The Impact of RA on Muscles

Several recent observations caused me to wonder about the impact of RA on muscles. In the almost five years since being diagnosed with RA, I’ve seen a steady decrease of muscle strength coupled with an increase in periodic pain and aching in muscle tissue. I’ve thought that the aching could be caused by either overuse (comparatively speaking) or by biomechanical processes since the muscles are attached to RA-damaged joints via tendons. I can feel myself getting weaker as time goes on. In fact, muscle strength in RA patients can be reduced by up to 75% of normal (see this study from 1992). During a follow-up visit about one of my ankle surgeries a few years back, the orthopedic surgeon noted in my chart that my calf muscles were getting atrophied. I no longer have the strength to open jars, dig a hole, or even maintain extended use of a muscle on a given task. I began to wonder about the impact of rheumatoid arthritis on muscles.

While muscles haven’t been a primary research target, there have been a few studies about muscles and RA. As far back as 1951, researchers found that inflammation of arteries in muscle tissue was observed in RA patients. In a study of 350 RA patients in Spain, weakness, muscle atrophy, and muscle inflammation were commonly observed in those suffering from RA. A detailed research study by Helliwell and Jackson published in 1994 documented RA’s impact on muscle tissue. They concluded, “Although there is significant muscle wasting in RA, it is likely that reduction in strength is also attributable to joint deformity and pain leading to inhibition of grip directly and, indirectly, by arthrogenous muscle inhibition. Doubts remain about the quality of muscle in RA”. Arthrogenous refers to “starting from a joint”. In 1993, Young produced a model demonstrating the connection between joint damage and muscles.

In addition to biomechanical problems, it is entirely plausible that biochemical processes involved with RA may negatively impact muscle tissue. According to some researchers, RA related cytokines including IL-1 and TNF are involved with breaking down the protein in muscles. According to Rall, et al (1996), “Adults with RA have increased whole-body protein breakdown, which correlates with growth hormone, glucagon, and TNFα production.” They concluded…”And although progressive resistance training led to improved strength and functional status in patients with RA and in controls, we saw no changes in protein metabolism or hormone levels as a result of the training intervention among any of the groups of subjects.” In other words, muscle breakdown continued even in midst of exercise. This mirrors a study by a group from Finland who noted that exercise helped RA patients’ muscle strength but not bone density. In 1974, a group of researchers from Sweden noticed changes in the muscle tissue of RA patients. They stated, “It is emphasized that the type II atrophy must be the result of a more complex mechanism than simple ‘disuse’.”

My suspicions about the biochemical impact and connectedness to RA impacted joints are both confirmed in the research literature. The question then remains as to what may be done to stop or reverse the impact of RA on muscles. Some argue that RA patients should engage in regular exercise in order to maintain muscle tone (see Mayo Clinic, NCHPAD). In a 2003 review of research studies on the impact of exercise on RA patients, it was found that most studies demonstrated that exercise positively impacted muscle strength without negatively impacting pain or daily activities. These results are interesting to me personally because every time I try to engage in exercise or strenuous activity, I feel worse and daily activities are limited (see recent post). Regarding exercise, many experts now recommend, “If you can, you should; if you can’t, you shouldn’t.” (Dr. Borogini Health Central RA website).

The evidence is clear – rheumatoid arthritis does impact muscle tissue. But more research is needed to identify the specific causes and to develop long term solutions. Of course, a bona fide cure for RA would do the trick. Fortunately, there are still researchers seeking answers as attested to by the fact that funding is being provided to study muscles in RA patients (see recent grant award in the UK).

Creative Commons Photo Credit – Public Domain:
http://commons.wikimedia.org/wiki/File:Muscle_posterior.png

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Paying the Price for Activity

The last four days have been a grand time of celebrating our oldest son’s college graduation. It’s been a whirlwind of events including his senior engineering project presentation, three formal ceremonies of various sizes and durations, dinners, and a large party hosted at our house. This meant much physical activity around the yard and house the principal of which was 10 hours of smoking five large pork shoulders for 50 people (it was tasty and you should check out the website
http://www.amazingribs.com/
).

Going into this set of events, a nagging thought persisted…”I’m going to pay for this later.” Sure enough, by Sunday evening I could barely walk, my fingers were swollen and throbbing in pain, and sheer exhaustion washed over my body causing me to collapse. I knew that going to work Monday morning would not be possible.

