Flares

Rheumatoid arthritis seldom goes away. Eighty percent or more of patients will continue to live with it. When its initial symptoms appear,it's almost impossible to tell who will do well and who will do badly. But we do know that joint damage occurs early on,and we have only a short period of time--a year or less-to prevent this damage with an effective treatment program

In practise,this means that treatment is divided into two phases:

1) An initial phase (preferably short) where RA is suppressed as completely as possible.

2) A long-term surveillance phase where local complications of RA are spotted and dealt with before damage can be caused,and where major flare-ups are anticipated and prevented if possible.

Treatment involves a long-term contract between physician and patient. Each must understand the other as fully as possible. Communication must be open. there will be times when contact is broken off because the disease is stable,but it must be re-established when necessary. And the patient be able to judge that when that time is.

It is important for the patient to learn as much as possible about the disease,its complications and its treatment. Know when treatment is working and when it is not. Be aware of possible side effects and inform the physician when it occurs.

It's also essential to be open and be honest with the physician, If you don't understand something,or you're worrying over something,ask. Physicians often assume that patients know more then they do,while patients are often afraid to appear "stupid". And if you are hesitant to take a medication,or in fact not taking it-for whatever reason-say so.

Your right to refuse treatment is (or should be) recognized by the physician. The fact that you are refusing should't be taken as a challenge to the physician's authority,and shouldn't cause him/her to treat you. There is almost always another way to approach a problem. If the treatment being recommended is truly necessary,more information or changing circumstances will probably enable you to accep it in time.

Five basic rules for treating Ra: 1) Treat as soon as the diagnosis is made. 2) Treat to suppress all evidence of inflammation. 3) Fear rhe disease more than the treatment. 4) Treat the specific problem in the individual patient. 5) Use all available resources such as social work,surgery,hospitalization and monitoring the disease

NSAIDs-nonsteriodal anti-inflammatory drugs are invariably the first class of medication given ( there's a host of them ),and one of the last stopped. Whether it's naproxen or a relative new one like celecoxib,no single drug has ever been shown to be significantly better than another. But different people react differently,with regard to both good and bad effects. this means that a patient may have to try two or three different NSAIDs before deciding which one is best. "Best" may mean "most effective" or "best tolerated". If two drugs are equally good,the choice may boil down to "most convient" or "cheapest."

No NSAID can completely suppress RA inflamation. At best 25 percent of this problem will be dealt with-just enough to take the edge off. Because NSAIDs have both anti-inflammatory and analgesic (pain-killing) properties,it's sometimes hard to tell which of the two effects is helping the most.

NSAIDs are "base-line" therapy-the first treatment. Once it's determined which one seems to work best,it usually takes a few weeks,it's time to add a "second-line" agent. The second-line drug is taken in addition to the NSAID.

Disease modifying drugs (DMARDs) can significantly suppress the rheumatoid disease process. As with NSAIDs,the discovery of the best one for the individual patient is a trial-and error process,sometimes. This doesn't rule out intelligent guesses,because the odds are better for some than for others. At best,a given drug will work in about two-thirds of all patients,and have no effect on the other third.

These agents are also called "slow-acting" drugs,because it may take up to six months for their full benifit to develop;even the fastest usually takes about a month. Even though a drug works well initially,as time goes by the benifit may weaken or lose it. This happens with most drugs in this class.

Combination drugs are being used more-and-more in rheumatology. (such as hydroxychloroquine,sulfasazine and methotrexate) Results seem to be better,especially in aggressive disease.

In choosing a DMARD,the patient's disease severity is considered. Relatively mild RA may require hydroxychloroquine; very painful and extensive RA,particularily in an elderly person with a positive test for rheumatoid factor (RF),calls for one of the stronger agents like methotrexate or gold

For the very severe patient,one who has not responded to any of the conventional approaches ,alone or in combination,biologic drugs are available.

