Monday, October 7, 2013

Rheumatoid Arthritis Symptoms and Causes

The cause or causes of arthritis are oftentimes difficult to determine because there are many factors that contribute to the development of this common disease.

Arthritis involves the breakdown of cartilage. Cartilage normally protects the joint, allowing for smooth movement. Cartilage also absorbs shock when pressure is placed on the joint, like when you walk. Without the usual amount of cartilage, the bones rub together, causing pain, swelling (inflammation), and stiffness.

You may have joint inflammation for a variety of reasons, including:

* Broken bone
* Infection (usually caused by bacteria or viruses)
* An autoimmune disease (the body attacks itself because the immune system believes a body part is foreign)
* General "wear and tear" on joints

Often, the inflammation goes away after the injury has healed, the disease is treated, or the infection has been cleared.

With some injuries and diseases, the inflammation does not go away or destruction results in long-term pain and deformity.

When this happens, you have chronic arthritis. Osteoarthritis is the most common type and is more likely to occur as you age.

You may feel it in any of your joints, but most commonly in your hips, knees or fingers. Risk factors for osteoarthritis include:

* Being overweight
* Previously injuring the affected joint
* Using the affected joint in a repetitive action that puts stress on the joint (baseball players, ballet dancers, and construction workers are all at risk)

Arthritis can occur in men and women of all ages. About 37 million people in America have arthritis of some kind, which is almost 1 out of every 7 people.

Other types or cause of arthritis include:

* Rheumatoid arthritis (in adults)
* Juvenile rheumatoid arthritis (in children)
* Systemic lupus erythematosus (SLE)
* Gout
* Scleroderma
* Psoriatic arthritis
* Ankylosing spondylitis
* Reiter's syndrome (reactive arthritis)
* Adult Still's disease
* Viral arthritis
* Gonococcal arthritis
* Other bacterial infections (non-gonococcal bacterial arthritis )
* Tertiary Lyme disease (the late stage)
* Tuberculous arthritis
* Fungal infections such as blastomycosis

Rheumatoid Arthritis Symptom

If you have arthritis, you may experience:

* Joint pain
* Joint swelling
* Stiffness, especially in the morning
* Warmth around a joint
* Redness of the skin around a joint
* Reduced ability to move the joint

Self-destructive immune response of R.A may be caused by a combination of genetic susceptibility and an environmental trigger. Changing hormones may also play an important role in disease, possibly in response to an infection of the environment.

More than one gene has been linked to the risk of R.A. Specific genes may increase the likelihood of a person developing the disease, and could also partly determine how serious his condition is. However, because not all people with a genetic predisposition to rheumatoid arthritis actually have the disease, other factors should be important.

A specific environmental trigger has not been found, but some research suggests that infection by a virus or bacterium leads to rheumatoid arthritis in people genetically susceptible. That does not mean that rheumatoid arthritis is contagious. People with rheumatoid arthritis appear to have more antibodies in the synovial fluid in their joints, suggesting that there may be an infection. Low levels of hormones of the adrenal gland are common in people with rheumatoid arthritis, but how hormones interact with genetic and environmental factors is unknown. Changes hormone can contribute to the progression of rheumatoid arthritis.

Rheumatoid arthritis may occur independently of other conditions, but its causes and its relationship with other diseases are not well understood. A different way of chronic arthritis can sometimes develop in rheumatoid arthritis. It is also possible that infections or other environmental triggers exist that may cause rheumatoid arthritis in people who already have a gene for the disease.

What Foods Can I Eat If I Have Arthritis?

The link between food and arthritis has been difficult to prove because of the difficulty inherent in study design. However, observations made over the last several decades point to trends that may be important. Multiple studies have suggested that rheumatoid arthritis symptoms could be reproduced by the reintroduction of certain foods and ameliorated by excluding these foods from the diet.

More recently, rheumatoid arthritis has been shown to worsen when there is an excessive amount of Omega-3 fatty acids in the diet. Excessive ingestion of feedlot beef, refined cooking oils and margarines result in an increase of inflammatory symptoms. Some evidence has linked the consumption of saturated fats found in whole milk, cheese, as well as other animal products such as red meat and poultry to worsening RA symptoms. (O'Banion DR. J Holistic Med 1982; 4: 49-57)

An interesting connection has been proposed by some researchers that a food allergy to high saturated fat foods, meat, dairy, omega-6 fatty acids, and refined vegetable oils may be responsible for some rheumatoid arthritis flares (Hicklin JA, et al. Clin Allergy 1980; 10: 463-470.)