Many argue that movement and exercise is critical medicine for arthritic joints stating that it relieves pain and stiffness (see these websites – Mayo Clinic, NCHPAD). In addition to potential positive impact on joints and muscles, exercise is obviously important for other reasons include cardiovascular and mental health. But my experience over the years has been that exercise and movement causes rebound pain and stiffness. Yet, I know that I’m missing out on the benefits of exercise.

It’s interesting to read some of the recommendations from medical websites. From WedMD…“Regular exercise can actually reduce overall pain from rheumatoid arthritis.” In my experience with RA, exercise always causes more pain. There are many times when I’ve had to stop movement because the pain got worse. WebMD also makes this statement, “Regular exercise improves functional ability and lets you do more for yourself.” This may be true for some but the functional ability of my ankles and Achilles tendons actually got worse after exercising. The tendons tore at a quicker rate and my orthopedic surgeon and physical therapist both recommended that I avoid any activity that puts stress on the tendons.

Can exercise actually be contraindicated for RA? Kelly Young at RA Warrior has an excellent series of posts about this topic. She concludes, “If you can, you should; if you can’t, you shouldn’t.” At the Health Central RA website, Dr. Borogini wrote a balanced article about the topic and makes an excellent suggestion which is in alignment with Kelly Young’s statement, “Rest More When RA Is Active, Exercise More When It Is Not.” The Johns Hopkins Arthritis Center website makes a great observation about movement and RA.

“Acutely, resting of involved joints can assist with pain management and decrease the inflammation of the involved joint. However, the potential side effects of inactivity include decrease range of motion, loss of strength, altered joint-loading response, and decrease aerobic capacity.”

This leaves those with active disease in a real quandary.

The conclusion that must be drawn from the recent set of weekend experiences is that my RA is not under control and I should probably avoid strenuous physical activity. But of course, I already knew that going into the weekend. The difficulty lies in the fact that life must go on and I was not about to miss this once-in-a-lifetime celebration. I just have to be ready to pay the consequences afterwards.

Creative Commons Photo Credit: 
http://commons.wikimedia.org/wiki/File:Tired_brown_bear_050701_01.JPG

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Living within Limitations

Gardening has been a favorite outdoor activity for years. This love of the ground and raising plants began in 6th grade when I dug up a spot in our yard and planted a vegetable garden. Tomatoes grew like weeds and the joy that came with watching and nurturing plants sank deep in my psyche like tap roots.

As a twenty something high school teacher, summers were spent operating a small landscaping business. I had a truck and hired several high school students as laborers. We would plant shrubs and trees, build retaining walls, and haul bulk items like top soil, rock, and mulch. During this phase of life, I also regularly ran 20-30 miles per week and participated in 5Ks periodically. I never felt better!

Every home we lived in over the years would get hours of loving care in terms of landscaping and gardening. Redoing lawns, building greenhouses, planting flowers, edging and mulching planting beds, planting trees and shrubs, and building fences (see photo) were just a part of life.

Thirty years later and living with rheumatoid arthritis has dramatically changed these activities. This fact was recently evident when my wife started edging a planter bed and digging up sod in order to plant new flowers and lay mulch. In the past, I would’ve been in the thick of this kind of work. She began the digging knowing that I couldn’t help. We were delighted when our wonderful neighbor came over and started helping edge and pulling up sod. Instead of just passively standing by watching someone else do the work, I decided to work on bonsai gardening. The kind of work needed to maintain bonsai – pruning, watering, etc. - is doable given the impact of RA on my joints and energy levels. My dwarf Cedar of Lebanon and Western Red Cedar bonsai seem to be doing very well (see photo).

I can no longer dig sod or haul mulch, but I can still get my hands dirty and nurture plants – just on a much smaller scale!

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The Pains of Sleep

While waiting for the next treatment plan to be revealed by my rheumatologist this Friday, the RA beast seems to be running at will. Joint swelling, redness, warmth along with fatigue are at levels rarely experienced during this RA journey. And this means that pain levels have also increased. At one point a few days ago, finger joint pain induced wincing almost to the point of tears making me ready to pull out the “big gun” painkillers. Friends came over to play spades and it was difficult to hold the cards. Besides the regular squaking joints, joints that tend to lay low, rarely speaking that RA is there, are now screaming loudly. Such was the case a few days ago when the elbows were quite conspicuous. Laying down to bed was anticpated in an effort to get some much needed rest. But the pain was too great. Adding insult to injury, knees and ankles joined in the chorus and throbbed incessantly in an effort to gain attention. Rest was not to be had. No amount of tossing or turning helped. I arose out of bed and stumbled back downstairs and turned on the TV. Of course, this was Thursday night and the live coverage of the tragic events in Boston were unfolding. Attention was rivted to the talking heads trying to get the latest scoop until I crashed from exhaustion somewhere around 2:30 a.m.

