affected and result in no symptoms before the
joint can hardly be touched or moved. first gout attack. During or after an acute

Gout
Genes also play a major role. Other ill-

nesses, pharmaceuticals, restricted
movement, high levels of blood fat, high
blood pressure and excess weight all
promote an attack of gout. Infections or
stress can also bring about a gout epi-
sode.
Who suffers from Gout?

The typical gout patient is male, be-
tween 40 and 60 years old and often
overweight. Women are usually only
prone following menopause.
Severe joint pain attacks often begin at the base of What is the treatment like?
the big toe. The most important thing to do is change
the diet. It is important to maintain a diet
episode of gout, often no increase of uric low in purines. This means that you
acid levels can be detected in the blood should avoid liver, kidneys and the like,
since the uric acid has already deposited and eat as little red meat (e.g. beef, pork
itself in the joints and is no longer roam- or goose) as possible. Fish in general is
ing free throughout the body. Only high- allowed, however mackerel, sardines,
er levels of CRP can be detected, and the herring, sardines or shellfish can raise the
Leukocytes (white blood vessels) are level of uric acid and should only be eaten
also usually increased. The only way to occaisionally. You should also abstain
get a good diagnosis is to be repeatedly from alcohol. Drink a lot of mineral or
tested for uric acid. tap water - about 2.5 liters every day - in
A more informative examination is the order to flush out the uric acid with the
extraction of joint fluid and the subse- urine. Eat more fruits and vegetables. Be
quent examination of this fluid for uric sure to eat more low-fat foods. Sugar and
acid crystals. Whether or not permanent salt should only be eaten in moderation.
damage has been done to the joints can If you‘re overweight, careful weight re-
be shown quite well by imaging proce- duction is very helpful. Physical activity
dures such as x-ray, ultrasound and CAT (walking, cycling, swimming) has nu-
scan. merous benefits, one of which is weight-
loss, another the reduction of uric acid.
What causes an attack of Gout?
The main reason for gout is diet. Rich,
heavy foods (high in purines) and in-
creased alcohol consumption are often
the triggers for an acute attack of gout.

Gout
No excuses: Afflicted joints profit from exercise.
What pharmaceutical therapy is avail- What can be done in case of an acute

able for treating Gout? attack of Gout?
If, despite switching to a healthy diet, In addition to the treatment with painkill-
the levels of uric acid in your blood can- ers, the immobillization of the painful
not be gotten back down to normal lev- joint also helps to reduce pain. In addi-
els, then it is necessary to begin treat- tion, it helps to apply cold compresses to
ment with pharmaceutical medication as the affected joints.
a supporting therapy in order to avoid NSAIDs are also recommended, since
permanent damage to joints and organs. they have a pain-killing and anti-inflam-
In principle, however, any treatment matory effect. The treating doctor can also
with pharmaceutical medication will not inject cortisone. A suitable treatment for
result in success if the required lifestyle acutely painful cases can significantly re-
changes are also not carried out. duce pain within a few hours.

Medicinal Therapy
TREATING INFLAMMATORY RHEUMATIC

ILLNESSES WITH PHARMACEUTICAL MEDICA-
TION
What drugs are available? inflammation over a longer period of

NSAIDs (non-steroidal anti-inflamma- time, and thereby secure a conservation
tory drugs) are among the non-corti- of the joint‘s function. Biopharmaceuti-
sone pharmaceutical medications cals, available since 1999, belong to the
that have a pain-reducing effect. Oth- family of DMARDs.
erwise, those anti-inflammatory drugs
that contain the body‘s own hormone, What exactly are DMARDs?
Cortisone, are available. Both groups DMARDs are drugs that lead to improve-
of medication bring about rapid change. ment of joint symptoms and to reduction
However, they only work against the - or, in the best case, the stop - of joint
signs of illness such as pain and swell- destruction. The name Disease Modify-
ing, but do not influence the longer- ing Antirheumatic Drugs (DMARDs) de-
term course of the disease, or – as is the scribes the effect quite clearly. The fol-
case with Cortisone – can only limit it. lowing active ingredients are among the
Therefore, it is very important to imple- NSAIDs and are commonly used in Aus-
ment so-called DMARDs (Disease Modify- tria: Sulfasalazine, Hydroxychloroquine,
ing Antirheumatic Drugs) that are usually Leflunomids and Methotrexate. The last
administered as long-term medication. one is the most widely implemented drug
They should positively influence the from the NSAID family. Dosage is usu-
progress of the illness, arrest the active ally at around 30 mg once per week. It is
Pain control Combatting

Combatting
and radiological change
joint swelling
Inflammation (joint deformation)
NSAIDs yes yes no
no
Cortisone yes yes
(in early stages yes)*
Classic Antirheumatics yes yes yes
Biopharmaceuticals yes yes yes
* no indication for long-term therapy

Medicinal Therapy
administered either as a tablet or a subcu- cannot be ruled out, doctors recommend

taneous injection. pregnancy only several months after
treatment has ended.
How do NSAIDs work?
They soften or normalize excessive reac- For what ailments is it best to use
tions of the immune system. This leads to a NSAIDs?
lessening of the inflammatory reaction in Rheumatoid Arthritis, Juvenile Idiopath-
the joints, whereby joint swelling and pain ic Arthritis, Psoriatic Arthritis, Ankylo-
are prevented. NSAIDs exert a long-term sierend Spondyloarthritis with joint in-
effect on the progress of the illness by stop- flammation and, partially, for
ping or at least slowing down the progres- Collagenoses (e.g. Systemic Lupus Ery-
sive destruction of the cartilage or bone. thematosus).
The effects of these substances often show
themselves only after several months, but Cortisone – how does it work?
in the long term they do lead to significant Cortisone is the generic term for an entire
improvements in and, sometimes, even a group of active ingredients. It has to do
total absence of pain and swelling. In the with descendents of the body‘s own hor-
best case, it leads to a complete stop of the mone Cortisol, produced in the adrenal
disease. They must be taken regularly and glands. Cortisone puts the brakes on the
may only be stopped on the recommenda- immune reaction and works efficiently
tion of a doctor. To date, only rarely has against strong inflammation. This effect
anyone been able to stop taking their comes to bear in particular with rheumat-
NSAIDs altogether; rather, as long as the ic illnesses, since Cortisone suppresses
patient has a good response to the medica- inflammation in the joints in a quick, ef-
tion, then dosage or frequency can often be fective manner. After being administered,
reduced. the discomfort usually improves within
one to two hours. Cortisone is often im-
What are the side effects of taking plemented as a stop-gap measure until the
NSAIDs? NSAIDs can begin their work.
As is the case with alll medications, of Important Note: Cortisone eliminates
course isolated side effects can occur. only the symptoms, and does not heal
Therefore, one must begin with a contin- the patient of the illness!
ual examination by the attending physi-
cian – initially every four to six weeks, Why are people so afraid of
then in two- to three-month intervals. In Cortisone?
this way, often invisible side effects can As soon as a doctor mentions the name
be quickly targeted and treated. The most “Cortisone”, people often immediately be-
common side effects are infections, nau- come anxious. The reason for this is the
sea, diarrhea, mild hairloss and malfunc- experience with Cortisone overdoses of
tions of the kidneys and liver. Since dam- the 1970s, before the long-term effects
age to sperm and egg cells by NSAIDs were known. Due to the high dosage

Medicinal Therapy
through long periods of application, cer-

tain side effects arose which are now well-
known. Today, we know that large doses of
Cortisone can only be administered for a
short time. The side effects of reasonably-
dosed Cortisone are far less pronounced.
What should be kept in mind when

taking Cortisone?
Cortisone compounds must be taken regu-
larly and at the right time. They should
never be stopped suddenly; rather, the dose
must be reduced step-by-step, because the
body can stop its own Cortisone produc-
tion during therapy and, therefore, if
stopped all of a sudden, the result can be
life-threatening. Furthermore, the risk of
the occurrence of osteoperosis before ther-
apy has begun can be shown by means of a
bone density scan. Regular blood pressure,
blood sugar and keeping an eye on weight
also make sense.
Biopharmaceuticals
What are Biopharmaceuticals and

how do they work?
Biologicals, also referred to as Biologics
or Biopharmaceuticals, are proteins pro-
duced with the most modern biotechnol-
ogy and with great technical effort, and
which target and intervene in the mecha-
nisms of the illness. They are able to
greatly influence the regulatory mecha-
nisms of inflammatory rheumatic ill-
nesses. They therefore distinguish them-
selves from the rest of the drugs used in
rheumatic therapy. They access the im-
munological defenses of the body, for Kortison unterdrückt Entzündungen.

Medicinal Therapy
example, by switching off Zytokines – ceuticals and NSAIDs is almost always

the messengers in the body responsible shown in the treatment of rheumatoid
for the body‘s immune system response. arthritis (combination therapy). Patients
The long-term effects of many immuno- with Psoriatic Arthritis and Ankylosing
logical illnesses (e.g. changes to and Spondylitis (Morbus Bechterew) can
damage in the joints) can be lessened, also be treated with a biopharmaceutical
stopped or at least delayed with the help monotherapy. Up to half of all patients
of Biopharmaceuticals. treated with the new substances report
Administration: Since these proteins are that their conditions have improved sig-
broken down in the gastrointestinal tract, nificantly – whereby starting with the
and would therefore never arrive at their treatment early on is key to the suc-
destination, they are either administered cessful outcome of the therapy.
per infusion by the doctor, or injected by
the patient themselves in the fatty tissue What illnesses call for the adminstra-
just below the skin (subcutaneous injection of Biopharmaceuticals?
tion). Rheumatoid Arthritis, Juvenile Idiopath-
ic Arthritis, Psoriasis, Psoriatic Arthritis,
How is therapy administered? Morbus Bechterew, chronic inflammato-
The typical course of therapy is designed ry bowel disease and iritis, among others.
to maintain the use of Biopharmaceuti-
cals, if a biopharmaceutical therapy has Biopharmaceuticals in the form of
been initiated. Improvement is often ap- infusions – what are the advantages?
parent within two to four weeks, and by The infusion is administered via the pa-
around eight weeks a maximum effect is tient‘s vein by a specialist physician in his
achieved. If no acceptable level of suc- practice or clinic. The advantages to ad-
cess has been achieved within three ministering with infusiones are tailored
months, then a change must be made to dosing, longer intervals and direct con-
another biopharmaceutical, or another trol by the administering physician or
method should be examined. nurse. Following the infusion, the effects
are seen very quickly for most biophar-
When should one start with a Bio- maceuticals. Pain and morning stiffness
pharmaceutical therapy, and what are reduced. Even the signs of inflamma-
advantages does it have? tion in the blood (CRP, erythrocyte sedi-
Biopharmaceuticals are first implement- mentation rate) improve. It is important
ed following unsuccessful experiments that the treatment by continued, even if
with NSAIDs. Therefore, biopharma- the symptoms have gotten better; other-
ceuticals are cleared for treating patients wise, the illness can worsen. Another ad-
for whom basic medicines do not work, vantage is the feeling patients have of
or have not worked satisfactorily. The not having to do anything themselves.
parallel administration of Biopharma- This means that they don‘t have to worry

Overview: Biopharmeceuticals in Rheumatology
Active Ingr. Administration Prescribed for
TNF-alpha Infliximab intravenous infusion, initially at chimeric human- rheumatoid arthritis, psoriatic
Blockers weeks 0, 2 and 6, every four to murine monoclonal arthritis, ankylosing spondylitis,
eight weeks later, depending on antibody Crohn‘s disease, ulcerative coli-
the disease tis, Crohn‘s disease with fistula
formation, pediatric Crohn‘s
disease
Adalimumab subcutaneously: pre-filled syringe monoclonal human rheumatoid arthritis, psoriatic
or pen; vial exclusively for kids, antibodies arthritis, ankylosing spondylitis,
every two weeks Crohn‘s disease, juvenile idiopa-
thic arthritis, ulcerative colitis
Etanercept vial; subcutaneously: pre-filled sy- human TNF recep- rheumatoid arthritis, psoriatic
ringe or pen, once or twice a week tor p75 Fc fusion arthritis, ankylosing spondylitis,
protein juvenile idiopathic arthritis
Certolizumab subcutaneously: pre-filled syringe, pegylated recom- rheumatoid arthritis, psoriatic

two injections each at weeks 0, binant humanized arthritis, ankylosing spondylitis
2 and 4, then one injection every antibody Fab
other week fragment
Golimumab subcutaneously: pre-filled syringe human monoclonal rheumatoid arthritis, psoriatic

or pen, once a month antibody IgG1k arthritis, ankylosing spondylitis,
ulcerative colitis
Interleu- Ustekinumab subcutaneously: vial or pre-filled human monoclonal psoriatic Arthritis
kin-12/23 syringe, 1st injection week 0, 2nd antibody IgG1k
Blocker after 4 weeks, every twelve weeks
thereafter
B-cell antibody Rituximab intravenous infusion at weeks chimeric mono- rheumatoid Arthritis
0 and 2 infusion, then every six clonal antibody to
months or as needed CD20 on B cells
isolated surface
protein
Selective T-cells Abatacept intravenous infusion: at week recombinant fusion rheumatoid arthritis, JIA
Co-Stimulation 0, 2 and 4 once every 4 weeks protein
Inhibitor thereafter; subcutaneously: at the
beginning of therapy optional single
intravenous infusion (loading dose).
general: weekly subcutaneous
injection
IL-6 Receptor Tocilizumab intravenous infusion every four monoclonal, rheumatoid arthritis, JIA
Inhibitor weeks recombinant human
antibodies
IL-1 Receptor Anakinra subcutaneously: pre-filled syringe, recombinant human rheumatoid arthritis
Inhibitor once daily receptor antagonist
BLyS Inhibitor Belimumab intravenous infusion, initially at monoklonaler systemischer Lupus erythema-
week 0, 2 and 4, every four weeks humaner IgG1λ- todes
thereafter Antikörper