Corticosteriods is used when the situation calls for it. This is usually when starting a patient on DMARD therapy. Steriods can be used as a "bridge" until the DMARDs take full effect or later, as a supplement if the effect isn't quite good enough.

If you have inflammatory arthritis or you're going through a periodic inflammatory phase of osteoarthritis,you're probably experiencing pain. Since it usually takes al least two to four weeks before any NSAID begins to reduce inflammation-the source of the pain-patients will want something that will help in the interim.

That's where straighforward analgesics-pain relieving medications,come in. For minimal to moderate pain,there are a number of over-the-counter formulations; for more severe pain,you may require prescription medication.

In the meantime,chart exactly how much pain you're experiencing. On a sheet of paper,draw a scale from 0 to 10,where 10 is the worst pain you've ever felt or can imagine.,then mark where you feel your present pain is. this allows you to measure whether you're getting better or worse by giving you a baseline reference point,and it provides your doctor with valuable information when prescribing your pain medication. If you're in a lot of pain,don't be bashful about asking your physician for strong medicine.

Once you've established your pain reference point,you can determine whether nonprescription medication will provide enough relief or whether you need stronger,prescription medication from your doctor. If,for example,your pain level is at 3 or below,try a nonprescription analgesic,or even a nonmedical approach (such as a ice bag). If the pain persists for more than seventyotwo hours or worsens,consult your doctor. But you be the judge;everybody experiences pain differently.

There are many nonprescription pain relievers for arthritis-acetaminophen (Tylenol,Panadol,Exdol etc.) ASA (Aspirin,Entrophe,Anacin etc.) and ibuprofen (Advil,Motrin etc.). They're more or less equally effective and well tolerated,provided you're not already taking prescription NSAID: ASA and ibuprofen are also anti-inflammatory medications and should't be taken in addition to a prescription NSAID,because of a slightly higher risk of side effects. If you are taking aan NSAID,acetaminophen is the preferred choice,because it can be safely combined with a prescrition NSAID for increased pain relief or for headaches and fever.

Acetaminophen is safe and effective,but it does have limits. You can take regular-strength tablets (325mg.) every four hours to a maximum of 12 in a 24-hour period,or extra-strength tablets (500 mg.) every six hours,to a maximum of 8 tablets in a 24 hour period. Be careful about exceeding those limits,a serious overdose can cause permanent liver damage If you find yourself repeatedly taking acetaminphen repeatedly than recommended,consult your doctor about a stronger pain medication.

One option is an acetaminophen formulation with codeine,which affects the central nervous system,reducing pain sensivity. It's most often available in combination with 325 mg. of acetaminophen and 32 mg of caffeine (the caffeine's to combat any drowsiness the codeine causes). Regardless of the brand,the amount of codiene ranges from 8 mg. per tablet in nonprescription formulations,such as Tylenol 1,Exdol-8,or Atasol-8,to 15 mg. of codiene in Tylenol 2,Tylenol 3 has 30 mg per tablet (which requires a prescription.

A common fear about pain relievers is addiction (codiene is a narcotic) even some doctors are wary about prescribing what some of their patients believe to be essential levels of pain-relieving medication. The important point is that pain medications only make pain more bearable-they don't treat the underlying cause. Make sure you treat the underlying cause. Make sure you also seek treatment for the real source of the pain. Certainly analgesics shouldn't be used to mask pain. If you feel no pain at all from an arthritic joint,you might bbe tempted to overuse it,causing irrepairable damage. Again,the best approach to controlling pain involves medication with complementary therapies and coping strategies (though if you're in extreme pain,your doctor can prescribe a limited course of a stronger pain reliever).

Clinical research shows that people who take a narcotic at a appropriate dose for their level of pain are at a very low risk of becoming addicted. Drug dependency is fuelled by a psychological cravings for the euphoric effects of certain narcotics,such as the opiates.