Sleep with RA can be an elusive goal. While not inspired by RA but likely by his own personal battles, a poem by the famous English writer Samuel Taylor Coleridge captures the “Pains of Sleep” while living with rheumatoid arthritis.

THE PAINS OF SLEEP

by: Samuel Taylor Coleridge (1772-1834)

Ere on my bed my limbs I lay,

It hath not been my use to pray

With moving lips or bended knees;

But silently, by slow degrees,

My spirit I to Love compose,

In humble trust mine eye-lids close,

With reverential resignation

No wish conceived, no thought exprest,

Only a sense of supplication;

A sense o’er all my soul imprest

That I am weak, yet not unblest,

Since in me, round me, every where

Eternal strength and Wisdom are.

 

But yester-night I prayed aloud

In anguish and in agony,

Up-starting from the fiendish crowd

Of shapes and thoughts that tortured me:

A lurid light, a trampling throng,

Sense of intolerable wrong,

And whom I scorned, those only strong!

Thirst of revenge, the powerless will

Still baffled, and yet burning still!

Desire with loathing strangely mixed

On wild or hateful objects fixed.

Fantastic passions! maddening brawl!

And shame and terror over all!

Deeds to be hid which were not hid,

Which all confused I could not know

Whether I suffered, or I did:

For all seemed guilt, remorse or woe,

My own or others still the same

Life-stifling fear, soul-stifling shame.

 

So two nights passed: the night’s dismay

Saddened and stunned the coming day.

Sleep, the wide blessing, seemed to me

Distemper’s worst calamity.

The third night, when my own loud scream

Had waked me from the fiendish dream,

O’ercome with sufferings strange and wild,

I wept as I had been a child;

And having thus by tears subdued

My anguish to a milder mood,

Such punishments, I said, were due

To natures deepliest stained with sin,–

For aye entempesting anew

The unfathomable hell within,

The horror of their deeds to view,

To know and loathe, yet wish and do!

Such griefs with such men well agree,

But wherefore, wherefore fall on me?

To be loved is all I need,

And whom I love, I love indeed.

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Knowing When It’s Time to Switch RA Medications

A weird thing happened at my Actemra (tocilizumab) infusion last Friday…I was dog tired and started dozing off in the chair when all of a sudden about half way through the infusion I got a rapid burst of energy. I went home feeling great and even mowed my front yard! But by Saturday night it was all over and I was back to feeling terrible – it was a great tease!

My rheumatologist always states that her goal is for me to not pay much attention to RA throughout the day. If the RA is causing issues to which I must attend during the day, then she believes that the medications aren’t working well. For the past five months since starting Actemra, I can clearly state that RA persistently reminds me that it’s present. I knew in the back of my mind that a change may be needed. But after being through so many RA treatments over the past 4 ½ years, I’m very hesitant to switch medications because I’m getting to the point where choices are limited. Below are some factors that are working towards a change.

