Arthritis Flares

Arthritis Flares Are Normal but Still DifficultA sudden increase in symptoms can hit at any time.

You've been managing your arthritis symptoms well and doing all the right things to stay healthy, but one day you wake up and feel like it was all for naught. Your joints ache like crazy, the worst you can remember in a long time. It could be an arthritis flare.

Is your arthritis getting worse despite all your efforts? Are you going to feel like this from now on?

Probably not. Although arthritis is a chronic disease, you can have acute episodes of pain and inflammation, known as flares. While troublesome and unpredictable, flares are temporary. They do not signal a failure in your efforts to control arthritis symptoms.

Flares may be seen after infections or after highly stressful situations. Often, however, it isn't clear what triggers a flare. You may have long periods of time when your arthritis is quiet, or in remission. Then, suddenly, the inflammation becomes more active and you have an arthritis flare.

Flares can be alarming, not only because of the pain, but because of their unpredictability. You may feel discouraged or afraid of further damage to your joints. You sometimes wonder whether something you did may have caused the flare.

What can you do to combat these feelings? Remember that you have a range of tools in your arsenal to address pain, from asking your doctor to increase your pain medications, to applying cold packs or practicing deep breathing techniques.

Also, remember that flares do calm down. You may want to think about how you handle the inevitable 'bad days" and flares before you experience them. Just as regular fire drills help people deal with real emergencies, preparing for a flare can help you jump into action when it happens.

Discuss a plan of action with your doctor. One possible approach would be to adjust your medications temporarily while the disease is unusually active. This will not only relieve some of the pain associated with a flare; it will also help minimize any damage that may occur from unchecked inflammation.

Be aware that your medications may not control the flare right away, even if your doctor increases the dosage. Or they may only have a limited effect on your flare. Of course you and your doctors should be in agreement about possible increases in your medications, or even new medications at the time of a flare. Many doctors will review such a plan for a flare that can be implemented when needed without permission from the doctor.

How much a flare affects your everyday life will depend on its severity and how often it occurs, says David Pisetsky, MD, a rheumatologist at Duke University Medical Center in Durham, NC. If they occur only occasionally and with minimal pain and fatigue, you may be possible to work during a flare and keep up other activities. A good measure, Pisetsky says, is how you feel after work and the next day.

If you hurt or feel very tired after work, a period of rest and time away from the job is likely a good idea, the doctor says.

The following is a list of some other steps you might want to incorporate in your plan of action. Remember, some techniques work better for some people than for others. Try a few of these, and if they don't work for you, discard them and try others.

• Balance periods of activity with periods of rest. Although more rest can help during a flare, you probably don't need to abandon your regular activities, work or exercise program. Spending long periods of time in bed is counterproductive; it usually will prolong your pain. Instead, try to intersperse periods of rest with some light activity.
• Have a plan to deal with your obligations. Plan ahead so that you can still get things done. At work, try to arrange for coverage, work fewer hours per week, or bring work home. Discuss your plan with your supervisors and co-workers ahead of time and assure them of your commitment. At home plan to apportion a few extra jobs among family members, and make sure everyone knows what they are expected to do to keep things running smoothly.
• Communicate with your family and friends. The time to let your family and friends know that you may need more help is when things are going well, not when the flare hits. They will understand better what is needed and how they can help when you call to say that you're having a particularly bad day. If someone volunteers to help you through a flare, give them a specific job to do or else their assistance may go unused.
• Apply a hot or cold pack to inflamed joints. Different people prefer one or the other. Some people even prefer warm packs for certain joints and cold packs for other joints. You will learn your own preferences through trial and error.
• Practice relaxation or mind-diversion techniques. These techniques work best when you practice them on a regular basis. Even though relaxation may not directly reduce your pain, it can minimize stress, which is a factor shown to amplify pain.

Understanding RA FlaresWhat researchers have learned about these bursts of RA symptoms could help you better manage your condition. | By Stepahnie Watson

Rheumatoid arthritis (RA) is a disease of ups and downs. One day, your joints feel pretty good. The next, swelling and pain ratchet up and you can barely get out of bed. These symptom episodes – called flares – can be unpredictable and debilitating. Because symptoms differ from person to person, doctors have had trouble agreeing on a standard definition to guide them in treating flares.

For the last decade, Clifton O. Bingham III, MD, has been working to make life easier for RA patients who experience flares, and the doctors who treat them. He’s led an international initiative from a group called OMERACT (Outcome Measures in Rheumatology) that aims to better understand and identify RA flares.

“We conducted a significant amount of work with RA patients from around the world in focus groups, interviews and surveys to understand from the patient’s perspective what flare meant to them and what was involved when they experienced a flare,” says Bingham, who is director of the Johns Hopkins Arthritis Center and director of research for its Division of Rheumatology. “The concepts that came from this were that flares were a common part of the RA experience, even when the condition was otherwise well controlled.”

Flare Types and Triggers

Flares come in two varieties, according to Bingham. “Predictable” flares have a known trigger. For example, you decide to clean your house from top to bottom one day, overdo it and end up with swollen, stiff joints the next day. Overexertion, poor sleep, stress or an infection like the flu can all set off RA symptoms. With a predictable flare you’ll temporarily feel worse, but your symptoms will resolve in time.