For centuries, nightshade foods such as potatoes, eggplant, and pepper have been claimed to aggravate arthritis. Firm data here, though, is not compelling. Study design has been a drawback. Doing a randomized double-blind study using foods is exceedingly difficult.

Small studies evaluating the effects of foods in rheumatoid arthritis sufferers have continued to make a case for food being a significant inciting factor in disease. Studies performed by researchers have demonstrated that partial fasting with avoidance of animal fat, refined sugar, citrus fruits, preservatives, coffee, tea, alcohol, salt, and strong spices which were associated with symptoms led to a reduction of symptoms.

Another study published by Beri et al showed that an elimination and rechallenge diet provided significant improvement in 71% of patients tested. (Beri, D, et al Ann Rheum Dis 1988; 47: 69-72)

In another study, Darlington evaluated 70 patients with rheumatoid arthritis. By eliminating foods deemed to provoke symptoms, he was able to eliminate symptoms as well as need for medications in 19% of patients. Darlington also identified foods such as grapefruit, cheese, malt, coffee, beef, eggs, rye, oats, milk, oranges, bacon, tomato, peanuts, cane sugar, butter, lamb, lemon, and soy as causative factors. (Darlington LG. Rheum Dis North Am 1991; 127: 273-285)

A recent study suggested that a diet high in vitamin D such as is found with salmon, tuna, shrimp, sunflower seeds, eggs, and vitamin-D fortified milk may prevent rheumatoid arthritis. (Merlino, LA et al. Arthritis Rheum 2004; 50: 72-77)

The upshot of these studies indicates that perhaps dietary manipulation should be considered as a possible therapeutic intervention. Elimination of all foods believed to be causing symptoms followed by single food reintroductions to determine which foods might be the culprits seems a reasonable course of action. Foods such as corn, wheat, cow's milk, pork, oranges, oats, rye, eggs, beef, coffee, malt, cheese, grapefruit, lemon, tomato, peanuts, and soy seem to be the most common offenders.

In our office we have found the Immunolab assay (Fort Lauderdale, FL) to be useful in excluding food allergies as a potentially important contributing factor to arthritis symptoms.

Sunday, October 6, 2013

Arthritis - Facts and Helpful Tips

The colder months of the year can be miserable for sufferers of Arthritis. The cold and damp can play havoc with joint mobility, causing inflammation and pain. If you suffer from this condition you are far from alone. The information that follows will hopefully provide you with some useful tips to help you get through the winter months with less pain.

The Statistics

  • Arthritis and Rheumatic disease affect around 8 million people in the UK

  • More than 3 million people have a significant disability

  • Osteoarthritis - the most common joint disorder in the UK affects more than one million people.

  • It affects 10 - 25% of people aged over 65

  • Around 600,000 people have Rheumatoid arthritis

  • Arthritis and rheumatic disease are the most common causes of long-standing illness, and account for one fifth of all visits to the doctor.

The Facts

The term "Arthritis" means damage or swelling of joints. Joints are the points where 2 bones meet. The ends of bones are covered by a thin layer of gristle or cartilage, which acts as a shock absorber when you put weight on a joint.

Cartilage is the tough, rubbery coating you can see on the ends of chicken thigh bones. It cushions the joints and ensures a smooth motion.

Joints are surrounded by a membrane called the Synovium, which produces a small amount of thick fluid called Synovial Fluid. This nourishes the cartilage and keeps it slippery. The Synovium has a tough outer layer called the Capsule, which stops the bones moving too much. Ligaments on both sides keep bones firmly in place. These are thick, strong bands usually just outside the Capsule. Tendons are also on both sides and attach muscles to bones. They keep the joint in place and help to move it.


Osteoarthritis is the end result of a number of different episodes of damage to the joint over a period of time. Genetic inheritance may play a part with some people. Being overweight, injury to the joint and repeated minor pressures on the joint, e.g. some sports or occupations involving repeated kneeling or lifting, can also cause this condition.
Osteoarthritis usually occurs at the knee (more common in women), the hip (equally common in men and women), the spine, and in the hands, especially at the base of the thumb and in the fingers. Osteoarthritis can produce a mild ache to crippling pain, when Total Hip Replacement or Knee Replacement may be indicated.