Medicinal Therapy
about storing their medication, for ex- flammation in the joints diminishes,
ample, on vacation; nor do they have to and the changes to the bone can be
be concerned about any issues during slowed or stopped. The way in which
self-administration. the patient realizes successful treat-
ment is by feeling less pain and the
Biopharmaceuticals in the form of joint swelling either fades or stops alto-
pre-filled syringes or pens – what are gether. The main disadvantage is the
the advantages? high cost.
The first time a patient administers a Important: Before taking the substance,
drug using pre-filled syringes or pens, it the existance of a serious infection, espe-
should be done under the supervision of cially tuberculosis, must be excluded!
their doctor. The drug is administered,
for example, as a ready solution in the What is the importance of the B -cell
pre-dosed pen with built-in needle, with therapy?
no additional preparation needed. If the In contrast to the TNF alpha blockers,
patient has gained enough confidence in which focus mainly on the regulation of
handling it alone, then he can administer Zytokines, this therapy targets the B-cells,
the drug to himself at home. For many or B-Lymphocytes, a subclass of the white
patients this constitutes an advantage, blood cells. An important task of the B-
since this makes them independent of cells is form abtibodies. In the case of
the hospital or their doctor. It is impor- rheumatoid arthritis, however, the B-cells
tant, however, to note that the patient are called up to attack the body‘s own
must ensure that the substance is kept joints. In B-cell therapy, B-cells - which
cool in the refrigerator - at between 2 carry a special marker (CD20) on their sur-
and 8 degrees Celcius. face - are greatly reduced. Thereby, the
illness activity and the radiologically veri-
TNF-alpha blockers are also Biophar- fiable destruction of the joints can be re-
maceuticals. What can they do? duced.
The substances that are used – Adalim- Rituximab is a substance that was origi-
umab, Certolizumab, Etanercept, Goli- nally developed as a therapy for malicious
mumab und Infliximab – block the illnesses of the lymphatic system. Cells
body‘s own inflammation-causing such as plasma cells, which do not carry
messenger known as TNF alpha. In this the CD20 marker, are not eliminated, al-
way they inhibit the further progres- lowing part of the body‘s own immune
sion of joint inflammation, stopping system to remain intact. As a general rule,
the destruction of the joint. The mobil- two infusions at intervals of 14 days are
ity of the joint is preserved. The advan- administered – if this shows no effects,
tages over and above conventional then the administration of Rituximab is
NSAIDs: Many patients react quickly ceased. If it is shown to have a positive ef-
and well to TNF alpha blockers, the in- fect, then continuation for between six

Medicinal Therapy
months and one year is allowed. Usually, What other pharmaceutical options
Rituximab is administered in combina- are available?
tion with an NSAID. An additional therapeutic option for rheu-
matoid arthritis is the IL-1 receptor in-
How can blocking the activation of hibitor Anakinra, which is also used for
T-cells help? adult patients who have been shown to
When a patient does not react satisfactorily react unsatisfactorily to NSAIDs. This
to therapy with NSAIDs, then the Bio- substance arrests the inflammation-
pharmaceutical Abatacept can be ad- promoting messenger Interleukin-1. In
ministered. This substance is admitted its effectiveness, however, Anakinra is
for use by patients with moderate to se- inferior to the other Biopharmaceuticals
vere rheumatoid arthritis (RA) and Juve- and therefore does not represent a pri-
nile Idiopathic Arthritis, and is usually mary form of treatment.
taken together with Methotrexat. Its im- When it comes to Psoriatic Arthritis, the
munomodulating effect is due to the Interleukin-12/23 blocker known as
blocking of the activation of T-cells. The Ustekinumab is available. This drug
active ingredient impedes the activation fixes itself to the inflammatory messen-
of T-Lymphocytes (T-cells) which play a gers Interleukin-12 and 23, and can
role in the regulation of the immune sys- thereby reduce inflammation.
tem‘s defense processes, thereby sup- The BLyS-Inhibitor Belimumab is a bio-
pressing the inflammation process. pharmaceutical prescribed to patients
with systemic Lupus erythematodes (see
When is an Interleukin-6 Receptor page 87) who still display high illness ac-
Inhibitor used? tivity following standard therapy. Its ef-
The IL-6 Receptor Inhibitor is a humanised fectiveness is based on its bonding to the
monoclonal antibody against the Interleu- soluble B-Lymphocytes stimulator hu-
kin-6 Receptor (IL-6), which suppresses man protein BLyS, which shortens the
the activity of IL-6, another important trig- lifetime of B-Lymphocytes.
ger of the inflammation process. The sub-
stance Tocilizumab, employed here, is ap- What types of monitoring are impor-
proved for use by patients with tant for long-term therapy?
moderately to severely active RA, or with In order to identify damage early on
polyarticular Juveniler Idiopathic Arthritis, which is not subjectively recognizable,
and who have not reacted satisfactorily to the following should be monitored:
an NSAID therapy. The mechanism of ac- blood count, liver function, kidney
tion reduces the inflammation of the function, CRP and urine. Some com-
joints and mitigates the systemic symp- pounds or a combination of multiple
toms. The onset of action is, as a rule, to be substances require additional monitor-
expected quickly. ing.

NON-MEDICAL TREATMENT FOR INFLAMM-
ATORY RHEUMATIC ILLNESSES
When does it make sense to have an In the case of pre-emptive surgery, the
operation? operation takes place early on, when the
An operation is carried out with the in- cartilage tissue and ligaments are still in-
tention of improving the functionality tact, with the goal of stopping or delaying
of the joint and reducing pain. Opera- irreversible damage to joints and liga-
tions are never a replacement for medi- ments. Functionality should remain in-
cal therapy, but are rather resorted to tact.
when all conventional methods (such as Reconstructive surgery, on the other
physical therapy, drugs, assistive devic- hand, is when the fuctionality of the
es, etc.) have been exhausted, yet the joint has been compromised. It should
pain in a joint remains. An operation be restored and pain should thereby be
can be either a preventive or a rehabili- reduced.
tative measure.

Non-Medicinal Therapy
What operations or methods exist? rect Cortisone injections have not been
• Synovectomy: This is a surgical proce- adequately successful.
dure whereby the synovial membrane -
the soft tissue between the joint capsule When should a joint be surgically
and joint cavity - is removed. The re- replaced?
quirement is that the weight-bearing If damage has reached a certain point,
area is still intact. With the help of this then the only alternative is joint replace-
operation, the progression of destruc- ment made of materials such as metal,
tion to the joint can be delayed and, in ceramics, polyethylene or silastic. In the
some cases, even brought to a standstill. case of a total endoprosthetic, the ball of
Today, with the benefit of so-called key- the joint as well as the socket are re-
hole surgery by means of arthroscopy, placed, whereby for a partial prosthetic
surgery can be performed - mainly out only the joint ball is replaced, and not the
on the knee or shoulder - with only very socket. This procedure can be applied to
small incisions. Arthroscopic surgery almost all joints - shoulder, elbow, hand,
can often not be carried out on hand and finger, hip, knee, upper ankle or toe
finger joints, however, since tendons joints. The most common are knee and
and ligaments must be treated simulta- hip replacement.
neously. This is when an “open” syno- In general, it can be said that the imple-
vectomy is performed which requires mentation of artificial joints can lead to
larger incisions. Following the surgery, great improvements in pain reduction
the synovium grows back within only a and almost normal mobility. 90–95% of
few weeks. all implants last at least 15 years,
• Corrective Surgery in the case of joint through for very active young patients
malposition or functional restrictions this can be somewhat shorter. Certain
(preventative and reconstructive proce- materials match to enable extremely
dures) low friction, such as ceramic on ceram-
• Joint replacement (partial or total en- ic, whereby even high loads exerted
doprosthetics) during athletic activity are supported.
• Arthrodeses, Spondylodeses (stabilis-
ing Albee‘s operation) What is an Albee‘s Operation?
This is the surgical stiffening of a joint,
What is Radiosynoviorthesis? for example in the case of a very severe
Radiosynoviorthesis is a procedure rheumatic illness (often used for small-
wherein a weak radioactive liquid is in- er joints in the feet and vertebrae) and
jected into a chronically inflamed joint, mainly serves to reduce pain. The mo-
thereby cauterising the surface of the bility of the joint is disabled, the parts
inflamed synovium. This form of treat- of the bone of the stiffened joint grow
ment should only be implemented together.
when treatment with NSAIDs and di-

What types of operations are until a bony bridge can be formed that
available? stops the progession of the illness.
• Rheumatoid Arthritis (RA): Depend- • Psoriatic Arthritis: Depending on the
ing on the phase of the illness, the in- stage of the disease, the inflamed joint
flammably changed articular capsule or capsule or oder tendon sheath is re-
synovial sheath is removed (synovecto- moved (synovectomy), damaged ten-
my), damaged ligaments are recon- dons are restored and a partial joint re-
structed, a partial joint removal (resec- moval ( resection arthroplasty) is carried
tion arthroplasty) is carried out, a joint out, a joint stiffening (Arthrodesis) is
stiffening (arthrodesis) is performed or performed or an artificial joint is im-
an artificial joint is implemented. Artifi- planted.
cal joints are usually implemented in the
hips, knees or shoulders, and more rare-
ly in the elbows or ankles. In the case of
smaller joints, a stiffening operation is
carried out. For patients with rheuma-
toid arthritis, inflammatory changes are
often apparent in the second vertebral
body, which can lead to neurological de-
ficiencies in later stages. The initial
damage to spinal marrow is apparent
due to pain in the neck and back of the
head, and a weakening of the extremi-
ties and uncertainty while walking. A
stiffening operation can protect the spi-
nal marrow and additional damage can
be avoided. The choice of the correct
point in time for the operation is deci-
sive.
• For Morbus Bechterew: Primarily,
life-long gymnastics is necessary to
strengthen the spinal erector. When the
course of the disease, however, is so
strongly progressive that the curvature
of the spine is exaggerated, then a stiff-
ening operation can be carried out on
the spine. Screws are inserted into the
vertebrae and linked in series with rods
in order to achieve stability. These im-
plants are only temporary stabilisors, Neck pain due to RA is often very distressing.

What physiotherapy options exist? Attention: Cold therapy should not be

For all illnesses affecting the mobility and applied in case of fever, kidney or blad-
supporting apparatus, physiotherapeutic der problems, oversensitivity to cold or
measures focus on maintaining joint mo- blood vessel inflammation.
bility. These include:
• Exercise therapy How do massages help?
• Heat and cold therapy Massages relax tense muscles, which in
• Massage (manual and reflex therapy) turn releives the joint. Massages also
• Electrotherapy promote circulation and encourage
• Medicinial training therapy muscle toning. Massages can also re-
duce swelling. It is important that the
Why is physical activity so important? patient perceives them to be comfort-
Remedial gymnastics can bring about an able.
improvement in joint mobility, re-invig-
oration of muscles and a reduction in What is electrotherapy?
pain. Electrotherapeutic procedures involve
Caution: When a phase of acute illness the therapeutic application of electricity
activity occurs, gymnastics should be in medicine. They distinguish them-
put on hold until it resides. selves from one another both physi-
cally as well as biologically.
When are heat and cold used? The high-frequency therapy is a pure
Heat therapy is intended to help reduce heat therapy with great power of pene-
pain and relax muscles. Hot wraps, baths tration. Using special electrodes, high-
and mud packs or the use of hay or par- frequency electricity is conducted
affin as heat convectors (often used for through the skin and transforms body
finger or knee joint arthrosis) and also heat.
infrared lamps are all heat therapy op- Attention: This form of therapy is not
tions. suitable for patients with a prosthesis in
Attention: In the case of acute inflam- the area to be treated, or for patients with
mation, heat should not be used as this a pacemaker!
can worsen the symptoms of the illness.
Low-frequency therapy works in the
Cold therapy has anti-inflammatory, frequency range of up to 1,000 Hertz.
pain-relieving qualities and promotes It serves to reduce pain, muscle train-
movement. It is used for swollen joints, ing and promotion of circulation.
pain and acute inflammation. The op- Thus, pain medication can be reduced
tions are ice packs, cold mudpacks, or muscle training (gentle on the cir-
cryopacks, cold baths (15 °C) and whole- culation) can be done.
body treatments in cold chambers with Contradictions are, for example, active
temperaturens of down to -110 °C. inflammations or skin defects.

