Pain-Free Living

Managing RA Flare-Ups

by Wendy McBrair, MS, BSN, CHES

If you have rheumatoid arthritis (RA), you take medicines to help keep symptoms such as joint pain and inflammation under control. Even when RA is well-controlled, however, it’s possible to have a flare-up, or flare, of the condition. During a flare-up, RA symptoms get temporarily worse after being quiet or less severe for a period of time. If you experience a flare-up, a joint or joints may swell or become more swollen; you may feel more pain and stiffness, especially in the morning; and your body may feel more fatigued. When all of these things happen at the same time, the flare-up is considered more serious.

Fortunately, there are ways to deal with a flare-up. Here are three important steps you can take to help yourself if your RA ever flares.

Step 1: Recognize what’s happening

The first step to managing a flare-up is to realize that you are having one. By identifying a flare-up early, you can get an early start on managing it. This is easier for the individual who is very aware of his or her body and how it feels. Learn to pay attention to how RA affects your body so that if something changes, you recognize it. When you realize there’s been a change, acknowledge it — don’t go into denial and hope that everything will just get better on its own.

Step 2: Find the reason

Once you’ve recognized that you are having a flare-up, it’s important to try to identify why the flare-up is occurring. While in many cases flare-ups have no known cause and are just part of the natural ups and downs of RA, sometimes they have triggers. How you manage the symptoms of the flare-up may be determined by what you think the cause is. For instance, you may recognize that your flare-ups are often triggered by stress. By identifying the stressors in your life, you may then be able to change them and thus diminish the severity of the flare-up (or prevent future flare-ups). This sort of information can be very important for both you and your doctor.

Other possible triggers for flare-ups may include not taking your medicines properly, overdoing activity and not getting enough rest, overusing certain joints, or experiencing a general worsening of your condition. Some people also think changes in the weather provoke their flare-ups. Let’s take a closer look at some of these flare-up triggers.

Medicine. A flare-up can occur when you are not taking your medicine regularly or not taking it as prescribed by the doctor. Some people are afraid of the side effects of medicines and try to reduce the amount they are taking or even stop taking the medicine entirely, even when they’re still experiencing symptoms. Others begin to feel better and either stop taking or forget to take their medicine. In both cases, not taking the medicines as prescribed can have serious consequences. It increases the risk of permanent damage to the joints.

Overdoing it. Overdoing activities and becoming severely tired may also bring about a flare-up. Let’s say you’re feeling better and trying to get a particular project done, such as hosting a big party. In the excitement of the event, you can push yourself too hard and wind up paying for it later. That’s why it’s important to have a clear idea of what is too much for your body to handle. While exercise and activity are important, it is also important to balance them with rest. Avoiding tiredness as much as possible is a key part of your RA treatment.

Overusing it. Overusing a joint can cause your RA to flare up. You can overuse a joint or joints in a number of ways. For example, if you have RA in your hands, doing an activity that is too hard for your hands, such as hammering, opening a tricky jar, or washing all your home’s windows in one day, can bring about a flare-up in the hands. If you have RA in your knees, you might flare up after spending several hours on your knees planting your garden. In each case, the swelling may occur any time from soon after the activity to a few days later. When swelling occurs in a particular joint, think back to what you’ve done over the last few days.

Other triggers. As already mentioned, stress can contribute to a flare-up. In addition, some people find that certain weather conditions, such as humidity, can cause increased joint pain. The weather does not necessarily make the joint inflammation worse but may make the joint discomfort more obvious. Finally, a flare-up may be a sign that your condition is getting worse. If you have a flare-up that just won’t go away, you should see a doctor for more effective ways to treat your RA.

Step 3: Fight the flare-up

The third step to managing flare-ups involves actions you can take to relieve the pain and inflammation. The following are known to be effective.

Do a medicine check. If you haven’t been taking your medicines as prescribed, it’s time to get back on track. If you stopped taking your medicine because you think it is causing undesirable side effects, make sure to tell your doctor. The doctor may be able to change your dose or prescribe a new medicine for you. If you are having trouble paying for your medicines, your doctor may be able to help you find ways to pay for them or to prescribe less expensive ones. Whatever your reason for stopping your medicine, it’s best not to allow this situation to continue for too long. The hope is that getting back on a regular schedule with your medicines will cause the RA to again respond and calm down quickly.

Check in with your doctor. You may want to check in with your doctor. You should already have worked out with your doctor the best way to get in touch should you have a flare-up. Some doctors prefer that you visit, especially if you are newly diagnosed. Others would prefer you to e-mail or phone. To treat your flare-up, the doctor may change the dose of your medicine, give you a new medicine, or advise you on other techniques to reduce your symptoms. You and your doctor can also work out a plan for changing or adding medicines or making other changes to your program that you can do yourself at home before checking in with the doctor. For example, your doctor may advise you to increase the dose of a pain-relief drug temporarily when you are having a flare-up.