In severe osteoarthritis, the cartilage can become so thin that it no longer covers the bone ends. The bone ends touch and start to wear away. The loss of cartilage, the wearing of the bone, and the bony spurs at the edges can change the shape of the joint. This forces the bones out of their normal position and causes deformity.

Rheumatoid Arthritis

Rheumatoid arthritis is an inflammatory, auto-immune disease where the body turns against itself. Normally, inflammation is our immune system's response to fighting bacteria, viruses etc. In the case of rheumatoid arthritis the tissues and joints are attacked, which damages the cartilage, bones and sometimes the ligaments and tendons, too. When this happens the joints become unstable and deformities can occur.

Rheumatoid arthritis is more common in women and usually occurs between the ages of 40 to 60 but can appear earlier. It can also be hereditary in some families.

With rheumatoid arthritis the symptoms can come and go unpredictably. Sometimes physical exertion, an illness, or an emotional experience may trigger a 'flare up' but other times there may be no obvious cause.

Helpful Tips

Information and education - knowing how and why arthritis occurs can help to slow down or prevent further deterioration.

Weight management - being overweight puts further stresses on the joints, particularly the knees and hips. A reduction in weight can make a significant difference.

Exercise - aerobic exercise where the individual raises their heartbeat, sweats and becomes breathless is good for the whole body and can help in the management of weight. It may also increase general well being. Local strengthening exercise is particularly useful in arthritis of the knee. By strengthening the quadriceps muscle on the front of the thigh, pain can be reduced and balance and stability can be improved, therefore lessening disability. A physiotherapist can teach the exercises.

Frequent breaks in activities - it is sensible to have frequent breaks when gardening or doing housework to avoid mechanical stress.

Sensible footwear - a good training shoe for arthritis of the hip or knee is designed to absorb any impact when walking. Shoes should have a thick sole, no raised heel, a broad forefoot and soft uppers.

Drug therapy - no drugs are totally safe but Paracetamol is usually the first painkiller to try. Non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen may be the next choice but they have the potential to cause side effects, especially stomach problems, and may interact with other drugs. NSAIDs can inhibit repair of the joint.

Natraflex - a natural, herbal balm containing Boswellia, Capsaicin and MSM has been shown in trials to be effective in over 75% of people with arthritis and is available from Health Food Shops or the internet.

Diet - Nutritionists recommend that we eat a diet which is 80% alkaline and 20% acid. Instead, most people eat the opposite. Acidic bodies also cause calcium to be leached out from the joints, making the condition worse.

Foods that should be avoided

  • Alcoholic drinks

  • Caffeine-Coffee, Tea, & Chocolate

  • Packaged or processed food with artificial additives

  • Chinese food (contains Monosodium glutamate)

  • Dairy products

  • Eggs

  • Refined flour

  • White sugar

  • Salted foods

  • Fried foods

  • Burnt, charred or rancid food

  • Animal proteins-red meat

  • Foods containing nitrates

  • Citrus fruits

  • Aubergines

  • Tomatoes

Foods that may help Arthritis sufferers

  • Yams

  • Celery

  • Sea vegetables e.g. seaweed, kelp

  • Garlic and onions

  • Pineapple -contains the enzyme Bromelain

  • Bananas

  • Apples, pears and paw paws

  • Water - at least 2 litres of filtered water each day

  • Herbal tea

  • Rice milk

  • Oats, oatcake biscuits

  • Rice cakes (with no added salt)

  • Brown rice

  • Millet

  • Flax seed or linseeds

  • Linseed oil

  • Cider vinegar

  • Tuna, mackerel and sardines

  • Nuts and seeds (make sure they are not mouldy) - Brazil nuts, almonds, hazel nuts, cashew nuts (not peanuts), sunflower seeds, pumpkin seeds, sesame seeds (Tahini paste)

  • Dried fruits

  • Pulses -lentils and beans

  • White meat -chicken, lamb, and game

  • Herbs -basil, coriander, and ginseng

Any allergens or food intolerances should be identified to reduce the load on the immune system, particularly with Rheumatoid arthritis sufferers. Milk, yeast, eggs, grains and citrus fruits are the common foods that cause intolerance (see list of foods to avoid, above).