Although codeine is a narcotic,when its used solely for pain relief it rarely produces the "highs" that drug users seek-if anything,it tends to make life seem a little dull and colourless. Furthermore codiene is the weakest of all the narcotic agents and can be taken for relatively long periods of time without fear of addiction-particularily if you decrease your daily dose as your pain decreases over time.

Still concerned ? Then ask yourself these questions: If you're not in pain and you don't take the codiene,do you feel a need for it ? Do you require rapidly increasing doses to control the same level of pain ? Do you get "high" when you take codiene ? Chances are, you answered "no" to all of these questions. If so,relax. You're not addicted to codiene.

The biggest problem with codiene is constipation (because it slows down the digestive tract). The best response is to increase your fibre and liquid intake You can try Metamucil,a nonabsorbed fibre,which may take a few days or a week to work but is an effective preventive (not a treatment) for most people. Psyllium,the active ingredient,is also available as Prodiem Plain,in chocolate mint,some people find it easier to tolerate. N.B. Don't take Metamucil WITH your medications,because they may pass right through your system with it,losing their effectiveness.

For the most part,stimulant laxatives aren't avisable,because the bowel can become "addicted" to them-i.e., it doesn't evacuate easily without them Glycerin suppositories are an alternative. They dehydrate the bowel,helping to soften stools. Mineral oils aren't a good idea. They deplete the body of vitamin A,D,E,and K.

Range-of-motion (ROM) exercises are the key to maintaining maximum range of motion and flexibility (not strength) in arthritic joints. They involve gentle movements that exercises each joint as fully as possible. Many ROM exercises can be done before you get out of bed in the morning,and some may alleviate the morning stiffness associated with certain forms of arthritis.

Hands are most easily exercised on a tabletop,with your forearms and hands face down. Keeping your palms flat on the table lift each finger and thumb (of both hands) one after another as high as you can without causing pain. Once all your fingers are up,raise your whole hand,bending it gently back,with your forearm still resting on the table.

Exercise your wrists simply by slackening the tension in your fingers and bending your hand back and forth in all the normal range of motion,several times. Then relax.

With your hands flat on the table and your fingers together,slowly slide your first finger toward your thumb and hold. Repeat the motion with your second finger,then the third and fourth,until all your fingers are together. Repeat three times.

Hold your hand straight up,with the fingers extended. Now slowly bend the fingers down to your palm without bending the large knucles. Open and repeat three times. For the thumb,hold your hand open,with the fingers straight. Reach your thumb across your palm and try to touch the base of your little finger. Hold,relax,and repeat.

You can do your elbows lying down,with your arms lying close to your body. Keeping your upper arms flat on the bed (or floor),raise your forearms so that the're perpendicular to your body. Now rotate them slowly,so that you're looking alternately at your palms and the back of your hands. Repeat several times.

Still lying on your back,with your arms flat at the sides,move them out,as though you're making "an angel" in the snow,then return them to their original position and repeat. This exercises one plane of motion for your shoulders.

For another plane,stay flat,with your arms at your sides. Now raise one arm at a time through an arc directly in front of you until it's flat on the bed or floor over your head (as if,standing,you tried to touch the ceiling). Return it to the original position,then repeat with the other arm.

You can exercise your neck standing or sitting. Turn your head slowly so that you're looking over your right shoulder,then turn it back to face forward. Stop. Then turn it to look over your left shoulder. Repeat. Now try tilting your head to the side,so that it comes as close as you can bring it to your shoulder without pin. Repeat on the other side,and repeat both motions twice more.

To work the back of the neck,tuck your chin down onto your chest and hold,keeping your neck straight ( you should be able to feel the muscles on the back of the neck pulling slightly).

For your back,stand with your hands on your hips and your feet shoulder-width apart. Swivel your head and shoulders to the right and hold. Return to face forward. Swivel to the left and hold. Repeat.