Medicinal Training Therapy

In phases of cronic illness, a common
problem is muscle atrophy. In this case, a
well-dosed, medically-monitored aero-
bic and weight training is indicated. Nat-
urally, the biomechanical changes in the
joint must be considered and workout
machines as well as intensity must be in-
dividually adapted. The effects, however,
are not only an improvement in bodily
performance and improved well-being,
rather a decline in inflammatory activity.
How does Ergotherapy help?

Ergotherapy attempts to give the sufferer
the greatest possible independence and
freedom of action in every-day life, there-
by restoring or maintaining these after or
during a debilitating illness. Together
with the sufferers, assistive devices that
help solve problems in every-day life are
tested and, if they prove to be helpful,
procured. How the workplace can be ar-
ranged in a manner that is easy on the
joints, or which physical exercises are
less stressful on the joints, are discussed
in detail. There are also special orthope-
dic assistive devices that support the af-
flicted joints with braces, and which also
help relieve pain during day-to-day activi-
ties. The goal is more self-reliance in day-
to-day life, less pain and protection of the Accupuncture as an alternative
affected joint.
and not turned or twisted, as happens
What does joint protection mean? when wringing out a towel. Joints should
Joint protection means a balanced rela- also not be exposed to vibrations: One
tionship between resting and loading, should not work with a kitchen mixer or
and serves therapy and especially sec- sit on a tractor very often, as they can
ondary prophylactics. The joints should create too much strong vibration. The
be loaded directly in line with the axis, strain should be modest and be distrib-

uted among as many joints as possible,

e.g. loads should be carried with both
hands, drinking glasses should be held
with both hands, etc.
What assistive devices are available

for day-to-day living?
When routine activities such as holding a
coffee cup, cutting bread or buttoning a
shirt become too difficult or impossible,
then it might be time to invest in assistive
devices which can be found at well-
stocked specialty shops. Finger and hand Vibrations damage the joints.
splints, so-called buttonhole and swan
neck splints. special knives (the handle is Overview: Non-medicinal treat-
bent 90 degrees away from the blade) ments
and bottle openers prove helpful to those
suffering from rheumatoid illnesses. Er- Relieving pain:
gonomic keyboards for the computer Thermotherapy, electrotherapy,
ultrasound, massages (depending on
make it possible to hold the wrist inline source of pain, a highly diverse selection
with the axis, and an ergonomic comput- of therapeutic options)
er mouse relieves strain. Canes and walk-
ers can help relieve pain that occurs when Blocking inflammation:
walking. Thermotherapy (cold for acute, heat for
chronic inflammation)
Treating restricted movement:

Remedial gymnastics, ergotherapy, sports
therapy
Muscle relaxation and better circu-

lation:
Remedial gymnastics, classic massage,
heat therapy, cold therapy
Inproving muscle strength:

Remedial gymnastics, stimulation current
therapy, electrotherapy
Prevention and correction of

malposition:
Remedial gymnastics, ergotherapy, sports
therapy
Relaxing massages promote circulation

Gender-Specific Differences
GENDER-
SPECIFIC
DIFFERENCES
Do gender-specific differences really

exist when it comes to rheumatic
illnesses?
Yes. Women are more commonly affect-
ed and suffer more in regards to frequen-
cy, characteristics of illness patterns, the • Fibromyalgia: Six times more women
course of the illness and health conse- than men are susceptible to this ill-
quences. ness.
From which rheumatic illnesses are Do any rheumatic illnesses exist that
women more likely to be affected affect more men than women?
than men? • Morbus Bechterew: Around twice as
• Rheumatoid Arthritis (RA): Two to many men are affected by this disease
three times more women become ill than women. In addition, the symp-
with RA than men. Hormones like Pro- toms of Morbus Bechterew in women
lactin and Estrogen have a good deal of are usually considerably less pro-
influence. nounced than in men.
• Osteoarthritis: Women are clearly at
more risk to fall ill to knee joint arthro- Do women who suffer from rheumatic
sis or finger polyarthrosis. In addition, illnesses sense more pain than do
women also suffer more from joint men?
pain and related physical burden than Research has shown that, when it comes
do men with the same illness. to rheumatoid arthritis, the pain thresh-
• Systemic Lupus Erythematosus hold is considerably lower for women
(SLE): SLE is present in about 1 per- than for men. The functional restrictions
cent of the population, and occurs 10 for women are also more pronounced for
times more often in women than in women and become more severe for
men. This ratio is stacked even higher women as they get older. Associated ill-
against females when it comes to nesses such as depression and anxiety
young adults – though this does not ap- disorders are also more frequent and can
ply to children. Irrespective of genetic amplify the symptoms of pain. On the
factors, hormonal factors also play a other hand, moreso than men, women
large role in the development of this ill- tend to develop very good strategies for
ness. dealing with pain.

Regular Monitoring & Therapeutic Adjustments
REGULAR MONITORING &

THERAPEUTIC ADJUSTMENTS
tologist about once a month. This spe-

cialist will test to see whether the thera-
py is also really tailored to the individual
needs of the patient, and whether the
goals of the therapy have been achieved,
or whether changes in therapy are nece-
seary. One of the main goals of the ther-
apy is to eventually be free of the afflic-
tion (remission).
What is meant by the term

“Remission”?
What can the patient do to prevent or Remission is used to refer to the state
curtail progression of the illness? that is reached when no swelling or pain
When joint pains and/or swelling appear are apparent. This accompanies the re-
together with morning stiffness for no covery or maintenance of joint function-
apparent reason, then a doctor should be ality. Should it not be possible to achieve
called on right away! The earlier a pa- remission, then at least a state with less
tient with rheumatoid arthritis can iden- illness activity can be achieved.
tify his or her illness, and can start with
the basic medicinal therapy, the better What monitoring is most important for
the illness activity can be contained. long-term therapy?
Patients can best prevent the progres- Clinical monitoring by Rheumatologists
sion of rheumatoid arthritis by adher- is necessary to judge the effectiveness of
ing to the recommended medicinal and basic drug therapy. During consultation
non-medicinal measures, and always with the doctor is when the drugs and a
getting regular checkups as recom- possible change in or supplement to the
mended by the doctor! existing therapy can be discussed. In ad-
dition, a review of the blood tests is
Why are so many trips to the doctor necessaary in order to identify the side
necessary at the start of the therapy? effects of the medication which the pa-
Those who wish to start therapy for tient couldn‘t identify him/herself. X-
rheumatoid arthritis should have a rays should also be taken in specified
checkup appointment at their Rheuma- intervals.

DEGENERATIVE
RHEUMATISM
More women than men suffer from
Arthrosis.

Arthrosis
ARTHROSIS
Who suffers from Arthrosis? ailment known as Arthritis, Arthrosis

Two million Austrians fall victim to ill- represents progressive, primarily non-
nesses affecting their bones and joints in inflammatory erosion of joint tissue.
the course of their lives. Around 1.4 mil-
lion - more female than male - suffer Which joints are affected?
from degenerative rheumatic joint dis- The knee and hip joints are often af-
eases (Arthrosis). The problems usually fected. They carry the heaviest loads as
start between the ages of 50 and 60, they must carry the most body weight.
sometimes earlier (following an accident The reduced mobility and load-carrying
or an injury, for example). capacity following Arthrosis affect the
posture and gait, whereby pain and other
How does Arthrosis occur? degenerative changes can result in areas
Arthroses are chronic joint illnesses such as the spine. Indications of wear in
brought on by changes in the joint carti- the hip joints can be found in various
lage and the underlying bone tissue. The stages in persons between 30 and 40
causes are change processes in the carti- years of age.
lage tissue and bone tissue near the joint. Even Arthrosis of the small finger joints
This brings about a disruption in the bal- (Polyarthrosis), which mainly affects the
ance of cartilage metabolism, whereby proximal (Heberden‘s nodes) and distal
cartilage decomposition is greater. The interphalangeal (Bouchard Arthrosis)
body can no longer stop the loss of carti- joints, and carpometacarpal thumb joint
lage. Sufferers experience pain, muscle (Rhiz Arthrosis), often occur.
tension, limitation of move-
ment and, in some cases, What are the factors that promote
swelling in the area of the Arthrosis?
affected joint. Over time, • Age: Every other 70-year-old
deformations of the suffers from joint attri-
joints and and therefore tion, noticable by
degenerative functional some level of
limitation can occur. A pain or other.
trauma (accident, injury) • Genetics:
can also promote the occur- Arthrosis oc-
rence of arthrosis. curs more often
in certain fami-
What is the difference between lies. The cause
Arthritis and Arthrosis? seems to be arthro-
In contrast to the inflammatory joint specific genes.

Arthrosis
• Excess weight: More weight causes Using ultrasound screening, misalign-

additional strain on the joints, thereby ment in the hips of newborns can be
promoting wear and tear. In particular detected and treated early on with, for
the knee joints, to a lesser degree the example, double diapering or abduc-
hip joints, and also the joints in the tion pants. In any case, knee or hip pain
hands and fingers of overweight per- experienced by children and young
sons are commonly affected by Arthro- persons must always be taken serious-
sis. ly!
• Misalignment: Joints which are mis- • Sedentary lifestyle: Physically active
aligned from birth, as is the case with people are less often affected by Ar-
persons suffering from knock-knee or throsis and, if and when, then later in
bow-leggedness, or persons who have life. This is because physical activity
suffered from injuries such as untreat- leads to muscle buildup and therefore
ed meniscus damage, are especially at better cushioning of the joint region.
risk for the development of Arthrosis. • Metabolic dysfunction such as gout or
iron overload
• Overload: Years of hard physical labor,
such as working on the feet for long
hours and the lifting of heavy weights
during construction, landscaping, etc.,
or activities with high levels of stress
and strain on certain joints or joint ar-
eas - such as the meniscus after having
done years of floor work - can promote
Arthrosis
• Extreme sports: Soccer players suffer
quite often due to Arthrosis in the
knees, hips and ankles, cyclists experi-
ence a change in the meniscus or knee
joint, and ballett dancers are prone to
Arthrosis in the ankles, knees and hips.
What is the typical progression?

Progression varies, and is usually a slow
process. When judging by physical ap-
pearance, the various stages can be dif-
ferentiated as the clinically silent stage
(arthrosis visible on xrays but no pain
apparent), the chronic stage (low to high
Physically active persons suffer less from arthrosis. levels of pain depending on load levels)
and the acute (or activated) Arthrosis

Arthrosis
stage whereby swelling of the joints, • When swelling of the joints occurs,
overheating, contusion (bruising) and joint fluid is extracted via puncture and
pain are apparent, and which leads to an examined in the laboratory. Draining
inability to move the joint. the fluid from the knee releases the
joint from painful pressure, and it is
What type of pain is characteristic? possible to confine different joint ill-
The typical kind of pain suffered by Ar- ness from one another - such as bacte-
throsis patients is, for example, when rial infections or crystal deposition dis-
they start to move, and which decreas- ease (Chondrocalcinosis).
es after a few steps. Another type of • Magnetic Resonance Imaging (MRI)
pain is due to loads on the joint, appar- or Ultrasound examinations provide a
ent on longer walks or when going higher level of certainty. Ultrasound is
down steps. Pain rarely occurs when at best for evaluating tendons, muscles,
rest or during sleep. Over time, joint bursitis, cysts and joint swelling. The
deformation can occur, resulting in ac- MRI - Magnetic Resonance Imaging,
cumulation of fluid and redness. The an imaging method that shows tissue
affected joints are hard and bony, be- structures inside the body - has proven
come knotty and scalloped, swell and highly useful in the examination of car-
“grate, grind or pop“ when performing tilage. In the case of bone necrosis (the
certain movements. The joint is sensi- death of some or all of the cells in an
tive to touch, and movement is restrict- organ or tissue, in this case bone),
ed. which can cause afflictions similar to
those causes by Arthrosis, an MRI can
What examinations are necessary? produce diagnostic proof of ailment at
The examination of movement restric- an earlier stage than can an x-ray.
tion, functionality, ligament stability,
joint shape, pain tests and identifica- What are the laboratory findings that
tion of defective position (such as the can indicate the presence of Arthro-
legs) reveal an initial, tentative diagnosis?
sis. It is also important to note when A laboratory procedure for detecting the
and during which activities the pain presence of Arthrosis does not exist.
occurs. However, clinical and laboratory testing
can be used to exclude the existence of
Which imaging methods can reveal Arthrosis-causing illnesses, as well as
the presence of Arthrosis? other ailments which cause discomforts
• Structural changes such as the reduction similar to those caused by Arthrosis.
in joint space, defective and degraded • Rheumatoid factor: normal
joint cartilage and bones, hardening of • Erythrocyte sedimentation rate (ESR):
tissue and the buildup of cysts can be re- normal or only slightly above-normal
vealed with the help of an x-ray examina- • ACPA: negative (Anti–citrullinated
tion. protein antibodies such as Anti-CCP or