Fish oils are recommended to help lubricate the joints and therefore reduce the damage. MSM (methylsulphonylmethane) has also been found to reduce degeneration of the joints and can be taken orally or as a skin cream. Glucosamine is also recommended by Rheumatologists as it speeds up joint repair.

Doctors practising in nutrition recommend taking a multi-vitamin and multi-mineral supplement each day, which provides the daily values of all essential vitamins and minerals.

By understanding the facts about arthritis and following these simple diet and lifestyle recommendations, you can help to control or even reduce the symptoms of this common disease.

Top Tips To Treat Morning Stiffness

Morning stiffness in the muscles and joints is the hallmark of inflammatory kinds of arthritis. With a sprained ankle, with rheumatoid arthritis, with ankylosing spondylitis, or with other kinds of inflammation, you may notice that the sore area is stiff in the morning but loosens up as the day goes on. This phenomenon is most pronounced in rheumatoid arthritis, in which the morning stiffness generally lasts for an hour or more and can be a great aggravation. With osteoarthritis the stiffness usually lasts only a few moments.

No one really understands the reason for morning stiffness. Presumably, while the body is inactive, fluid leaks out from the small blood vessels and capillaries and the tissues become "waterlogged." Then, if you try to move the part, the swollen tissues feel stiff until the motion pumps the fluid out through the lymph channels and the veins. If you sit or lie down during the day the stiffness may return. This phenomenon is called "gelling" or the "gel phenomenon," after the behavior of gelatin, which remains liquid if kept moving and warm but solidifies if it sits for long. The phenomenon appears to be normal, but in the patient with inflammatory arthritis it can be very vexing. Don't let morning stiffness keep you in bed. If your stiffness is that severe, call the doctor and discuss the problem today.

With a minor local condition, such as a sprained ankle or a tennis elbow, don't worry about the stiffness. Think of it as a normal part of the process of bringing healing materials to the injured area. Loosen up carefully before activities and keep in mind that the healing is not yet complete. You should continue to protect the injured part. With a condition like rheumatoid arthritis, the stiffness is apt to persist and you are going to have to come to grips with the problem. Use all the tricks you can to reduce the inflammation and the stiffness. Be sure that you take any prescribed medication strictly according to schedule. Morning stiffness can be a sign of the activity of arthritis, and the best way to reduce stiffness is to treat the arthritis. Your stiffness may be a signal that you have been sloppy in taking prescribed drugs. Or you may need more medication or a different drug. In particular, don't forget to take the last dose in the evening.

Ask your doctor about changing your medication schedule. Perhaps you can take a drug later in the evening or in the middle of the night so that there is medication in your blood in the morning when you are most stiff. Some people taking aspirin find that taking a coated aspirin are absorbed more slowly, and the aspirin level in the bloodstream lasts a bit longer. Avoid painkillers, they don't help morning stiffness. Stretch gloves, of spandex or similar elastic material, may help morning stiffness in the hands if worn overnight. Give them a try, the idea is to prevent the tissues from becoming waterlogged. Try a warm bath or shower upon rising. Work at gentle exercises in the bed before you get up. You will have a certain amount of stiffness each day, and you might as well get it worked out as soon as possible. Some people find that they are helped by using an electric blanket.

Foot Arthritis - How To Treat It?

Foot arthritis could be described as one of the more common forms of arthritis. The problem with the foot is that it consists of 28 bones and 30 joints, of which any are susceptible to arthritis. If arthritis develops in any of these joints, its going to affect the way you walk, run and move in general. The joints in the foot which are more commonly affected are: the big toe, the ankle, the mid foot and the hind foot joint.

The most common form of arthritis which develops in the foot is osteoarthritis. Osteoarthritis is the result of getting older, and essentially wear and tear on the joints and cartilage. The cartilage wears down, and the bones rub together resulting in pain and swelling.

Traumatic arthritis is a common form of osteoarthritis that develops in the foot of a patient following some form of severe injury. This can develop in the foot even when the injury was treated correctly, and given time to recover fully. The most common forms of traumatic foot arthritis are a torn ligament, broken bone or severe sprain.

There are various symptoms and indications of foot arthritis, which should alert the sufferer to the condition immediately. These symptoms include swelling, tenderness, pain, stiffness and reduced mobility of the affected joint. All these symptoms will eventually lead to a difficulty in walking.