“Then there are the more unpredictable types of flares,” he says. “These were the ones patients described as having more uncertainty associated with them – feeling worse, but not having a trigger that was causing symptoms to get worse.” These flares might not get better on their own.

When self-care measures like rest and anti-inflammatory medicines aren’t enough, your symptoms could ultimately drive you to see your doctor. Repeated or consistent flares may need a medication adjustment or other change in treatment to help you find relief.

Defining a Flare

When it comes to defining flares, doctors and patients often don’t agree, and even individual patients have differing definitions.

In focus groups, patients have described their flare symptoms in subjective terms. One said the pain “…doesn’t let up. It just is unrelenting.” Another complained of stiffness so severe that, “I feel I am stuck together with superglue.” Though pain, stiffness and fatigue are common flare themes, duration, severity and frequency can vary widely from person to person.

Even though a flare can feel debilitating to you, your doctor’s assessment might not reveal your symptoms as significant. “The doctor is focusing on whether there are more swollen joints, and whether the lab tests have changed, and will use that information to determine if you’re worse,” Bingham says.

To create more alignment between patient experiences and doctor evaluations, Bingham’s group has focused not only on flare symptoms, but also on their consequences. In other words, is your flare severe enough to make you repeatedly stay home from work and miss social engagements?

The OMERACT group is developing a questionnaire to help patients better evaluate their symptoms and determine when to see their doctor, and to help doctors more accurately assess their patients’ symptom severity. “One of our goals is to help patients communicate the experience of worsening with their doctors,” Bingham says.

Finding Relief

Until this questionnaire is available, the best advice is to listen to your own body – and be open with your doctor about your symptoms. Even if lab tests don’t agree, let your doctor know that your RA is flaring and what symptoms have changed, Bingham advises. Continue to press until you get relief. Talking about your symptoms may open a discussion that identifies something besides RA that is causing you to feel worse, he notes.

During flares, when your joints are especially achy and stiff, have what British rheumatology professor Sarah Hewlett calls “duvet and chocolate days.” Just stay in bed, eat some chocolate, and be a little good to yourself. After a day or two, once you feel better, you can start getting active again. If you still hurt, it’s time to call your doctor.

Coping With an Arthritis FlareTips for managing episodes of increased pain and other symptoms. | By Michele Andwele

Rheumatoid arthritis (RA), psoriatic arthritis, and lupus are chronic diseases and with treatment your symptoms can be kept at bay. But you may still have acute episodes of pain and inflammation known as flares. An arthritis flare may occur after an infection or a highly stressful situation. Often, however, what triggers a flare is not clear. By working with your doctor, you can manage the pain and fatigue of a flare and keep them to a minimum.

Medication Adjustments

Discuss a plan of action with your doctor. One approach would be to adjust your medications temporarily while the disease is unusually active. This can help relieve pain and minimize or prevent damage that can occur from unchecked inflammation. Repeated flares could indicate you need a more aggressive treatment approach.

Many doctors will suggest a plan of action at the first signs of a flare so it doesn't get out of control quickly. Be aware that changing your medication may not control the symptoms of flare right away, so here are some self-help techniques you can also use.

Self-Care for Flares

Along with following your doctor’s recommendations, there are many self-care steps you can incorporate into your plan.

• Balance periods of activity with periods of rest. Although more rest can help during an arthritis flare, you probably don't need to abandon your regular activities or exercise program. But you may need to modify your usual program. Even though you may feel like spending long periods in bed, it may not be best. Instead, combine periods of rest with some light activity. Try to keep joints from becoming stiff by moving them through the fullest range of motion possible. You can do something as simple as slowly raising and lowering your legs while seated comfortably. Just make sure to pace yourself and don't overdo it. If this action is causing you more pain, stop immediately.
• Have a plan to deal with your obligations. Have a contingency plan for work and family obligations. At work, try to arrange for days off, change your daily work schedule, work fewer hours per week or work from home. Make a plan with supervisors and co-workers ahead of time so you can transition smoothly when a flare occurs. At home, let family members know which responsibilities will be shifted to them in order to keep things running smoothly.
• Communicate with your family and friends. It's important to let family and friends know how a flare may affect you and ways they can help before one occurs. Other sources of help can include your church or a local patient advocacy or volunteer organization.
• Apply a hot or cold pack to inflamed joints. Heat can soothe joint pain by increasing blood flow to the painful area and relaxing the muscles. Use heating pads, warm compresses, heat patches or warm baths; apply two or three times a day for 15 minutes at a time. Cold eases inflammation by constricting the blood vessels. It lessens pain because cold sensations travel along large nerve fibers and helps to disrupt pain sensations. Apply cold packs – bags of frozen vegetables work well – two to four times a day for 15 minutes at a time. Be careful not to overdo either treatment..
• Practice relaxation or mind-diversion techniques. These techniques work best when you do them on a regular basis. Even though relaxation may not directly reduce your pain, it can minimize stress, which will indirectly relieve your pain.