You can exercise the muscles of the lower back in a vertical direction by lying on your back and trying to press your back into the floor. Hold and repeat

Sit up for the hips. Stretch your legs out in front of you,then roll them in,so the toes of one foot are pointing to the toes of the other foot. Then roll your legs in the opposite direction,so your toes are pointing away from each other

Also for the hips,lie flat on your back with your legs about six inches apart. Slide one leg out to the side as far as you can,keeping the toes pointed up. Slide it back,and repeat with the other leg.

A variation that exercises both the hip and the knee is done from the same position,toes pointing up. Instead of sliding the leg out to the side,hold the knee straight and rotate your legs,so that your toes arepointing out. Hold and repeat with the other leg.

You can work your knees while you're sitting in a chair. Make sure the chair is high enough so that you can swing your legs. With your thigh on the seat of the chair,raise one leg from the knee and hold it out straight in front of you,bending your knee back as far as possible (without pain,of course)

Another knee exercise can be done while lying on your back with your legs extendd. Bring one knee up to your chest and hold,then lower it slowly to the floor. Repeat fouur times,then follow the same pattern with the other leg.

The "towel grab" is one of the best ROM exercises for the arch of the foot and the toes. Standing up or sitting,with a towel under your foot,try to pull the towel toward you,in bunches,with your toes. (You can get the same effect by trying to pick up marbles with your toes)

Sitting on the floor with your legs extended in front of you,rotate each foot in turn,describing circles in the air,first in one direction,then the other.

These are just a few of the many exercises that can be done to increase the joints'range of motion. Do exercises you enjoy doing. for more exercises and the proper way of doing them consult a physiotherapist or occupational therapist. there are also modified strengthening exercises you can learn to do that will strengthen muscles around a joint,again consult the P.T and O.T, for the proper exercise and the proper way to do it.

Light weights are good strengthening exercisess for most people.

Dancing is good exercise for everyone who can.

Flares:

For those with RA, osteoarthritis and many other rheumatic conditions, flares are a fact of life. Mild or devastating, the one thing flares have in common is that theyre never convenient or comfortable. You might wake up one morning and feel like someone has wrung your neck in the night. Maybe that niggling pain in your hip or back will suddenly knock you right off your feet. And have you found yourself falling asleep at the supper table or in the middle of a conversation? Someones pulled your plug, right?

This is where experience comes into play. If arthritis has been part of your life for any length of time, you head for the firstline of defence, something to help you deal with the pain: analgesics, ice, heat, splints, rest. While youre waiting for the fire to subside, you think back to what youve been doing that might have set this off. Sometimes its easy: You should have known better than to play 18 holes the first time you went golfing this year. Certainly you should have resisted the temptation to keep wall papering until it was finished. And that hole you stumbled into in the garden could account for the red, swollen knee now buried in a bag of frozen peas. Or those three late nights in a row at meetings that had to be attend could be the reason. It could even be your simmering anger and frustration because life handed you an unexpected lemon yesterday or depending on the length of your fuse two weeks ago.

In any case, with luck, youve identified the probable cause of the flare, and youll avoid that pitfall in future. In the meantime, youve taken time out to rest those nagging joints and throbbing muscles. With a little more luck, the regular therapies cool the flare, and youre soon back in business, swearing to follow your arthritis management program more closely. Gradually you get movement and strength back and put the discomfort behind you. Until next time.

Most folks who suffer with arthritis experience such flares; each time, diligent attention is required to keep the inflammation from getting out of hand. But there may come a day when nothing you do seems to help, and the pain and mobility get worse. Your regular medications dont do the job and you begin to worry, because now another joint has joined the battle against you, and youre fighting on two fronts, or three, maybe a dozen or more.

It can get worse I know: the relentless misery of a systemic flare, when the whole body seems to hurt at once. Deciding which joint hurts most changes from hour to hour, and a smile doesnt come easily. (Its hard to smile when its all you can do to hold onto a fork or put one foot in front of the other.)