For a doctor to properly diagnose foot arthritis, a serious of tests and physical examinations will need to be performed. The doctor will also require information about your health and lifestyle to give clues on the complexity of the condition. The next step is to perform a walking analysis. In performing this walking analysis, the doctor will measure your stride and test your ankle and foot strength. Certain diagnostic imaging tests may also be required to further diagnose your condition- theses may include and X-Ray, CT or MRI scan.

After fully evaluating your foot arthritis, your doctor/physician will devise the most suitable treatment plan. There are many non-surgical treatments available, these include:

Taking anti-inflammatory medication

Steroid injection

Foot brace or cane usage

Ankle and foot support usage

Physical therapy

The final treatment option is surgery, and is generally reserved as a 'last resort' when all other treatment methods have failed. The key to effectively treating arthritis is early diagnosis. Don't ignore those sensations of stiffness and soreness; see a doctor as soon as possible, so that you have the best chance of treating your foot arthritis.

Your Rheumatoid Arthritis Diet - Balance, Moderation And Variety

A lot of people believe that rheumatoid arthritis only affects older people, but it is in fact also prevalent among people aged twenty to fifty. It can, however, affect people younger or older than the given age range; is more common with women than men. Rheumatoid arthritis is one of the worst types of arthritis - it doesn't stop with joint pain but gradually progresses to joint deformity.

There is no known cure for this disease, but the right rheumatoid arthritis diet and lifestyle, coupled with regular medication and other treatments, could allow people to continue leading normal lifestyles.

What Research Says About Rheumatoid Arthritis and Diet

Research is needed to accurately gauge the effects of diet on rheumatoid arthritis. As symptoms of this disease change in frequency and intensity from one day to another, it is virtually impossible to determine which foods caused which episode. Expert studies, however, have been able to determine that healthy food choices will always benefit individuals of any age afflicted with rheumatoid arthritis.

Today, researchers acknowledge the link between diet and rheumatoid arthritis. Nutritional supplements have been proven to be helpful as well not only for rheumatoid arthritis but other musculoskeletal problems like reactive arthritis, osteoarthritis, and osteoporosis.

Researchers however emphatically warn individuals from believing all the diet claims they hear. The US Department of Food and Drug Administration always request food and drug manufacturers to state if their claims are not sufficiently proven with research - if you see a disclaimer of this type then know that the claims provided are unsubstantiated.

Worse, there are even food products and supplements that are completely fraudulent and only out to con consumers. Such products may also contain harmful ingredients like zinc or alfalfa, both of which have been suspected to have unwanted side effects.

The Makings of the Right Diet for Rheumatoid Arthritis

There is no official recipe for the right diet. You can create your own menu plans just as long as your diet is based on three essential principles: balance, moderation and variety.

A balanced diet contains all the necessary components to ensure that you receive complete nourishment. Intake must always be moderate - eating too much of anything is not good. Lastly, what you eat must vary from time to time because it's easy to lose interest in eating and sticking with your diet if you force yourself to eat the same thing day after day.

Preparing this type of diet isn't easy and especially if you suffer from daily arthritic pain. Consider asking one of your family members or hiring an individual to ensure that your meals are carefully laid out everyday.

Caution In Preparing Your Diet

Special concerns may also dictate necessary changes for your diet. Arthritis can sometimes make you sensitive to certain food groups. Obviously, your meals will therefore avoid including any of those food groups. Depression and other emotional problems caused by arthritis may make you lose your appetite - your meals must therefore be more visually appealing and delicious than usual.

Also, rheumatoid arthritis can make a person suffer from potassium deficiency and sodium retention problems. As such, your meals will have to be particularly rich in potassium to make up for these losses.

Do your best to keep your weight ideal. Obesity has long been discovered to be disadvantageous to people suffering from rheumatoid arthritis. Besides the right diet, regular exercise can prevent you from gaining weight. Exercises may be done at home or through sports - what's important is to get yourself moving!

What's In, What's Out

Reduce intake of foods rich in cholesterol and fat. You don't have to avoid them completely, but you do need to eat less of them. The same goes for foods that are particularly sweet or salty.

On the other hand, increase intake of fruits, vegetables, and whole-grain products. They reduce the inflammatory response of your joints.