Arthrosis
Anti-MCV antibodies, are used to dis- spite joint deterioration, with the help
gnose the early stages of rheumatoid of therapy the resilience and mobility
arthritis.) of the joint should preserved for as
long as possible. If the damage is too
How is the illness treated? great and the pain is unbearable, then
The goal of Arthrosis therapy is to re- the only remaining option is to have
lieve pain and to slow down the develop- the joint replaced.
mental progression of the various ail-
ments. It is important that patients get What non-pharmaceutical options are
enough exercise without overloading available to Arthrosis patients?
joints, to protect their joint injuries, to Physiotherapeutic remedies like heat,
avoid gaining or to lose excess body mechanics (such as sports therapy, reme-
weight, and to take the right drugs. De- dial gymnastics, occupational therapy
and massage) and electrotherapeutics
should be applied regularly for Arthrosis
Healthy versus diseased joint patients.
Remedial gymnastics are carried out
with the help of items like elastic straps,
balls and even elaborate machines that
target the root causes of reduced mo-
tion, muscle contraction and muscle
weakness.
Special support devices for daily use
support the joints and delay the advance-
ment of the ailment. Splints, sturdy
shoes or the use of a cane can relieve the
joint of undue pressure.
One very helpful and effective form of
Intact cartilage treatment is therapy in water, known as
aqua training.
What is the procedure for

pharmaceutical therapy?
An important goal in pharmaceutical
therapy is the alleviation of pain. Pain
relievers cannot influence the damage
caused to cartilage by the underlying
illness. However, only by generally
eliminating pain is it possible to carry
Severe cartilage loss out physical therapy – and movement
is required in order to improve the car-

Arthrosis
Characteristic: Joint deformation leads to immobility
tilage metabolism. The following are • Cortisone: If the synovium (layer of in-
used to alleviate pain: ner skin) of an individual joint has un-
• Pain creams: These are available for dergone strong patholocial change or
topical application as anti-inflammato- has developed an inflammatory pro-
ry ointments or gels. The application of gression, Cortisone can be injected di-
compresses soaked with ointment is rectly into the joint for a short period of
advantageous since the active ingredi- days or weeks. It has strong anti-in-
ent is not applied directly into the af- flammatory properties.
flicted area right away, but rather an • Diacerein: This is a slow-acting medi-
adequate amount remains in the dress- cine which inhibits special semio-
ing and can be absorbed later. chemicals (such as Interleukin-1, Inter-
• Non-steroidal anti-inflammatory leukin-6 and Tumor necrosis factor
drugs (NSAIDs): In contrast to other alpha) that are involved in inflamma-
pain relievers, these anti-inflammatory tion and the destruction of cartilage.
drugs do not act on the brain, but rather • Injecting Hyaluronan directly into the
the affected tissue itself. There they knee joint: The goal is pain relief, be-
block the tissue hormones (pros cause a diseased joint cannot produce
taglandins) which transmit the pain. In anymore Hyaluronan, which works to
addition to the pain-relieving effect, reduce the abrasion of cartilage tissue.
the anti-inflammatory aspect reduces • Protective or regenerative substances:
swelling. NSAIDs should only ever be Glucosamine (sulfate) or chondroitin
taken on the advice of your doctor. sulfate can block the breakdown of car-
• Systemic analgesics such as tilage tissue.
Paracetamol

Arthrosis
When should Arthroscopy be

performed? What is Abrasion Arthroplasty?
This is a special endoscopic examination Abrasion (from Latin: abrasio) in ortho-
of joints whereby an arthroscope – more pedic medicine describes a procedure in
or less a small camera – is inserted into which organic material, such as bone, is
the joint space through a small cut in the mechanically removed. One form of ap-
skin. In this way, the doctor can directly plication is Arthroscopic Abrasion Ar-
observe the joint structure. This proce- throplasty, by which the regeneration of
dure is used primarily when examining the body‘s own cartilage is stimulated by
and treating knee, ankle and shoulder grinding down the damaged surface us-
joints. Arthroscopes are usually imple- ing a rotating burr, removing any rough
mented in order to perform joint reha- areas and drilling down to the subchon-
bilitation diagnostics and carry out an dral bone. This allows blood and bone
operation at the same time. In contrast to marrow cells to come to the surface and
traditional open surgical procedures, this nourish the damaged area. Ideally, over
minimally-invasive procedure has the time, the primitive blood cells turn into
advantage of less strain on the organism, cartilage cells which cover the damaged
less pain following an operation, less area with a new, healthy surface. Tech-
healing time and therefore faster reha- niques and results vary; generally, this
bilitation and return to day-to-day activi- procedure is used when the patient wish-
ties. es to delay the surgical replacement of
an afflicted joint.
When is the right time to start think-

ing about total joint replacement?
When pain and disability become too
great, an artificial joint can bring relief
and restore mobility. For all large and
medium-sized joints (such as hips,
knees, shoulders), joint replacement is
first of all the most sucessful form of
therapy when, despite pharmaceutical
treatment, the patient suffers from
constant pain, and second, when the
joint‘s functionality has been greatly
restricted.
Following an invasive operation, phys-
As a short-term solution, Corti- iotherapy and regular movement are
sone can be injected directly into required to ensure proper functioning
the joint. of the new artificial joint.

Die wirksame Schmerzsalbe
• schmerzlindernd
end
• entzündungshemm
• abschwellend
Mach mit
®
bei den Kytta
Wandertagen:
C
www.kytta.at
M
CM
MY
Simple movement exercises are integrated into CY
everyday life.
CMY
What should be done following an

operation?
In general, mobilisation begins already
on the day after the operation. This in-
cludes movement exercises and light
gymnastics under the professional di-
rection of a physiotherapist. These ex-
KY-14/07-CH-28-D
ercises are very important and, among

other things, reduce the risk of Throm- Bis zu 55 %
bosis. Later on, a regular programme of Schmerz-
remedial gymnastics is necessary to linderung bei
promote muscle growth and to im- Kniearthrose
prove the mobility of affected joints.
Finally, a special set of movement exer-
cises should be performed at home on
a daily basis.
Wirkstoff: Flüssigextrakt aus der Beinwellwurzel
Über Wirkung und mögliche unerwünschte Wirkungen informieren Sie sich
in der Gebrauchsinformation oder fragen Sie Ihren Arzt oder Apotheker.
Osteoporosis
OSTEOPOROSE
es are usually in equilibrium, which is

mainly regulated by the “resting” bone
cells (osteocytes).
The bones are built up throughout the
childhood and adolescence years,
when the need for calcium and vitamin
D is very high. The body produces Vita-
min D itself in sufficient sunlight, but a
smaller proportion can also be sup-
plied through diet. Ideal sources of cal-
cium are milk, yoghurt, whey products
and cheese. Children 7-13 years old
need about 1,000 mg of calcium daily.
By comparison, a quart of milk contains
about 300 mg of calcium. In addition to
a calcium-rich diet, physical activity
supports proper bone mass. The differ-
ent loads while running, hopping,
jumping and stopping are ideal for
bone growth - this establishes a sort of
“bone stock“ which one consumes
throughout his entire life.
When is the maximum possible bone

What is the role of bone mass in our density reached?
body? In females, the maximum bone density
Our skeleton has several important func- is reached at the age of 16, and in males
tions: It protects the internal organs, somewhere between 18 and 20.
regulates our calcium balance and car-
ries us through life. Bones are living Why does bone density increase with
matter; they are well supplied with blood advancing age?
and bone mass is in a constant state of A measurable physiological loss of bone
flux. For this purpuse, the body has dedi- density occurs at about the age of 30.
cated cells: bone resorption cells (osteo- The loss is around 0.5-1.0% per year and
clasts) “strip” the bone, and the bone may rise at least temporarily to 8-10%
formation cells (osteoblasts) refill the per year in females who are entering
cavities in the bone tissue. Both process- menopause.

Osteoporosis
How many people are affected?

Tip: A lot of movement from childhood It is estimated that around 800,000 peo-
onward, and a balanced diet (calcium, ple in Austria are affected by Osteoporo-
vitamin D), help to slow down this pro- sis. Probably the best studied of all frac-
cess! tures is the hip fracture, which occurs
approximately 14,000 to 16,000 times
What exactly is Osteoperosis? per year in Austria. The probability that
Osteoporosis is a skeletal disease char- an Austrian woman over the age of 50
acterized by low bone density and de- will suffer from one of the typical osteo-
creased bone quality. Significantly porotic fractures is around 45%, Austri-
more bone mass is broken down than an men about half as often as women.
is built back up; thus, the bone is light-
er, weaker and more fragile. The risk of Why are women more susceptible than
fractures increases substantially; espe- men?
cially in old age, this risk increases For genetic reasons, the bone mass of a
greatly. woman is lower than that of a man. In
addition, with the onset of menopause,
What are the consequences of less and less estrogen is produced. This
Osteoperosis? hormone has a bone-protecting effect.
Typical for osteoporosis are fractures of As estrogen decreases, more bone is dis-
the vertebrae, the hip (especially the solved than is replenished. However, not
femoral neck region), the upper arm or only women in menopause are affected
wrist. Osteoporotic fractures typically by osteoporosis; underweight women
occur with minimal force. They can and girls also have an increased risk of
even occur spontaneously while stand- osteoporosis, because a
ing, walking or sitting - or even sleep- hormone disorder of-
ing. Simple movements, e.g. lifting a ten accompanies
tote bag, or hitting a hand on a box, their condition.
can also end up in a fractured bone.
For patients with osteoporotic vertebral
fractures, in addition to a significant de-
A kyphosis is caused by dips in
crease in body size, the result can be de-
the spine.
formations of the spine - leading to the
so-called “dowager‘s hump”. The defor-
mation of the spine can then restrict the
breathing or may also result in painful
and problematic displacements of the
internal organs.

Osteoporosis
What risk factors contribute to • A lack of the hormone testosterone in

Osteoperosis? men.
• Sex: Women are more often affected. • Reduced formation of the hormone
• Genetics: If inner-circle blood relatives estrogen in women: for example, by
have suffered from a broken hip or fe- late first menstrual period (after the
mur. age of 16), early menopause (before
• Advancing age: The rist of new bone the age of 45) or frequent menstrual
fractures rises with each decade (60, 70, disorders.
80 years old, etc.). • Unhealthy lifestyles: Lack of exercise,
• Bone fractures: Previous bone frac- many years of smoking, too much al-
tures raise the risk of further bone frac- cohol, malnutrition with too little cal-
ture. cium, and too little vitamin D and pro-
• Significant Disabilities (such as being tein (e.g. as with anorexia).
bedridden) • Underweight or very slim stature
• Pre-existing conditions: For example, (body mass index <18)
Hyperthyroidism, rheumatoid arthri- • Medications: Some medications can
tis, types 1 and 2 diabetes, kidney or adversely affect bone metabolism. In
liver disease, COPD, hormonal disor- this way, for example, Cortisone re-
ders and intestinal disorders such as duces calcium absorption into the
chronic inflammatory bowel disease bone if it is taken for more than three
or celiac disease. months. The same is true for gli-
Osteoporosis is characterized by a porous bone structure.

Osteoporosis
tazones (for diabetics) and proton

pump inhibitors (stomach protection).
How can I tell if Osteoperosis is

developing?
The first signs of this disease can be
chronic back pain after the age of 50,
height loss, increasing kyphosis, pro-
trusion of the abdomen without
weight gain, lightning attacks of pain
in the spine, increased wrinkling on the
back as well as fractures, especially of
the hands, arms, ribs and hips (not due
to sports or car accidents). Still, the loss
of bone mass can continue for a long
time without being noticed. Therefore,
regular check-ups are very important!
What screening examinations are Milk delivers calcium which is important to counter
recommended? the loss of bone mass.
An important preventive measure is
bone density scanning, which - depend-
ing on what risk factors are present - 1500 mg daily) and vitamin D (800
should be carried out between the ages units daily), whose dosage is deter-
of 50 and 60 in consultation with a doc- mined by the physician.
tor. Basically, the first bone density test
is given to women not at risk of fractures Important sources of calcium are milk
at the age of 65; earlier for women who and milk products, also spinach, broc-
are at risk. For men not at risk, the first coli, hazelnuts and calcium-rich min-
measurement is advised at the age of 70; eral water. However, the total calcium
for at-risk men regardless of age. intake should be taken into account, as
it is now well established that an excess
Blood tests provide information about of calcium, especially if it is adminis-
bone metabolism and hormone levels. tered with medications, can also cause
Also, X-ray, CAT scan or MRI examina- damage to the organism. Large quanti-
tions are important for detecting sig- ties of alcohol and excessive smoking
nificant changes in the spine. can have negative influence on calcium
levels.
What is treatment like?
The basis of any osteoporosis treatment Tip: Calcium should be taken with a lot
is the adequate intake of calcium (1000- of water!