What you absolutely must not do, if your body starts sending signals be it one joint or your whole body is ignore it. Ships send up flares when theyre in distress. Thats what your body is doing. Listen to it. And if your regular therapies dont do the job, its time to enlist the help of your team, starting with your doctor. Toughing out a definite change in your arthritis is asking for troubles you dont need: joint destruction, deformities, impaired function, lengthy disability, hospitalization. Be realistic and kind to yourself and to your doctors. Theyre there to help you get things back under control, and the importance of their role cannot be overstressed.

Toronto rheumatologist Dr. Dan Mehta calls doctor-patient relationships fundamental to the well being of anyone who must deal with a chronic disease. The triangle of patient, family physician and specialist, if they have made the effort to know and understand each other, can greatly minimize the suffering and potential damage of flares.

Sometimes, if such a relationship exists, a phone call can approve medication changes, but more often the doctor needs to see you and visually assess active inflammation and multiple joint involvement. Is it a new situation or a flare-up of joints previously troubled? Lab tests may be required, medications adjusted, etc. As a rule of thumb, I advise patients that if they think theyre experiencing a flare and it lasts more than a week, its time to consult your doctor. Because there are so many variables, what feels like a flare may be just muscle involvement or, indeed, it may be the beginning of real trouble. So, good communication is vital and well worth taking the time to cultivate.

I find that setting aside my regular lifestyle while I adapt to a new routine of drugs, rest, physiotherapy or whatever is needed to settle the flare, is frustrating. However, stewing over what isnt getting done (like spring cleaning) takes energy. Quite simply, its counterproductive. Ive found that some combination of the following suggestions is usually more productive.

Theres a book youve been trying to find time to read. This is the perfect time.
In winter, surround yourself with travel magazines for exotic, warm places. In summer, plan to avoid next winter! Gardening, home-repair and decorating magazines can keep you looking forward in a positive way, provided youre realistic about who does the actual work. You may not be able to plant the rose bushes, but you can enjoy the miracle of their blooming. Having goals is vital to every aspect of your health, particularly during a flare. As long as youre willing to delegate responsibilities and accept help, those goals may be more attainable than you think and that applies to your workplace, too.

Its imperative that you be straight forward about flares and the care you must take at those times, Mehta says. Positive communication is critical on the job. Once your employer understands the nature of arthritis, should you need an extended break or a day or two off, therell be more flexibility and less stress on both parties.

Music, music, music! Put on a selection of soothing favourites while youre lying on the bed (preferably on your back, neck supported, hands at your sides, legs out straight). Try breathing slowly and evenly until youre part of the music and it overrides the tension your pain is causing. There are many good relaxation tapes that can be used this way.
Let the people who love you know whats going on and accept their help. Being a martyr can extend a flare, and it takes too much energy to fake feeling good for any length of time. Families and friends are members of the health team; dont let pride block the many wonderful ways they can help us fight this war. They know arthritis hurts and letting them help may help ease their frustration. TLC (tender loving care) may not be the cure for arthritis, but it goes a long way in lightening the reality of coping.
Laughter really is the best medicine. Try renting a few comedy videos or audio cassettes. In fact, try to find laughter wherever you can. I find that the family album is usually a goodsource of comic relief: Can you believe the clothes we wore?
Dont fret about overdue letters to out-of-town friends. Let them know if you find it difficult to write; chances are theyll understand. Maybe you could indulge in an after-hours phone call instead, when rates are low.
Be patient. A flare may seem to happen overnight, but you can be pretty sure itll take longer to get rid of it.
If you can get into the bath, nows the time for long, warm soaks. Pamper yourself, and as your body responds to the heat, gently move your joints through their range of motion. (Swimming, though, may not be appropriate if youre in a flare. Check with your doctor or physiotherapist.)