Use cold or warmth. If one or two joints flare up, putting ice packs or running cool water on the joints a few times a day can help reduce pain and swelling. Some people find it uncomfortable to use cold and prefer warm moisture instead. Hot packs, heating pads, paraffin wax baths (for the hands), warm tub baths, showers, or warm-water pools can all help the joints feel better.

Rest the body. During a flare-up, getting plenty of rest will help the medicines you are taking do their job. Doctors usually recommend a good night’s sleep — at least eight hours — and an additional rest in the afternoon, if possible. Alternating rest and work is also a good plan, as long as you stop working before you get too tired. In general, a flare-up is a good time to put off any projects you’re working on and be extra good to yourself.

Rest the joint. If one of your joints is swollen, be careful about overusing it. In particular, avoid aggressive or repetitive activities. That includes some kinds of exercise. It is best to suspend more strenuous exercise programs during an RA flare-up. As the swelling subsides, you can return to your normal activities.

Do range-of-motion exercise. Although strenuous exercise is out during a flare-up, light range-of-motion exercises can be helpful. In range-of-motion exercise, you simply put a joint through its normal range of motion, without stretching or forcing it. This is especially important for swollen joints. You should not force a swollen joint to bend too much and should stop if you experience a lot of pain. However, making sure the joint stays as flexible as possible during a flare-up will help preserve the joint’s range of motion and prevent long-term stiffness.

Pace yourself. Take your time when you do activities during a flare-up. Save your energy. Do a little every day rather than doing a lot on one day and nothing the next. The art of pacing can be difficult to master, but its rewards are less pain and stiffness.

Consider a joint injection. If, during a flare, one or two joints are very painful and swollen, you may be a candidate for a cortisone injection into the joint(s). Cortisone injections can reduce swelling, relieve pain, and allow for more normal range of motion. Your doctor can determine whether you would benefit from a joint injection and then administer the injection in his or her office. After the injection the doctor can decide if changes to your drug regimen are also needed.

Ask for help. When you are worried that you are having a flare-up, it may be time to ask for help with projects or even everyday tasks that are overwhelming and possibly harmful to swollen joints. Of course, asking for help is not as easy as it sounds. But remember that most family and friends would rather have you ask for help than have you do harm to your body and joints.

Avoid “catastrophizing.” Despite your flare-up, try your best to remain calm and not to worry. Just because your joints are swelling again, it does not mean that the flare-up represents a permanent change. It will probably be short-lived, so avoid imagining “worst-case” scenarios. Negative thinking can bring you more stress and can make the flare-up worse. Remind yourself that you are doing all you can do to improve the situation and live with RA.

Manage stress. As I’ve noted before, stress can be a major contributor to an RA flare-up. Of course, it is not so easy to eliminate stress from your life. But even a small reduction in stress can have an impact. One way to get started is to try to change how you think about the stressors in your life. For example, you may become stressed at the first sign of an RA flare-up (which only makes the situation worse). But once you realize that RA has its ups and downs and that you can sometimes have an impact on the flare-up, your confidence in your and your doctor’s ability to manage flares will increase. As it does, your stress will decrease.

Another way to combat stress is through stress-management activities, such as yoga, deep breathing, and meditation. These activities are most effective when you practice them regularly.

Use assistive devices. To avoid causing a swollen joint more pain and discomfort, use assistive devices that make it easier to do painful chores or activities. There is a wide range of available assistive devices, from devices that make it easy to hold a pencil, to “reachers” that allow you to get to items on high shelves, to simple canes and crutches. (These devices and many more can be found on Web sites such as Sammons Preston and Aids for Arthitis.) You may not need these assistive devices all the time, but they can be helpful when you are having a flare-up.

A word on working

A flare-up can have a significant effect on your ability to work. If a flare-up is making it difficult for you to do your job and does not settle down in a few days, get to the doctor early and discuss your work issues. If you can, you might find it helpful to take a few vacation days to get some extra rest. Also, if you have not told your manager that you have RA, this may be the time to consider doing so. Explain that you have your RA under control, but that on occasion it flares up. Telling your manager puts you in a position to request small accommodations. For example, if the flare-up is worse in the morning, you could suggest coming in an hour later and staying an hour later. Or you might be able to work out a compromise so that you get a rest period on the days when your RA is flaring up. Always remember, however, that even if you have an understanding employer, the employer expects you to be at work and to do the job you were hired for.

If your flare-up continues to get worse, it is time to visit your doctor. Make sure you communicate to the doctor’s staff exactly what is happening and how worried you are so you get an appointment as soon as possible. With good treatment, the flare-up may be short-lived, and your RA will remain under control. Then you can get back to your job — and to your regular activities and hobbies.

Last Reviewed May 19, 2010

Wendy McBrair spent 30 years as a health-care professional in the fields of rheumatology and orthopedics, where she specialized in patient and community service, patient education, and advocacy. Her husband's company, Aids for Arthritis, sells assistive devices through a catalog and online.

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