Osteoporose
The first signs of osteoporosis can

be breaks, especially in the forearms,
vertebrae and hips.
The bone vitamin D can only be devel- As a third pillar supporting the treat-
oped in meaningful amounts via sun- ment, classes of active pharmaceutical
light. Therefore, you should spend at ingredients can be implemented to
least 30 minutes a day outdoors. A lower the risk of a fracture, to minimize
smaller proportion may also be includ- the loss of bone mass, and to promote
ed in the diet; plenty of vitamin D can bone mass buildup and therefore the
gotten from fatty fish and egg yolks, for bone stability. In any case, this medica-
example. tion should be taken according to pre-
scription, since die danger of bone
The second important pillar of treat- fracture increases again.
ment is regular exercise. with the assis-
tance of a therapist, risk patients should Which medications help with Osteo-
carry out special exercises for muscle porosis?
and bone strengthening. Using a tar-
geted pain therapy is again possible 1. Bone resorption-inhibiting substances
and necessary for osteoporosis patient These are substances that inhibit bone re-
fitness. sorption in the first place. They increase

Osteoporose
bone density in all skeletal regions and,

with continued treatment, reduce the inci-
dence of fractures. This class of substances
includes:
• Bisphosphonates: These medications
slow down the activation of those cells
(osteoclasts) involved in bone resorp-
tion. You can take them in tablet form
once a day, once a week or once a
month, and they are available as
three-month injections or short infu-
sions administered once per year.
Bisphosphonates lead to an improve-
ment of bone stability through en-
hanced mineralization of bone tissue.
• Denosumab: This substance is one of
the so-called biologicals, which often
find useful application in Rheumatol-
ogy. Similar to bisphosphonates, they
lead to increased bone stability
through an increase in mineraliza-
tion. The administration is every six
months as an injection into the ab-
dominal skin.
• Selective east (E) estrogen receptor
modulators (SERMs): They also have Consult with your doctor to better understand
a similar effect as do bisphosphonates. treatment options.
An improvement in bone stability is
achieved mainly through increased
bone mineralization. • Parathyroid hormone: Currently, only
the PTH analogue 1-34 (teriparatide)
2. Dual active substances is available for the treatment of osteo-
• Strontium ranelate: reduced fracture porosis. This ingredient stimulates the
risk by promoting bone formation and bone-building cells and thus leads to a
inhibiting bone resorption. “real“ new bone formation. It is ad-
ministered once daily, preferably in
3. Bone formation-promoting substances the abdominal skin. The duration of
These substances are used in high-risk treatment is limited to two years, after
patients who are particularly at risk of which the targeted bone buildup is
fracture, and used when treatment consolidated with bone-resorbing in-
with bisphosphonates is not sufficient. flammatory drugs.

SOFT-TISSUE
RHEUMATISM
A typical indicator of Fibromyal-
gia is pain throughout the body.

Fibromyalgia
THE FIBROMYALGIA SYNDROME
What is Fibromyalgia? Fibromyalgia is not only associated

Fibromyalgia is a chronic disorder charac- with great distress for the patient, but
terized by musculoskeletal pain. It is in- can rather in many cases lead to social
flammable and non-deforming. Since the impairments such as the loss of a job,
symptoms are quite varied and the disease relationship problems and social with-
is difficult to detect, the causes have been drawal.
unknown for a long time. Today, scientists
suspect a disturbance in the body‘s pro- Who is affected?
cessing of pain. In Austria there are likely well over
100,000 people who suffer from this dis-
What are the symptoms? ease. Women are seven times more fre-
Fibromyalgia paints a uniquely complex quently affected than men by fibromyal-
clinical picture. The patients have both gia. Although rare, children can also be
physical and psychological symptoms; affected. The disease usually begins slow-
they feel sick and suffer greatly. A typi- ly at the age of about 35 years and reaches
cal characteristic of fibromyalgia is the its peak during menopause. Throughout
so-called whole-body pains lasting at their professional or private lives, Fibro-
least three months: The patient com- myalgia patients often feel extremely
plains of large (muscle) pain from head stressed, are hyperactive and tend to-
to toe, especially in the spine, arms and
legs, but also insomnia, anxiety, ex-
haustion, chronic fatigue and depres-
sion can occur. These symptoms vary in Sufferers often withdraw due
severity and often occur after minimal to a general air of misunder-
physical strain. standing.
Often, the pain all over the body is am-
plified by stress, cold or physical stress.
There may be a perceived swelling of
the extremities and burning skin pain.
Furthermore, reduced performance,
dry eyes or mouth, irritable bowel syn-
drome, headaches, feelings of anxiety,
sensitivity to cold, migraine or heart
problems are cited by sufferers.
Many of these symptoms point to in-
creased activity of the sympathetic
nervous system.

Fibromyalgia
ward perfectionism, putting aside their tients to engage in an active lifestyle

own needs. and thereby obtain his social and pro-
A latent damage of the stress processing fessional functionality. Any therapy
system in early-childhood trauma or must be individualized to suit the par-
pain experiences can already lay the ticular disease activity. Basically, the
foundation for Fibromyalgia. treatment requires great personal at-
tention and is usually very time-con-
A “Secondary Fibromyalgia” can also be suming. The primary therapeutic mea-
a result of an inflammatory rheumatic sures - set after diagnosis - are
disease such as rheumatoid arthritis or psychotherapy, relaxation training and
systemic Lupus occur. a customized, graded exercise therapy,
which do not overwhelm the patient. As
With which methods is the illness
diagnosed?
Before the Rheumatologist has diag-
nosed you with Fibromyalgia, other dis-
eases must first be ruled out. The reason
is that other illnesses can hide behind the
symptoms. Therefore, a rheumatological
examination of the entire musculoskele-
tal system is carried out, and laboratory
and x-ray examinations are made to ex-
clude inflammatory forms of rheuma-
tism or thyroid disorders. If these find-
ings are unremarkable, then Fibromyalgia
syndrome presents itself as a diagnostic
option.
Important diagnostic aids can be pres-
sure-sensitive points on the body. The
doctor presses with his thumb on cer-
tain points which are distributed all
over the body. These so-called “tender
points” on the neck, above the shoulder
blades, at the clavicles, in the sacral re-
gion, the outer thighs (below the pelvic
bone) and in other places, are in any
cases not conclusive.
How is Fibromyalgia treated?

Fibromyalgia is not curable. The main
goal of treatment is to motivate the pa-

Fibromyalgia
drug adjunctive therapy antidepressants, Which complementary therapies can

antiepileptic drugs and other substances help?
can be used. As a supplement to the “classic” acu-
puncture therapy, traditional Chinese
What other treatment options are medicine (TCM), osteopathy, craniosa-
there? cral therapy, homeopathy, neural thera-
Since painkillers are for limited use only, py, manual medicine and even perma-
in the case of Fibromyalgia, experts also nent magnetic fields are used. The goal
use the following (“multimodal”) meth- is balance throughout the entire energy
ods: balance of the body, and thus pain re-
• Physical therapy, behavioral therapy lief.
and exercise, and active techniques Always discuss complementary thera-
for pain control. pies with your doctor!
• Heat treatments with local packs, ul-
trasound or spas help to relax muscles How important is physical activity?
and kill pain. Exercise is an important part of the reha-
• Lymphatic drainage and acupuncture bilitation programme, however, under su-
massages decreaase local congestion pervision and in moderation to avoid re-
and reduce pain. lapse. Cardiovascular exercise (ergometer,
•Treatments in infrared heat cabins as Nordic walking, cross trainer) has an anal-
well as cold chambers can lead to very gesic effect, since more growth hormones
good results. and endorphins are produced. In addition,
therapeutic exercise is necessary for
Why is mental care necessary? strengthening the muscles and improved
Psychotherapeutic treatment should aim posture. Individual physiotherapy and
at changing attitudes and behavior pat- small workout groups have proven very
terns. Patients with Fibromyalgia tend to successful. Underwater gymnastics is
have a catastrophic outlook on life, known for its excellent effects on pain and
thereby placing themselves under stress. the psyche. The combination of these two
Since stress can play a key role in the measures is therefore extremely useful,
pathogenesis of the disease, it is recom- and each workout should always start very
mended that sufferers work with a thera- gently.
pist to manage problem situations. It is
often important to involve family mem- Self-awareness programs focusing on
bers in the therapy. Support groups can the body have also achieved positive
also be helpful. results. This is where patients learn
In addition, relaxation exercises such as how to deal with their bodies and their
progressive muscle relaxation, auto- energy in more constructive ways. Em-
genic training and other relaxation phasis is placed on the balance be-
techniques have a positive effect on tween activity and rest phases.
stress.

Polymyalgia rheumatica
POLYMYALGIA RHEUMATICA (PMR)
What is Polymyalgia rheumatica? tory disease that usually occurs after the
Polymyalgia rheumatica (PMR; Greek/ age of 50. Women are much more fre-
Latin) is a member of the vascular in- quently affected than men. Every year,
flammation family. It manifests itself around 2000 to 4000 Austrians are af-
mainly with an acute onset and severe fected.
pain in the shoulder and pelvic girdle
muscles. It is clear that it has to do with What are the symptoms?
an overactivity of the immune system, Typical symptoms include severe pain in
which in turn attacks the body. the shoulder muscles on both sides, par-
Polymyalgia rheumatica can be treated tial lifting of the arms is hardly possible.
very well. It is one of the best prognostic Pain also appears in the pelvic girdle and
rheumatic diseases. However, here as thighs; the hands lose power. Pain is of-
well, early diagnosis is of great impor- ten particularly strong during the night
tance, so that you can start quickly with and early morning hours. The upper
the appropriate treatment. arms and thighs are often very sensitive
to pressure. In the morning the arms and
Who is affected? legs feel stiff, with mobility improving
PMR is a relatively common inflamma- throughout the day.

Where does the discomfort originate? ed, the lower the risk of permanent
An inflammation of the synovial mem- damage.
branes, especially of the shoulder and
hip joints, visible on ultrasound, is re- What causes GCA?
sponsible for these pains. Depending Patients with giant cell arteritis suffer
on the inflammatory activity it leads to from general malaise. It feels like the
weight loss, increased body tempera- flu, possibly associated with fever,
ture and general malaise. In approxi- weight loss, night-time sweating, loss
mately 50% of all cases, a giant-cell ar- of appetite and general weakness. The
teritis occurs together with the PMR, other symptoms are variable, depend-
especially the temporal artery near the ing on which vessel area is affected.
temples (Morbus Horton). Arteritis temporalis Horton, for exam-
ple, causes throbbing, one-sided
What is a Giant-Cell Arteriris (GCA)? headaches in the temple region, which
The giant-cell arteriris is also one of the
inflammatory diseases of the blood ves-
sels. Mainly found in women over 50
years of age, peaking around the age of
70. When the large arteries of the circu-
latory system are affected, mostly in the
coverage area of the external carotid ar-
tery (Arteria carotis externa) above the
aorta. In the case of Arteriitis temporalis
Horton, the affected temporal artery on
the temple is clearly visible from the
outside - therefore the name.
The persistent inflammatory activity
results in a narrowing of the affected
vessels up to the occlusion, whereby
the organs behind the damaged area
receive less blood. This may result in
pain when chewing, for example. With-
out treatment, the result could be inju-
ry to the eye - in the worst case, blind-
ness. However, there are treatments
available with which almost all patients
can achieve and maintain freedom
from pain. Again, the earlier the dis- Without treatment, the eye is in danger of damage
ease is detected and treatment is start- - even blindness.

PMR most often begins with strong neck pains and headaches.
are aggravated by coughing or moving tion rate and other inflammation pa-
of the head. Some patients experience rameters are strongly to very strongly
visual disturbances (diplopia), pain increased. Typical of Polymyalgia Rheu-
when moving the eye or impaired vi- matica is also the lack of laboratory val-
sion. ues that show damage to the muscles
(e.g. no increase in the so-called cre-
How does the doctor diagnose PMR? atine kinase).
There are no typical findings which can
be regarded as positive evidence of the How is PMR treated?
existence of Polymyalgia Rheumatica. PMR can be treated quite well with glu-
If the symptoms raise suspicion that cocorticoids (Cortisone). Characteristic
the illness is PMR, then at diagnosis of PMR is the almost immediate re-
other diseases must be excluded that sponse of the patient to the treatment.
display similar symptoms. Certain crite- The effect of the therapy is checked by
ria (see box) are then used to confirm monitoring the symptoms and the in-
the diagnosis of Polymyalgia Rheumat- flammation parameters - best summed
ica. Thus, for example, in laboratory up as PMR-AS (“Polymyalgia rheumati-
findings the erythrocyte sedimenta- ca activity score“). Accordingly, the

dosage of medication is slowed to a

minimum maintenance dose. The slow
reduction of drug therapy is recom-
mended to prevent relapses.
In general, patients can plan on an av-
erage treatment duration of approxi-
mately one year. If a Giant-Cell Arteriris
(GCA) is adjacent to the PMR, higher
drug doses are required in order to re-
duce inflammation and to prevent per-
manent damage.
How do Glucocorticoids work?

Glucocorticoids - natural hormones pro- Information is extremely important.
duced in the adrenal cortex - are espe-
cially useful in rheumatic diseases, the inflammation quickly and effective-
mainly because of their strong anti-in- ly; thereby the pain caused by the in-
flammatory properties. They suppress flammation also soon subsides.
EULAR/ACR classification criteria of

Polymyalgia rheumatica (PMR), 2012
The following must be present: age> 50 years, bilateral shoulder pain, increased CRP (laboratory value
that indicates inflammation) or elevated ESR (erythrocyte sedimentation rate measurement, a simple
and meaningful method for the detection of pathological changes in the body)
Points – Points –
clinical criteria clinical criteria
without ultrasound with ultrasound
Morning stiffness > 45 minutes 2 2
Hip pain or decreased range of motion 1 1
Absence of the rheumatoid factor or the ACP
2 2
(anti-citrullinisierte peptides)
Absence of other joint problems 1 1
Ultrasound criteria:
at least in a shoulder joint: subdeltoid bursitis, tenosy-
novitis of the biceps tendon or joint inflammation and 1
arthritis in at least one hip or trochanteric bursitis
in both shoulders: subdeltoid bursitis, tenosynovitis of
1
the biceps tendon or joint inflammation
The existence of PMR can be determined when 4 (clinically without ultrasound) or 5 (using ultrasound) points
have been scored (sensitivity 68% and 66% with ultrasound, specificity 78%, or by ultrasound 81%). (Arthr
Rheum 2012; Vol 64, No. 4, 943-954.)