Cathy Berges, Arthritis Society physiotherapist for the Parry Sound-Muskoka area, recommends using heat or ice to prepare your joints before you exercise and again after you exercise to settle them. Go slow! A slow, controlled movement through the greatest possible range, holding at the limit of the movement, is best. Begin with three to five repetitions of each movement twice daily. If you have increased pain that lasts longer than an hour, youve overdone it; cut back on the repetitions. If youre unsure of which exercises are right for you, consult the physiotherapist involved in your care.

Use your health team resources. If your doctor recommends physiotherapy, occupational therapy for splints, or a homemaker or visiting nurse, accept his or her professional understanding of the disease and follow the advice. Joyce Hadcroft, occupational therapist at Parry Sound District General Hospital, suggests an informal, private session so we can offer ways to protect joints, reduce pain and save energy. Custom-made splints can lessen the chance of deformities and may need adjusting during a flare.
A demonstration can show that those comfy slip-on shoes or slippers may not be the most comfortable footwear afterall. There are many ways an occupational therapist can help you maintain a good quality of life. The bottom line is Dont wait, ask! Something can be done.
Have you been wanting to try a new craft or hobby? Well,if it wont affect the joints that are in flare, now would be a good time. But again: Dont overdo it.
For years, Ive wanted to sort through all my old photo negatives and get prints made of all the memorable moments of my children growing up. I cant stay at it for long, but it puts a good strategy into play distraction. There are so many wonderful memories in those old shots. As I sort them into envelopes, for a while the pain seems less and Im grateful again that I didnt have to deal with the arthritis while we had four beautiful, active children at home to love and care for. And one positive result of this rough time will be a personal album for each of them, showing the greatest gift parents can givememories. With my Obus® form at my back, my feet up and a hot cuppa by my side, this is good therapy!
Dealing with flares can be an emotional rollercoaster that can wear you down. Depression is a common by-product, and there may be times when its a big help to have someone on your team whos familiar with this aspect of the disease. Taking care of your emotional health isnt wimpy; its wise. In most communities, there are mental-health care professionals you can consult without a referral, but if you require one, dont be shy about asking. A perceptive, caring therapist can do a lot to keep you on an even keel when the seas of arthritis get rough.

Fighting the battle against an arthritic flare uses up a great deal of emotional and physical energy, says Anne Marie Hoeschler, a clinical social worker with the Parry Sound-Muskoka Mental Health Service. We now recognize the connections between mind and body, but we often find it easier to seek help for physical symptoms than for emotional needs. Many survivors of chronic pain resist any suggestion of giving in to or acknowledging their physical or emotional needs. Seeking outside help may be misinterpreted as weakness or depence rather than a healthy acknowledgment of our interdepence.

In flare, one can feel vulnerable, helpless or frustrated by restrictions to activity and mobility. These feelings can be overwhelming, especially when combined with other life stresses. When a flare exhausts our usual emotional resources, it may be necessary to look elsewhere. Maybe we need to learn or regain ways of coping with emotions triggered by the flare, or learn to recognize and work with our emotions and thoughts rather than resisting or denying them. The goal is to avoid an exacerbation of the flare.

If theres a self-help group you can take advantage of, by all means, do so. Bluebird Club members have a wealth of tricks for dealing with tough times, and they really do care and want to help you. Trust me, youll get the chance to return the favour: We learn from each other. To learn to live with arthritis and cope with periodic flares, youll need all the help you can get. The provincial offices of The Arthritis Society can provide you with a contact in your area (see the addresses on the back cover of this magazine).
Do everything you can to make yourself look as good as possible; maintaining a good self-image gives you a lift. There are hairdressers and barbers who make home visits. Homemakers and homecare nurses recognize the value of helping you maintain a good image of yourself. Most people with arthritis understand this instinctively. Its simply another coping strategy.
Flares, whether in one joint or systemic, as usually happens in rheumatoid arthritis, tax ones strength in all areas, physical, emotional and spiritual. If youre in the habit of turning to your faith for balanced living, now is not the time to ignore that source of support. Ironically, as I interview people and review my own experience, it seems that often happens. Were taught that it is more blessed to give than to receive. There will always be people in need, and when youre in an arthritic flare, youre one of them. Pay attention to those things that heal the soul as well as those that restore the body.