1. Doctor recommendation. I don’t tend raise the issue of switching medicines and instead rely on my rheumatologist to broach the subject. Call me gun shy – I just want to make sure that we give a treatment a fair shot before moving on. Part of that hesitancy is based on the fact that we’re running out of options. After last month’s discussion and a recent set of blood tests a few days ago, my rheumatologist contacted me and wants me to stop the current combination of Actemra infusions and leflunomide (Arava).
2. Your body. My rheumatologist always asks me how I’m feeling in terms of joint pain, swelling, fatigue. She understands that I know my body better than anyone else and takes that into account. She even asked me yesterday, “Do you think the Actemra is working – if not, I’m fleshing out a super Plan B.” I have to admit that it does not seem to be working well. I’ve had increasing joint pain and swelling with over 28 joints impacted. Using the ubiquitous DAS28 tool for measuring RA disease activity (an online calculator is available), I currently have high disease activity.
3. Increase in Inflammatory Blood Markers. A sharp increase in inflammatory blood markers may demonstrate that the disease is becoming more active (see this study on the correlation). For the first time ever since being diagnosed with RA, I had a high C Reactive Protein test last week. While blood tests like sedimentation rate and C reactive protein are not always accurate indicators of disease as some RA patients like myself tend to not show high results (see this study), they can serve as some gauge of disease activity and are used for clinical trials (see this post from RA Warrior for more info). If the level of general inflammation in my body is increasing while taking certain medications, it may be a sign that they are not working well.
4. Side Effects. Many side effects of RA medications are tolerable. But sometimes side effects can have too great of an impact. Such is my case with Actemra as we’ve seen a steady increase in cholesterol, triglycerides, and blood pressure since starting infusions. Roche, the maker of Actemra, lists these side effects in the prescribing information as “Adverse Reactions” seen in at least 5% of the population taking the drug. While these side effects are not listed as “Warnings” which include more acute issues like serious infections and gastrointestinal perforations, my rheumatologist believes that they are serious enough to warrant a switch in medication.
5. Others Around You. Sometimes we can’t see the “forest for the trees” so to speak and we need others to observe how we are doing. I will tend to put my head in the sand and march on like nothing is wrong. As the British say, “hold a stiff upper lip” or “keep calm and carry on.” I’m fortunate to have a wife who can observe changes over time and call it like it is. She recently questioned the efficacy of the Actemra/Arava combination.

All of the information above tends to be pointing towards the fact that Actemra is not working for me and that it’s time to move on. The choices are becoming limited as it appears that Rituxin infusions and the newly approved Xeljanz are the only biological treatments currently on the market that I haven’t yet tried. Rituxan is an entirely different kind of biological which is usually reserved for patients who don’t respond to the more common biological treatments. Xeljanz is brand new and lacks long term efficacy and safety data in the open market.

Last December I wrote a post about how Orencia was not working and the switch over to Actemra. Five short months later I’m at the same place of limbo trying to figure out the next plan of attack.

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Sub-Types of Rheumatoid Arthritis?

My rheumatologist believes that I may have a combination of rheumatoid arthritis (RA) and ankylosing spondylitis (AS). I have had a positive rheumatoid factor (RF) test and I present classic examples of inflammation and damage in joints commonly associated with RA including in the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints in both hands. Add to that list, symmetrical joint presentation in the wrists, shoulders, hips, and knees along with fatigue and it seems like RA. At the same time, my rheumatologist noted limited spinal mobility and many problems with my ankles and Achilles’ tendons which are common with AS. My first autoimmune symptom, which occurred years before joint problems, was inflammatory uveitis in both eyes. While Achilles tendon problems and uveitis can be associated with RA, they are more commonly seen in AS patients. But a test for HLA-B27, a common genetic test related to ankylosing spondylitis (AS), was negative. These blood tests are not 100% accurate and the official diagnosis in my chart is RA (diagnosis code 714).

Muddying the water is the fact that I have been through a slew of RA treatments over the past four years in an effort to find a combination that works for the long term. I’m currently on Actemra infusions and now going back to add leflunomide (Arava) in an effort to capture the earlier success with Actemra. While many RA patients find relief from the most common treatments like methotrexate, Enbrel, and Humira, it seems to elude 30-40% of patients.[i] Every person seems to respond differently to various medicines and doses.

This personal evidence leads me to believe that there may be different sub-types of RA. In a recent conversation at the RA site on HealthCentral, the notion of sub-types of RA was mentioned. We already know that there are different types of inflammatory arthritis including RA, AS, psoriatic arthritis.[ii] And each of these diseases presents different patterns and may be treated with similar and/or different medications. But there seems to be a lack of scientifically defined sub-types of RA.

According to researchers from the Netherlands, “Rheumatoid arthritis (RA) is a heterogeneous disease with unknown cause.“[iii] Differences in genetic expressions of RA patients were seen by these researchers lending some credence to a genetic link to sub-types of RA. In an earlier study of the genetics of RA in 1989, researchers found a gene called HLA-DR was found in 83% of 149 patients with classical or definite RA.[iv] But no explanation is given for the 17% of RA patients who did not show the gene. In 2010, a group of researchers found four genetic sub-types of RA.[v] Japanese scientists found genetic differences at the molecular level. They stated, “Data from genome-wide screening, transcriptional profiling, and animal models indicate that RA consists with heterogeneous disease subsets.”[vi] Some researchers even found different emotional responses in RA patients.[vii]

While the causes of RA are not completely evident, most scientists suspect a combination of factors including genetic and environmental (see earlier post on the triggers of RA). Scientists are now beginning to unravel the complexities of RA and find that there may actually be a variety of sub-types of the disease. I hypothesize that future research into RA and other autoimmune diseases will reveal that genetics and environmental factors impact the way individuals present symptoms and respond to treatments. This knowledge may lead to definitions of RA sub-types and better treatments in the future. In the meantime, I’ll keep experimenting with treatments in order to find a combination that works.