AUTOIMMUNE
ILLNESSES
They can lead to chronic inflammation of
the skin, joints, nervous system and inner
organs.

Systemic Lupus erythematosus
SYSTEMIC LUPUS
INCLUDING DRUG THERAPY
What does the term “Systemic Lupus male hormones (estrogens) have an in-
erythematosus“ mean? fluence on the development of the dis-
Systemic lupus erythematosus (SLE) is ease.
an autoimmune disease in which there is Systemic lupus erythematosus is rare
chronic inflammation of the skin, joints, with approximately 50 sufferers per
nervous system, and internal organs. The 100,000 people.
disease usually comes and goes in phases
for years: High disease activity alternat- What causes systemic Lupus erythe-
ing with periods of improvement. The ill- matosus?
nees got its name due to the typical le- The exact causes of SLE are not (yet)
sions on the face since scarring, redness known. What is certain is that, antibodies
and furrows look like a “wolf rash“ (Latin are formed in the blood against cell compo-
lupus. Wolf; Greek erythematosus: red.). nents, often against the nucleus. These so-
However, such severe skin afflictions oc- called auto-antibodies attach themselves to
cur rarely anymore due to much better the body’s own healthy tissue and trigger
treatment options. inflammation from them. It then occurs
“Systemic“ means that internal organs that structures of autoantibodies, cellular
are affected by the disease. When only debris and immune
the skin is affected, the diagnosis is cells collect in the
“chronic discoid lupus“ (CDLE) or “sub- walls of small
acute cutaneous lupus“ (SCLE). Systemic blood vessels.
lupus erythematosus is one of the rheu-
matic and collagen (connective tissue)
diseases. However, in reality the disease
has nothing to do with the collagen in
our bodies.
Who becomes ill with SLE?

The patients are mostly young women
between the ages of 15 and 40 years (ra-
tio of female:male = 10:1). In children,
systemic lupus erythematosus occurs
predominantly between 11 and 15 years
of age. Here, too, the disease is much
more common among girls than boys.
For this reason, it is believed that the fe-
Regocnizing warning signs
The first signs of systemic lupus erythematosus are very

unspecific. The following questions may be helpful for
diagnosis:
• Are you sometimes tired and worn

out for no good reason? yes no
• Do you often have joint or
rheumatic pains? yes no
• Are you sometimes nauseated? yes no
• Do you often experience hair loss? yes no
• Do you often suffer from
headaches? yes no
• Do you get much sleep, but are still
tired? yes no
• Are your mouth and eyes sometimes
dry? Do you have conjunctivitis? yes no
• Do you experience repeatedly
elevated temperature or
inexplicably high fever? yes no
• Do you occasionally notice a butterfly-
shaped rash on your face or red
patches elsewhere on the body? yes no
• Are you sensitive to light and
cannot tolerate sun? yes no
• Have you been to many doctors
and not one could find an
explanation for your symptoms? yes no
If you answered three or more of these questions with “yes“,

this may indicate “Lupus erythematosus“ and you should
discuss the symptoms with your family doctor, who - if
necessary - will refer you to a Rheumatologist on suspicion
of SLE. Enlarged lymph nodes and fatigue may
be a sign of SLE.

The result is inflammation in various or- exhausted, many suffer fever, weak-
gans, whereby primarily blood vessels in ness and weight loss. The lymph nodes
the skin, kidney and joints are affected. are usually enlarged. Which organs are
An accumulation of the disease in some affected and to what extent the symp-
families suggests a genetic predisposi- toms may occur, is very individual.
tion. Scientists suspect a hereditary error In very rare cases, SLE spreads to the
of programmed cell death of certain im- nerves, leading to numbness, pain, in-
mune cells. The risk of passing on the creased sensitivity and a reduced tem-
disease to one’s own children is still con- perature sensitivity. This numbness usu-
sidered low, because even in genetically- ally occurs on both sides of the hands and
identical twins the disease affects both feet. Also, headache, seizures, visual dis-
siblings only in a quarter of cases. Vari- turbances, confusion and depression can
ous environmental factors may play a occur in systemic Lupus erythematosus.
role as a trigger in the pathogenesis of
SLE, such as infections with viruses or
bacteria, intense sunlight, extreme cli- Tips on SLE
mate changes, major mental stress and
hormonal changes such as can occur in
puberty, pregnancy and menopause.
An extremely rare special form of the The presence of SLE is likely if at least four of
disease is the so-called drug-induced the following are true (criteria of the American
Lupus erythematosus: In certain indi- College of Rheumatology - ACR):
viduals, some drugs (eg, antiepileptics,
blood pressure medications, antibiot- • butterfly rash
ics, hormones) can trigger SLE. The • disk-shaped raised exanthema/skin rash
symptoms usually disappear entirely • sensitivity to light
once the drug has been discontinued. • tissue defects of the mouth and nose
• inflammation of two or more joints
What are the symptoms of SLE? • pleura or pericarditis
A systemic Lupus erythematosus mani- • afflicted kidneys (protein in urine)
fests itself in many different symptoms. • infection of nerves and brain
A well-known, but not always present,
• typical blood findings (specific form of ane-
indicator of the disease is a butterfly- mia, decreased platelets [thrombocytopenia]
shaped redness (erythema) of the face and/or white blood cells [leucopenia])
on both cheeks and on the bridge of
• typical immunological findings: autoantibo-
the nose, which is more pronounced in
dies vs. endogenous DNA
sunlight. Other symptoms include joint
• antibodies directed against components of
pain, circulatory disorders of the fin-
the cell nucleus
gers and organs are affected (eg, kid-
ney inflammation, pleurisy or pericar-
ditis). Most patients feel tired and

The aim of the treatment of SLE is to calm the body‘s immune response.
Does it result in permament joint parts of one’s body (antibodies) in the

damange? blood. In addition, a histological exami-
Unlike other rheumatic diseases, sys- nation of a skin sample (and in some
temic Lupus erythematosus usually cases also a kidney sample = renal bi-
causes no permanent damage to the opsy) is performed. This plays a crucial
joints visible on X-ray. role in the diagnosis, regarding whether
more typical symptoms are simultane-
ously present (see the “Tipd on SLE”
box). Since SLE can also lead to circula-
How does the doctor reach his diag- tory disorders, microscopic examination
nosis? of the blood vessels can also be recom-
The diagnosis on whether systemic Lu- mended.
pus erythematosus is present is reached The detection of the disease (diagno-
by judging the affliction, conducting sis), treatment (therapy) and care are
technical investigations (laboratory necessarily in the hands of specialists
tests, ultrasound, etc.) and through the (for internal medicine and rheumatol-
determination of defensive substances ogy, specialized in SLE); skin-only forms
produced by the immune system against are handled by specialized dermatolo-

gists. The close cooperation between suppressive and cytotoxic drugs are used
specialist and family physician is par- in more severe phases of the disease.
ticularly important in SLE.
What side-effects can occur?
How is systemic Lupus erythemato- As with all medications, DMARDs can
sus treated? cause side effects even in the case of sys-
The aim of the treatment of SLE is the temic Lupus erythematosus. They are
defensive reaction of the body to calm each different. Therefore, regular blood
down (immune modulation) or to sup- tests are essential. Furthermore, suffer-
press (so-called immunosuppression). ers should note that the long-term use of
Different groups of drugs are used.The immunosuppressants can lead to infec-
first step is to relieve the symptoms tions, such as colds, due to the immune
with rheumatoid painkillers. Although system being weakened by drugs. Pa-
systemic Lupus erythematosus is not tients should therefore pay attention to
curable, the disease is still treatable. the first signs of infection and intervene
What treatment is used is determined quickly.
by the severity of the disease and the
organs affected by a specialist (rheu- Are complementary medicinal SLE
matologist). therapies useful?
A variety of complementary medical ther-
For the treatment of Lupus erythema- apies exist that can be applied for SLE,
tosus the following steps are valid such as homeopathy, traditional Chinese
(from lighter to heavier drugs): medicine (TCM) and acupuncture - just to
• Painkillers name a few. The choice of the method de-
• Antimalarials (chloroquine, for example) pends on the individual patient’s situation.
• Cortisone
• Immunosuppressants (medicines that slow
down the work of the immune system such as
azathioprine, cyclosporine A, mycophenolate
mofetil)
• Biologicals (belimumab)
• Cytotoxic drugs (eg, methotrexate, cyclophos-
phamide)
These drugs are designed to curb inflam-

mation and excessive immune system
activity. The use of antimalarial drugs
produce particularly good results in Lu-
pus erythematosus with respect to skin
symptoms and joint problems. Immuno-

Sufferers should avoid direct sunlight and always use sunscreen.
In controlled studies, the effects of com- ries”), therefore nicotine must be avoi-
plementary medicine have not been prov- ded!
en. It is important to ensure that the basic
treatment is continued, because the com- •
Contraception and pregnancy should
plementary measures should be consid- be discussed with the Lupus rheumato-
ered only as a supplement and the different logist specialist.
approaches are complementary and not
exclusive. Therefore, you should consult • Immunizations (e.g. influenza vaccina-
with your Rheumatologist on all forms of tion) should be discussed by SLE pati-
treatment that you wish to use! ents in advance with their doctor. Some
live vaccines can trigger a disease flare.
What else should SLE sufferers watch
out for? • Exercise and sports in moderation are
• Sunlight and UV light may enhance di- recommended because movement sup-
sease progression. Therefore, sufferers ports the function of the immune sys-
should avoid direct sunlight and always tem and the psyche.
use sunscreen. Above all, they should
steer clear of the tanning salon! • On long car rides or flights, SLE pati-
ents should consider a thrombosis pro-
• SLE patients have an increased risk of phylaxis, because they are particularly
atherosclerosis (“hardening of the arte- vulnerable to vascular complications.

tions. Basically, it cannot be ruled out

• In addition, sufferers should try to lead that women affected with Lupus ery-
a positive life despite the disease...be- thematosus can become pregnant. In
cause the immune system works better periods of high lupus activity and thus
for those who feel well mentally. Here, required higher quantities of drugs,
for example, the exchange with other however, it can lead to cessation of
sufferers can be helpful as part of a menstruation and ovulation and thus
support group. Specialized centers bring about temporary infertility. In
have counseling programs for disease times of severe disease activity or kid-
management (coping). ney problems, due to the high risks for
mother and child, it is better to wait for a
SLE and pregnancy – what should be more favorable time for a pregnancy.
considered? Any plans to have children should be
For women who suffer from SLE, the de- thoroughly discussed with the Rheuma-
sire to have children raises many ques- tologist as well as the gynecologist.
Those with Lupus erythematosus should find out more before getting pregnant.

PAIN:
CAUSES &
TREATMENT
Pain should be cleared up as
soon as possible.

Pain: Causes & Treatment
What can be done for pain? How is thepain treated?

Be sure to quickly discuss with a doctor By today‘s standards, the pharmaceuti-
how pain should be treated. Only a doc- cal treatment of chronic pain is carried
tor can make the right diagnosis and pre- out following the rules of the World
scribe the right treatment, and especially Health Organization (WHO) - estab-
eliminate or at least mitigate the pain. lished for the treatment of cancer pain.
As a basic therapy (schedule 1), so-
How does my doctor clarify the ill- called non-opioid analgesics are used
ness? (paracetamol, metamizol, NSAIDs,
First of all, a thorough investigation, clin- COX-2 inhibitors); in schedule 2, when
ical findings, imaging techniques (ultra- the schedule 1 medication has not
sound, magnetic resonance imaging) and been sufficient or is not tolerated, a
laboratory tests, during which primarily combination takes place with weak
inflammatory values and special rheuma- opioids. Only after exhausting these
tism values are ascertained. are strong opioids used (schedule 3).
Sufferers often have difficulty describ-
ing their pain. This is when the self-as- Step 1: What are the non-opioid
sessment can help by using a pain scale: analgesics?
The patient can mark his current pain as Non-opioid analgesics are pain-killing
a point on a scale - this also helps the drugs (analgesics) which act by sup-
doctor to assess the intensity. pressing pain-triggering biochemical
processes. Ideally, they suppress the sen-
sation of pain, without affecting aware-
Assessing the pain ness, sensory perception and other im-
portant functions of the central nervous
system. Substances such as dipyrone or
Answering the following questions is a
paracetamol are used for mild to moder-
good basis for consultation with your
ate pain. Many non-opioid analgesics
doctor:
also have an antipyretic effect.
Some substances from the group of non-
❑ When & where does pain occur? opioid analgesics are also effective anti-
❑ How strong is it? inflammatories. This drug group is also
❑ Do you experience stiffness or restricted called non-steroidal anti-inflammatory
movement? drugs (NSAIDs). These include the sub-
❑ Does the pain occur together with stance groups acetylsalicylic acid, ibu-
swelling? profen, dexibuprofen, diclofenac and
❑ Is it also accompanied by weakness, coxibs. Due to their anti-inflammatory
anxiety or fatigue? properties, they are the drugs of choice
for rheumatic pain.