I find it a most appropriate strategy for dealing with a flare-up of arthritis of any kind: A good general, I was told, knows when to retreat so that he can come back to fight another day. It makes sense and being sensible about your arthritis may be the best medicine of all. ------------Patient's perspective article on managing a flare.

Pain is the noxious sensation of a stimulus that a person feels. Generally, we would associate it with an injury to a body part, like a cut or a scrape. Perhaps it's an aberration of the internal workings of the body from a disease, like a cancer growing inside. But in that understanding, we know that the nerve endings of the different tissues -- and for RA it's the nerve endings in the joints that are being distorted and irritated -- are sending a signal back through the spinal cord and up to the brain where this understanding or the appreciation of pain is noted.

Rheumatoid arthritis is a systemic autoimmune disease. Systemic --the illness is generalized throughout a person's body-the whole system. Autoimmune--the immune system has gone awry and has begun to attack some of the body's normal tissues. What happens in this disease is the immune system is stimulated to attack the joint tissue. This attack on the tissue is waged by the different cells in the body - both white blood cells and other types - and the chemicals that they make(TNF,Interleukins etc.)

Some of the chemicals are messenger signals to other cells to tell them to go and do damage to the joints. Some of these chemical signals are released and cause the damage to the joints. What we have then is these nerve endings in the joint tissue are being stimulated, sending signals back to the brain. There is acute and chronic pain--pain we can associate with what is happening in the joint.

Fatigue is a sense of exhaustion, a lack of energy, a lack of motivation. And it may be the result of an over-effort - beyond what someone can do. And the result of fatigue is a decreased activity, or a lessened activity. Fatigue occurs in RA for several reasons. One reason for fatigue is the messenger chemicals-- tumor necrosis factor [TNF] and Interleukin-1. When these chemicals are released, they are actually released locally in the joint, but they also circulate throughout the body. They definitely cause fatigue.

Also, as a person is working around the pain in their joint and as the joint may become damaged and deformed, the amount of effort it takes to work through the day doing a person's activities will obviously exhaust them; and as the joints get damaged more and more, the ability to carry on some of these functions gets worse. As a person is working around the pain in their joint, the amount of effort it takes to work doing a person's activities will obviously exhaust them

Physical activity in general, particularly exercise is lessened, so a person becomes deconditioned. The muscles are deconditioned and the cardiovascular system is deconditioned, and the lungs are deconditioned. So now there are other reasons to be fatigued. And on top of that, there may be mental fatigue or psychic emotional exhaustion with it. These are all very poignant and difficult symptoms to deal with.

To strengthen your assertive frame of mind,practise this coping statement often: I expect to feel anxious when I assert myself, because most people do, I will feel disappointed if I don't get the result I want,but my best chance is to stick to being assertive. I might feel embarassed or even frightened if the other person reacts badly. I can cope with feeling disappointed or embarassed or even frightened. The chance of feeling bad is not a good enough reason for me to surrender my rights. It's important to me to assert myself,reasonably and responsibly. So I will consider the rights and feelings of others,before I assert myself. But,if it is genuinely important to me,I will assert myself.

Make a coping statement; I expect to feel anxious when I confront my worries and prevent myself from doing my worry behaviors,but I'll cope; I won't try to deny my understandable anxiety nor to avoid my worries,but I also won't only think about how badly they might turn out,because other outcomes are also possible;if this worry is some -thing I can tackle constructively,I'll do that,now,rather then just worrying about it;if there's nothing I can really do about this worry,at least now,then I'll find something else to do that will occupy my mind plesantly or constructively. I'm not obligated to make myself anxious with unnecessary worrying.