---

[i]
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2669237/

[ii]
http://www.arthritisresearchuk.org/arthritis-information/inflammatory-arthritis-pathway.aspx

[iii]
http://www.ncbi.nlm.nih.gov/pubmed/17223656

[iv]
http://www.ncbi.nlm.nih.gov/pubmed/2481309

[v]
http://www.blackwellpublishing.com/acrmeeting/abstract.asp?MeetingID=774&id=90254

[vi]
http://cdn.intechopen.com/pdfs/25397/InTech-Molecular_mechanisms_of_rheumatoid_arthritis_revealed_by_categorizing_subtypes_of_fibroblast_like_synoviocytes.pdf

[vii]
http://arthritis-research.com/content/15/2/R45/abstract

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Unplanned Costs of RA

While sitting in the infusion clinic a few days ago receiving my first dose of Actemra (see photo), I began to wonder about the extra costs of having RA that aren’t covered by insurance or planned for in my budget. This thought came to mind as I pulled a parking ticket out of my pocket and wondered how much I was spending on parking per year. Then the thought expanded to all RA related costs that aren’t included in insurance coverage and I decided to make an accounting of these costs.

Parking - Parking charge for clinic, $6.00 per trip to clinic for doctor visits and infusions x 22 trips = $132

Mileage – Driving to clinic for doctor visits and infusions, 22 trips x 30 miles round trip = 660 miles/24 miles per gallon = 27.5 gallons x $3.50 per gallon = $96.25

Co-pays – I have a maximum out of pocket of $2,500 annually and this was fully met the past few years due to the costs of office visits to expensive specialists, imaging including MRIs, RA related surgeries, expensive medications, etc.

Office Visit Co-pays - For my insurance, each office visit is covered except for a $15 copay that I pay at the appointment. 10 visits x $15 = $150

Prescription Co-pays - Most of my prescriptions have a $5-$15 copay. It helps when I can get a 90 day supply but that doesn’t always work. 15 refills per year x $10 average = $150

Missed work – Fortunately I am salaried and can flex my schedule as needed. But the work still must get done. Many RA patients are hourly employees and missed work may mean missed pay.

Over the counter drugs – Tylenol, Prilosec, vitamins, etc. estimated $250 per year.

Medical Supplies/Assistive Devices - Bandages for post surgery, ice packs, crutches, canes, jar openers, etc. estimated $200

This is a grand total of $3,478.25 for the year that comes out of my own pocket. Granted, that does not compare to the total cost of treatment for the year that can run upwards of $40,000 depending on medications, imaging, and surgeries. But it’s still a lot of money that could be used for other things like a new car, a vacation, clothes for my kids, house repairs, savings, etc. People with chronic illnesses must find a way to live with these added expenses. Rheumatoid arthritis is costly in so many ways.

On a side note, it’s been 6 days since my first Actemra infusion and there have been no noticeable effects yet. My joints probably feel the worst they ever have, my fingers feel swollen and frozen most of the day, and energy levels are quite low. But I hold out hope as it could be several weeks before I notice an impact.

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“Oh No I Can’t”…Changing RA Treatment Regimen Again

I received an official rheumatoid arthritis diagnosis almost four years ago. In that period of time I went through multiple treatment schemes (see the My Meds page) including four biologicals (Enbrel, Cimzia, Humira, and Orencia) and three DMARD chemicals (sulphsalazine, methotrexate, and Arava) in addition to numerous NSAIDS and the obligatory prednisone. As mentioned in blog posts over the past couple of months, it became increasingly apparent that the combination of Orencia and Arava was just not working. Sticking my head in the sand and ignoring the signs could only last so long while my wife and doctor tried to convince me that it was time to try something else. The evidence was becoming overwhelming…unrelenting fatigue beyond comprehension, increase in the number and intensity of swollen and tender joints, new joints including one shoulder and both hips presenting with signs of attack by RA, missed work, and a level of brain fog never experienced before. In addition, it felt like the monthly Orencia infusions might just as well have been plain saline solution as there was no improvement afterwards. On top of that, Arava was wrecking havoc on my digestive system and the bathroom and I became quite friendly.