NSAIDs: What can they do? What should be considered when

NSAIDs - non-steroidal anti-inflamma- taking NSAIDs?
tory drugs - are classic painkillers. They It is important to ensure that NSAID
are anti-inflammatory and analgesic. preparations are not taken on an empty
The complex name means nothing else stomach. Alcohol should not be con-
other than the fact that they are sub- sumed, especially not together with the
stances that have nothing to do with NSAID.
Cortisone (non-steroidal). These drugs Particularly at risk are patients,
inhibit the formation of pain media- • are older than 65 years,
tors, the prostaglandins (hormone-like • who have had a stomach ulcer or a
substances that increase the sensitivity duodenal ulcer (ulcer) in the past, or
of pain receptors). NSAIDs often take • additionally get Cortisone in addition
effect within a few hours. They can be to NSAIDs, or
administered in tablet form, as a sup- • blood-thinning medications.
pository, or via syringe. They are also
available as sustained-release prepara- Important Note:
tions - that is, the effect is a timed de- If aspirin has been coadministered with
lay. The choice of a suitable drug should NSAIDs, it should always be taken two
always be discussed with and approved hours before the NSAIDs. Periodic
by your doctor! blood tests relating to liver and kidney
function are essential. The intake of
Are there any side effects of NSAIDs? two different NSAIDs massively in-
The general rule is: The longer the treat- creases the risk of side effects. Interde-
ment lasts and the higher the dosage, the pendencies with drugs that inhibit
more undesirable the effects. Especially blood clotting or lower blood sugar are
the mucosa of the gastrointestinal tract is not rare, and therefore should be dis-
the target of these side effects. It is esti- cussed with your doctor.
mated that, with prolonged use, these
drugs will form a stomach or duodenal What is gastric protection in connec-
ulcer in about 10% of patients. The prob- tion with NSAIDs?
lem is that sufferers usually do not feel it Since negative effects on the gastric mu-
at all, as the resulting stomach problems cosa is one of the major side effects of
are not perceived due to the loss of the NSAIDs, a gastric protection therapy
sensation of pain. Especially in older pa- should be used in particular by those
tients, NSAIDs may also affect kidney risk patients described above. Three
function and lead to water retention in the modes of action are available:
legs (edema) or high blood pressure. • Proton pump inhibitor (PPI): reduces

stomach acid and prevent defects on

the stomach wall
• Prostaglandins (Pg): protect the gas-
tric mucosa
• H2 blockers: can be used in higher
doses, when PPI or Pg are contraindi-
cated
How do COX-2 inhibitors work?

This group of substances has the positive
effects, but not the side-effects, of NSAIDs
in the gastrointestinal tract. The improved
gastrointestinal tolerability of coxibs
based on the different inhibition of both
cyclooxygenase enzymes (COX-1 and When taking NSAIDs, gastric protection therapy is
COX-2), which were discovered in the required.
early 1990s. Like the non-steroidal anti-
inflammatory drugs (NSAIDs), Coxibs
also inhibit the formation of endogenous However, as with all other NSAIDs, par-
prostaglandin pain messengers (a COX-2 ticular caution is required in case of
inhibition). COX-2 is activated mainly in known cardiac, circulatory or kidney
inflammatory processes in the damaged disease...especially if they are taken dai-
tissue. COX-1 is responsible for the pro- ly for several weeks. Furthermore, skin
tection of the gastric mucosa from stom- reactions, respiratory distress, poor con-
ach acid, but is not inhibited. So Coxibs do centration and fatigue have been ob-
not interefere with the effectiveness of the served in rare cases.
protective COX-1 enzyme, but specifical- The use of COX-2 inhibitors is fully jus-
ly suppress the function of the enzyme tified by the absence of heart disease,
COX-2.. namely in groups of patients at risk for
the occurrence of gastrointestinal side
Are there any side effects of COX-2 effects due to an NSAIDs.
inhibitors?
Unfortunately, selective COX-2 inhibi- Schedule 2 and Schedule 3: At what
tors are not completely free from side point are opioids used?
effects. Due to the method of action, the According to national and international
rate of dangerous gastrointestinal side recommendations, opioids are used for
effects can be reduced significantly. the treatment of rheumatic pain if it can-

‘Joie de vivre‘ is important for dealing with pain.
not be satisfactorily treated with other (oxycodone, hydromorphone, buprenor-

measures, or when discontinuation of phine, fentanyl).
previous medication is necessary be-
cause of side effects. The approach is es- How great is the risk of addiction with
sentially this: According to the WHO opioids?
schedule plan, weak opioids such as tra- Such a risk is always present. However,
madol or dihydrocodeine are used first. when used properly, the concern of a possi-
Weak opioids may - mainly during the ble development of addiction is unfounded.
setting phase - cause side effects such as
nausea and constipation. Use of con- Are antidepressants also used in the
comitant treatment with laxatives, drugs treatment of pain?
for nausea and vomiting (antiemetics), Antidepressants can make an important
and antihistamines may, however, should contribution to freedom from pain in pa-
be well monitored. tients with Fibromyalgia or chronic pain
from other causes (eg, polymyalgia
If no pain relief has been achieved with rheumatica), on the one hand by improv-
this combination, weak opioids are re- ing the mood, and on the other by influ-
placed by strong schedule 3 opioids encing the perception of pain.

How can physiotherapy help? seems to relieve back pain immediate-

The application of physical therapy mea- ly (for a few hours maximum). High-
sures in pain patients has a long tradi- frequency pulses apparently work bet-
tion. It is important in the treatment ter than lower-frequency pulses.
compilation not to apply a “general reci- Whether the treatment works for lon-
pe,” but to respond to the particular ger periods is still unclear, according to
problems of individual patients and to studies. According to experts, TENS is
combine treatment options. more suitable as an adjunctive therapy
to relieve symptoms immediately and
What other non-pharmacological for a short time.
measures are used?
An integral part of non-pharmacologi- Who should not use TENS?
cal pain management is electrotherapy. • People with a pacemaker or other im-
Constant galvanization, iontophoresis, planted electrical device
impulse galvanisation, threshold and • if thrombosis is an issue
diadynamics are some current forms • pregnant women
which are used because of their circu-
lation-enhancing, pain relieving and How can massage help with pain?
muscle-relaxing effects. This includes Massage is applied to realize an analge-
TENS: The “transcutaneous electrical sic effect by releasing tension and dis-
nerve stimulation“ is a form of therapy persing pain-triggering substances (eg
with which one can treat acute and lactic acid). The pronounced psycholog-
chronic pain with currents of varying ical effect of massage treatment and care
frequency. Essentially, TENS works on should not be underestimated. Special
the principle of counter-irritation of massaging of the connective tissue,
pain stimuli. There are also small, por- manual lymphatic drainage, reflexology
table TENS units, which patients use and Periostmassage are also worth men-
independently at home - after instruction.
tion by the doctor or therapist.
How can heat or cold therapy help?
How long does a TENS session last? The application of heat promotes in-
A session normally lasts about 20-50 creased blood circulation and muscle
minutes. Since the analgesic effect usu- relaxation in the treatment area, and
ally lasts only a few hours, the treat- thus pain is relieved. Heat can be ad-
ment is often repeated several times a ministered in the form of mud packs,
day (two to four times). By contrast, in wraps, baths and hot air sauna. Ultra-
the case of chronic pain, TENS is often sound therapy and high-frequency
used for many years, e.g. in home treat- therapy are also considered heat treat-
ment. In general, treatment with TENS ments.

Cold therapy, whether in the How important is exercise for pain

form of ice packs or cold air relief?
in cold chambers, is a wide- An equally important part of pain man-
spread, supportive therapy agement is both passive and active phys-
for rheumatism, espe- ical activity. This includes every little
cially for inflammatory movement in the course of everyday life.
rheumatic diseases. Special physiotherapy fights not only
Cold therapy is locally symptoms such as morning stiffness, but
applicable to individual also reduces the fear of pain.
joints and body parts.
However, it is also used Why should pain patients seek psy-
as a full-body treatment. chological counseling?
The treatment of individ- Psychological support can help patients
ual body parts is carried with chronic pain to avoid the often
out using cold compress- onerous consequences of such disorders,
es of approximately mi- such as social isolation and hopeless-
nus 10 °C. When treating ness. Such professional advice should be
with cold compresses, an integral part of the therapeutic con-
care must be taken to cept. This also increases the motivation
ensure that the cold is for the long-term - sometimes unpleas-
transferred to the skin ant - therapies, thus improving success.
via a dry linen cloth
to avoid damage to
Reflexology for the skin‘s sur-
pain relief face.
How can acupuncture help rheuma-

tism therapy?
Acupuncture is primarily used to aug-
ment to pain relief efforts. Using acu-
puncture needles, certain acupuncture
points on the body are activated. These
points lie on certain lines on the skin -
the so-called meridians - and unfold me-
chanical irritation specific effects in the
body. Some patients respond well to
treatment with acupuncture.
Important Note: Although acupuncture

can relieve chronic pain, it does not af- Gespräche erleichtern den Umgang mit der
fect the course of the disease. Erkrankung.

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SUPPORT FROM
YOUR PHARMACY
Complementing your
basic therapy

SUPPORT FROM YOUR PHARMACY
Self-medication – what exactly does Important Note: Over-the-counter com-

it mean? pounds are no substitute for an estab-
In addition to the medications prescribed lished Rheumatic therapy!
by their doctors, patients often wish to
contribute to improving the state of their Does additional treatment for pain
health. The patient has access to non- make sense?
prescription, over-the-counter com- As a supplementary therapy for acute pain
pounds available in a pharmacy. The in terms of self medication, pain relievers
costs are not covered by medical insur- can be effective. Some of the more estab-
ance, and the patient must decide wheth- lished are:
er or not to use such products. In any • Acetylsalicylic acid
case, this should be discussed with a • Paracetamol
doctor as well as the pharmacist. • Ibuprofen
Below, you will find an excerpt of com-
pounds available in well-stocked phar- In addition to reducing pain, some re-
macies. duce swelling and lower fever.

Support from Your Pharmacy
It is most important to inform yourself about

the possible pharmacological interaction
with other drugs. Non-prescription pain re-
lievers should not be taken for longer than
two days without informing a doctor.
Are there additional effective non-

prescription remedies?
Yes. Drugs, dietary supplements and di-
etetic foods are available in the pharma-
cy in tablet or capsule form, which pro-
vide support in handling inflamation and
Fish high in Omega-3 fatty acids suppress
are not non-prescription. For example,
inflammatory activity.
Omega-3 fatty acids can help to relieve
rheumatic pains. Such compounds com-
plement pharmaceutical therapies pre- Omega-3 fatty acids can help regulate
scribed by doctors, and in many cases the inflammation process.
are helpful for individuals. Before tak- As has been mentioned, Omega-3 fatty
ing any such remedies, you should in- acids are ingested along with food. The
form your doctor of your intention to main sources are plant oils such as lin-
begin with a supplementary therapy. seed, sunflower, corn, rapeseed and soy-
bean oil, along with maritime cold-water
What do Omega-3 fatty fish high in fat, such as herring or mack-
acids do? erel. Two fish-based meals per week can
Certain fatty acids are deliver enough Omega-3 fatty acids.
not produced by the Since many people do not eat enough
human body; they fish, this means not enough Omega-3
must be introduced fatty acids are absorbed. Therefore, one
along with food. Ex- option is to take high-dosage Omega-3
ample: The Omega-3 fatty acid capsules. They can be taken in
fatty acids. These are addition to standard therapies, and are
essential vital fatty ac- available in your pharmacy.
ids because they are of
primary importance Can homeopathic remedies help?
for the various cel- Some concerned patients resort to ho-
lular functions. meopathic remedies, operating on the
Precisely with principle that the body‘s capacity to
regards to the heal itself needs to be stimulated. Ho-
rheumatic meopathic compounds, then, target
illnesses, it is the recovery of the body‘s natural reac-
assumed that tion and regulation. However, homeo-
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Dr. Böhm®: Qualität, die Vertrauen schafft Rheuma

– mitverstehen
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2014 105
eines GMP-zertifizierten pharmazeutischen Unternehmens.
Support from Your Pharmacy
pathic remedies should only be used as Which medicinal plants are available,
a supplement, and under no circum- especially to help with rheumatic ail-
stances as a replacement for basic ments?
pharmaceutical therapy! For the additional treatment of chronic
joint ailments, extracts of devil‘s claw
What natural remedies are used for (Harpagophytum procumbens), cat
rheumatic ailments? claw (Uncaria tomentosa) or frankin-
Even some natural products are assigned cense are available in the pharmacy.
certain positive effects. These include Other extracts such as poplar, willow
so-called phytopharmaceuticals, or stan- bark and nettle are said to have an in-
dardized remedies, created from plants. hibitive effect on the immune system,
These are available as plants and plant which can alleviate pain under certain
parts rendered non-perishable through circumstances. The external applica-
drying, or extracts processed into tab- tion of cayenne pepper, eucalyptus oil,
lets, capsules, etc. In order to achieve a spruce or pine-needle oil have also
therapeutic effect, then – as with all been said to work.
medications – precise dosage is required.
If the dose is too small, there will be no What can one expect of the Devil‘s
effect; if the dose is far too high, then Claw?
unwanted side effects can occur. In ethnic medicine in Africa, Devil‘s
Therefore, be sure to consult your phar- Claw has been used for hundreds of
macist and always discuss the taking of years to reduce pain and swelling. In
additional compounds with your pri- Western medicine, Devil‘s Claw ex-
mary care provider! tracts have been used as so-called “tra-
ditional herbal remedies“ (available in
the pharmacy without a prescription).
Important Note
Herbal compounds are not a replacement for

basic pharmaceutical therapy, but rather one
possible supplement. Discuss this with your
doctor before taking them. Self-therapy with
drugs purchased online is highly inadvisable!