Lessen consumption of alcohol - drinking too much will only make your joint pains worse.

If your diet is deficient in any vitamin or mineral, consider taking supplements to make up for the loss.

Lastly, consider consulting your doctor or nutritionist to determine other special conditions you may have to adhere to for your rheumatoid arthritis diet. Ask, for instance, if there are certain foods that could interact with the medications you're presently taking for your condition.

What Are the Joint Pain Causes?

There are many causes of joint pain, though the majority is from illnesses. Joint discomfort can also be felt from injuries, infections and some allergic reactions to medications. Treatment for joints will depend on the unique cause and situation. You may need to have joint replacement surgery, need to switch medications, or just take immune suppressant's. Most joint pain is destructive and degenerative, so you may need to change your activities or lifestyle to accommodate or find relief for the joint discomfort, depending on the severity.

Joint discomfort can be associated with pain, your nervous system, head symptoms, muscle symptoms, swelling, movement symptoms, skin symptoms, muscle weakness, fever, body temperature, stiffness, and fatigue. Some of these causes are very easy to treat while others cannot actually fix the cause, but allow you to function with the joint problems. Finger joint pain not only causes discomfort, but debilitation in some more serious cases.

Viral infections, the common cold, the flue and other bacterial infections all can cause joint pain. The many types of arthritis cause joint pain, from light pain to very sever and debilitating pain. The list of arthritic causes is extensive. Osteoarthritis, rheumatoid arthritis, juvenile rheumatoid arthritis, ankylosing spondylitis, rheumatism, Reiter's syndrome, psoriatic arthritis, gonococcal arthritis, and inflammatory bowel syndrome are common culprits.

Some other common causes for aching joints are African sleeping sickness, east African trypanosomiasis, optic neuropathy, anterior ischemic, and West African trypanosomiasis. Severe joint pain causes are avascular necrosis, bartonella infections, bertonellosis, haemoglobin S/haemoglobin Lepore, Boston, Hemoglobin S/haemoglobin ), Arab, and Hemoglobin SC. Charcot joint pain, which is the degeneration of a stress bearing joint, such as your knee, is caused by repeated trauma, chronic haemarthrosis, chondrocalcinosis, and rheumatoid arthritis.

Joint redness, painful joints, joint inflammation, joint swelling and other joint symptoms are all associated with arthritis. Some causes of arthritis are acrodysostosis, Behcet's disease, Blau syndrome, Caplan's disease, Ciproflaxin, Diffuse idiopathic skeletal hypertostosis, Escherichi coli, Farber's disease, Bone fracture, Hemophilia type A, Hepatitis A, Kawasaki disease, Mayaro virus fever, Methimazole, mixed connective tissue disease, Mycoplasma pneumonia, obesity, PAPA syndrome, pituitary tumor, rheumatic fever, rubella, sickle cell disease, Streptococcus suis, raised Urid acid levels, West Nile fever, and Winchester. And that's just naming a few.

Gout related arthritis is a joint condition associated with the accumulation of urate crystals in the joints. It can be caused by familial juvenile hyperuricemic nephropathy, juvenile gout, Kelley-seegmiller syndrome, lesch-nyhan syndrome. Rheumatoid arthritis which causes quite sever joint pain is caused by cartilaginous deafness syndrome, chromosome 22q deletion, chromosome 22q11.2 deletion syndrome, felty syndrome, Hashimoto's thyroiditis, human adjuvant disease, hyperprolactinemia, large granular lymphocyte leukaemia, systemic juvenile rheumatoid arthritis and X-linked agammaglobulinemia.

It is important to remember that painful joints are a symptom of many different causes. You need to diagnose and recognize, rather than target the symptoms of joint troubles. This will help in determining why you are experiencing the discomfort in joints. Joint problems are commonly found in those 45 years of age and older. Most commonly rest, exercise, massage, stretching and warm baths can effectively treat nonarthritic joint issues. There are also anti-inflammatory medications that can relieve any swelling and inflammation. There is also special physical therapy for muscle and joint rehabilitation. You may need to have fluid removed from your joints to get rid of painful joints.

Without a doubt joint pain plaques millions of individuals. In some cases treatments or medication are effective in treating this problem. In other cases a more aggressive approach may be necessary. Regardless, new developments and technologies are making treatments more and more successful.