While driving into the doctor’s office today, the inevitable started sinking in and I got nervous wondering what would happen. Most of this anxiety is probably grounded in the fact that I’ve been through a slew of treatments and I was feeling like options were beginning to run out. After an exam and conversation about symptoms, my rheumatologist emphatically stated that it’s time to change treatment. She continually expresses hope that we can find a medicine combination that will work for me. She got out a piece of paper and made two lists. The one on the left was for DMARDS that I haven’t tried yet and she wrote down Imuran and Cellcept. On the right she listed biologicals that I haven’t tried and she listed Remicade, Rituxin, and Actemra. In the middle she listed the newly approved oral biological Xeljanz which she dismissed as a possibility for now stating that she wanted to see more long-term data on efficacy and safety before widely using it. She recommended Imuran since it’s been around longer and has better efficacy data for treating RA. Imuran is an immunosuppressant commonly used to help organ transplant patients avoid tissue rejection. It is also used to treat many autoimmune diseases including RA, lupus, and MS. Since three TNF blockers didn’t seem to work well for me, she argued against Remicade but said that we’d keep that option on the list just in case we want to try it later. She said that Rituxan helps some of her RA patients but not as many as she would like. Actemra is the newest antibody biological for RA approved in the United States and she said that she’s seen it help some of her patients. It’s different from the TNF blockers and Orencia in that it targets interleukin 6 which is part of the autoimmune processes linked to RA. So we landed on the Imuran/Actemra combination and await insurance approval to begin the infusions. A trip to the lab for blood tests to establish baselines were ordered. In the meantime, doses of prednisone are prescribed to knock down inflammation.

Changing treatments brings about many questions but also hope that maybe it will provide some relief. Because relief would be a good thing right now!

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RA Feels Like Having Weights Strapped to My Body

Having RA brings about many different feelings, reactions, emotions, etc. Lately, in the middle of a particularly nasty flare, it’s become increasingly harder to get going and move around. The best analogy that comes to mind is of a deep-sea diver with lots of weight attached to your body. I’ve never dived before but can imagine that all that weight, the added water pressure of being deep undersea, breathing limited by the special gas mixtures, and the movement slowed by water makes one move incredibly slow.

Waking up in the morning may take 2-3 hours. Often times I will wake up at 5-6 a.m., stumble downstairs in the dark, take my daily prescribed pills, grab something to eat, then find myself on the coach wrapped up in a blanket and falling back to sleep until 8 or 9. Once getting up to really start the day, things move pretty slow. My head feels groggy from poor quality sleep and maybe even from side effects of various medications. Everything takes a little extra time while the joints loosen up. Forcing oneself to get going is a daily struggle. Sometimes inertia gains the upper hand and as Isaac Newton said, “a body at rest remains at rest”. Getting 6-8 hours of productive time represents a good day. Pushing beyond that, which is tempting with a type A personality, only results in feeling worse.

At least today offers an opportunity to work from home and slow down a little bit. But I’m tempted to dive in full bore and seek all of the “adventures” that lie before me. But I must pull back and move slowly with all of the “weight” attached.

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Stretched Too Thin…Not a Good Idea With RA

Life and work doesn’t seem to slow down and take notice of RA. It’s been a couple of weeks where keeping the head above water is a struggle. Two major reports due, teaching a class of smart graduate students, and preparing for a research presentation are causing my head to spin, work 12 plus hour days, and RA to raise its ugly head. While life goes on, RA doesn’t seem to take notice and give you a break. In fact, just the opposite happens. During times like this, the mental and physical stretching causes RA symptoms to multiply with more joint pain, increased fatigue, and lower sleep quality. Why can’t RA play nice!?

Focusing on the light at the end of the tunnel brings some hope coupled with the fact that my research presentation is in Florida next week…think sunshine, pools, good food, and palm trees. Of course, traveling across 3 time zones and staying in a new place brings it’s own set of RA-induced issues. Sometimes I wonder how or if this sort of increase in work pressure, even if it is not long term, can be maintained while battling RA. At least my RA treatments seem to be working to some degree for now and I have symptom checker medicines for pain and inflammation. I just have to keep from getting stretched too thin that I snap!

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