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Dieses pflanzliche Arzneimittel lindert die Beschwerden bei Rücken-, Nacken-
und Muskelschmerzen, ebenso bei Morgensteifigkeit und rheumatischen
Beschwerden. Die Anwendung über mehrere Monate ist möglich.
Über Wirkung und mögliche unerwünschte Wirkungen informieren Gebrauchsinformation, Arzt oder Apotheker. Die Anwendung dieses traditionellen pflanzlichen Arzneimittels in den
genannten Anwendungsgebieten beruht ausschließlich auf langjähriger Verwendung.
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– mitverstehen
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2014 107
eines GMP-zertifizierten pharmazeutischen Unternehmens.
Self-Test
Self-Test for Inflammatory Rheumatism:

1. Do you have two or more swollen knuckle, finger or toe joints?
yes no
2. Have you suffered from joint pain for more than 6 months, which you
do not believe is the result of an injury?
yes no
3. Are your hands so stiff in the morning that you have problems making
a fist for longer than an hour?
yes no
4. Do your joint pains increase when you move?

yes no
5. Do you experience pain when walking up or down stairs?

yes no
6. Can you feel knots under the skin near joints or bone protrusions?
yes no
7. Have you had afflictions in joint regions on both sides of the body
(both hands, both shoulders, both feet, etc.) for longer than six weeks?
yes no
8. Has a doctor recently informed you following a blood test that your
inflammation factor is elevated?
yes no
9. Does shaking hands hurt?

yes no
10. Does one parent or close relative suffer from Rheumatism

(predisposition as cause)?
yes no
If you have answered Question 1 with “yes“ or more than three of the remaining questions with
“yes,“ then you should visit a specialist (Rheumatologist) as soon as possible.

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Die neue Patienten-App für einen besseren
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KAPITEL 7
PHYSICAL
ACTIVITY
& SPORTS
Choose activities that are easy
on the joints.

Physical Activity & Sports
Physical activity without too much What other types of movement are
strain - is it possible? recommended?
Regular exercise is a key factor in the The Feldenkrais Method is a somatic edu-
fight against pain and stiffness of the cational method focused on the individu-
joints, especially in rheumatic pa- al‘s quality of movement and the personal
tients. Achieving sporting excellence movement learning process.
does not matter; rather, the goal is to Pilates is a gentle but very effective
make the muscles strong in a gentle workout that utilises the entire body.
way. Physical exercise can relieve joint The muscles are trained to elongate
pain, promote mobility and increase from the stricken rheumatism muscle
muscle strength. In addition, physical knots into smooth muscle strands.
activity helps with weight loss, be-
cause, remember: Every kilogram of Does pain make sports exercise
excess weight represents that much impossible?
more load on your joints and unnec- If you hardly get up the stairs due to
essarily exacerbates your symptoms! rheumatic pain, you will probably be
able to imagine just hard it is to engage
Important Note: Before each exercise, in sports. However, there is a variety of
a new sport consultation should be held workouts for the home, and beginners
with the doctor. as well as older persons may find the
exercise program that can do their
What types of sports are very stress- body some good and have fun doing it.
ful on the joints? Many rheumatism sufferers report that
Suitable sports in the case of arthrosis of only the first few steps (walking, jog-
the hip, knee or ankle are cycling, swim- ging) or swings (tennis, table tennis,
ming, water aerobics and (Nordic) walk- golf) are anywhere from very uncom-
ing. When cycling, you should, however, fortable to painful, but this pain will
avoid steep slopes because of the in- disappear after a short warm-up.
creased pressure on the knee and hip.
Many rheumatism sufferers also like to Should strength training be given up?
do gymnastic exercises in a group, No. Strength training is the counterpart
since one thereby learns how to prop- to endurance training and aims to get the
erly execute useful movements. Poor muscles strong and healthy. Especially
posture can be corrected quickly and when afflited with a rheumatic disease, a
the motivation is often much greater. healthy muscle system plays a very im-

Physical Activity & Sports
portant role. Your day-to-day activities

will become easier, and you thereby also Tips for weight training:
reduce the risk of injury.
• Train the large muscle groups of the
body like legs, chest, back and shoul-
Are ball and team sports not good? ders. To do this, first light dumbbells,
All types of sports in which players are gymnastics bars, rubber bands (Thera-
Band®) or expander and make-ups and
exposed to heavy loads on the joints by
other exercises for shoulders, arms and
legs.
• Avoid. „Overhead exercises“, ie exercises

where you lift weights higher than up to
the shoulder
• Complete the first strength training only

once or twice per week. Later, you can
increase to three times per week.
• Train calm and in control. Focus on the

stressed muscle and avoid this distrac-
tion (radio, TV, chat).
• Do not overtax yourself! Start with light

weights - 0.5kg to a maximum of 2.5
kg, depending on the particular exercise
- and increase the weight slowly.
Per exercise, you should aim for two to
three sets with 10-15 repetitions.
collisions are only conditionally recom-

mended for rheumatism sufferers (bas-
ketball, volleyball). However, there are
no general guidelines here. Find out for
yourself what type of sport suits you, or
which you practiced before the disease,
and discuss with your doctor whether the
Group workouts are often more fun. dangers that might exist for you.

Self-Test
Self-Test for Degenerative Rheumatism – Arthrosis:

1. Are you over 40 years old?
yes no
2. Are you overweight?

yes no
3. Are there known cases of joint illnesses, malalignment or arthrosis in

your family?
yes no
4. D
o you have an occupation in which you must often carry heavy things or work
on your knees?
yes no
5. Are you active for less than 30 minutes a day?

yes no
6. D
o you suffer from “startup pain,“ pressure pain or abrupt immobility?
yes no
7. D
o you have the feeling that your joints grind on one another or “pop“?
yes no
8. D
o your knee or hip joints hurt when you take your first steps, before
the pain then dissipates?
yes no
9. Do your ailments also occur at times of rest, when you are not moving?
yes no
10. Have you ever sprained or bruised your joint?

yes no
If you have answered more than three of the obove questions with “yes,“ then you should visit a
specialist (Rheumatologist) as soon as possible.

Self-Help Groups
Your contact:
• Bundessozialamt:
1010 Wien, Babenbergerstraße 5
Tel.: 05 99 88
Fax: 05 99 88-2131
bundessozialamt@basb.gv.at
www.sozialministeriumservice.at/
• Bundesministerium für Finanzen:
1030 Wien, Hintere Zollamtsstraße 2b
Bürgerservice: Tel.: 0810 001 228 Self-help groups:
www.bmf.gv.at • Österreichische Rheumaliga (ÖRL):
Gertraud Schaffer (Chairperson)
5762 Maria Alm, Dorfstraße 4
Tel.: 0699/155 41 679
www.rheumaliga.at
• Österreichische Vereinigung
Morbus Bechterew (ÖVMB):
Ing. Paul Pocek (President)
1020 Wien, Obere Augartenstraße 26-28
Tel.: 01/332 28 10
www.bechterew.at
• Fonds Soziales Wien: • PsO Austria
Pflege und Betreuung (Psoriasis association):
Tel.: 01/24 524 Friederike Schönauer (Obfrau)
www.fsw.at 1020 Wien,
• Bundesministerium für Arbeit, Obere Augartenstraße 26-28
Soziales und Konsumentenschutz Tel.: 01/350 12 86
(BMASK): www.psoriasis-hilfe.at
1010 Wien, Stubenring 1 • Rheumalis (SHG for parents of
Tel.: 01/711 00-0 rheumatic children & adolescents):
www.bmask.gv.at Karin Formanek
Tel.: 0699/19 74 88 11
www.rheumalis.org
Additional links:
www.rheumatologie.at
www.rheuma-online.at
www.netdoktor.at

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LIVING WITH RHEUMATISM10

JUVENILE IDIOPATHIC ARTHRITIS (JIA) 27

REGULAR MONITORING AND

2 Rheuma verstehen 2014

POLYMYALGIA RHEUMATICA (PMR)  82

SYSTEMIC LUPUS ERYTHEMATOSUS  87

PAIN: CAUSES & TREATMENTS94

SUPPORT FROM YOUR PHARMACY102

PHYSICAL ACTIVITY & SPORTS110

Rheuma verstehen 2014 3

SCIENTIFIC ADVISORS FOR THIS EDITION:

CONTRIBUTORS TO THIS EDITION:

Univ.-Prof. Dr. Hans Peter Dimai Prim. Dr. Monika Mustak-Blagusz

We thank all contributors and scientific consultants

4 Rheuma verstehen 2014

Univ.-Prof. Dr. Winfried Graninger,

Prim. Univ.-Prof. Dr. Ludwig Erlacher,

We wish you an enjoyable reading experience!

Univ.-Prof. Dr. Winfried Graninger Prim. Univ.-Prof. Dr. Ludwig Erlacher

Rheuma verstehen 2014 5

Paid advertising in this edition:

DR. BÖHM OMEGA-3 COMPLEX CAPSULES, AND

DR. BÖHM DEVIL‘S CLAW 600 MG COATED TABLETS 107

6 Rheuma verstehen 2014

Mag. pharm. Dr. Christian Müller-Uri,

I hope you find this information helpful!

Mag. pharm. Dr. Christian Müller-Uri,

Rheuma verstehen 2014 7

Editor: Mr. Spitzauer, you are one of around

8 Rheuma verstehen 2014

Rheuma verstehen 2014 11

In the case of inflammatory rheuma- Soft-Tissue Rheumatism is character-

What role does the immune system

12 Rheuma verstehen 2014

difference between foreign and innate sub-

tified. The influence of genetics has been

Rheuma verstehen 2014 13

Can another inflammation be the testine) is responsible as the trigger for a

Answer the “WH“ Question before seeing a doctor.

• Where – in what small/large joints does the pain occur?

• How – is swelling apparent - warmth, morning stiffness, etc.?

14 Rheuma verstehen 2014

What is an anamnesis, and what cal history on suspicion of Rheumatic

Rheuma verstehen 2014 15

16 Rheuma verstehen 2014

b. Juvenile Idiopathic Arthritis Pain/Swelling, joint overheating, morning stiffness,

2. Non-Inflammatory Rheumatic Illnesses

18 Rheuma verstehen 2014

Pharmaceutical Therapy Non-Pharmaceutical Therapy Page

NSAIDs (non-steroidal anti-inflammatory Remedial gymnastics, ergotherapy, thermo- 21

NSAIDs, Cortisone, DMARDs (Methotre- Physiotherapy, ergotherapy, ­joint-friendly 27

NSAIDs, TNF-alpha Inhibitors Daily gymnastics, heat and cryo-therapy, 32

, NSAIDs, Cortisone for surges, ­DMARDs, Physiotherapy 40

Anti-inflammatory creams/gels, NSAIDs, Sufficient activity, joint protection, weight 65

Antidepressives, analgesics, muscle- Psychological support, activity and training 79

Rheuma verstehen 2014 19

20 Rheuma verstehen 2014

What is Rheumatoid Arthritis? What happens in the body?

Rheuma verstehen 2014 21

• Joint pain or swelling, at first usually What happens if therapy is not

Which examinations are necessary

22 Rheuma verstehen 2014

Rheuma verstehen 2014 23

LIVING WITH RHEUMATISM10

JUVENILE IDIOPATHIC ARTHRITIS (JIA) 27

REGULAR MONITORING AND

POLYMYALGIA RHEUMATICA (PMR) 82

SYSTEMIC LUPUS ERYTHEMATOSUS 87

PAIN: CAUSES & TREATMENTS94

SUPPORT FROM YOUR PHARMACY102

PHYSICAL ACTIVITY & SPORTS110

DR. BÖHM DEVIL‘S CLAW 600 MG COATED TABLETS 107

• Where – in what small/large joints does the pain occur?

• How – is swelling apparent - warmth, morning stiffness, etc.?

b. Juvenile Idiopathic Arthritis Pain/Swelling, joint overheating, morning stiffness,

NSAIDs, Cortisone, DMARDs (Methotre- Physiotherapy, ergotherapy, joint-friendly 27

, NSAIDs, Cortisone for surges, DMARDs, Physiotherapy 40

• Joint pain or swelling, at first usually What happens if therapy is not