"Ooohhh... My Aching Knee!!!"
Insider Secrets on How You Can Get Relief Quickly and
Easily!
By
Nathan
Wei
When your knee hurts, getting relief is all that’s on your mind. Getting the right relief, though, depends on knowing what’s wrong. The correct diagnosis will lead to the correct treatment.
Know Your Knee!
The knee is the largest joint in the body. It’s also one of the most complicated. The knee joint is made up of four bones that are connected by muscles, ligaments, and tendons. The femur (large thigh bone) interacts with the two shin bones, the tibia (the larger one) located towards the inside and the fibula (the smaller one) located towards the outside. Where the femur meets the tibia is termed the joint line. The patella, (the knee cap) is the bone that sits in the front of the knee. It slides up and down in a groove in the lower part of the femur (the femoral groove) as the knee bends and straightens.
Ligaments are the strong rope-like structures that help connect bones and provide stability. In the knee, there are four major ligaments. On the inner (medial) aspect of the knee is the medial collateral ligament (MCL) and on the outer (lateral) aspect of the knee is the lateral collateral ligament (LCL). The other two main ligaments are found in the center of the knee. These ligaments are called the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). They are called cruciate ligaments because the ACL crosses in front of the PCL. Other smaller ligaments help hold the patella in place in the center of the femoral groove.
Two structures called menisci sit between the femur and the tibia. These structures act as cushions or shock absorbers. They also help provide stability for the knee. The menisci are made of a tough material called fibrocartilage. There is a medial meniscus and a lateral meniscus. When either meniscus is damaged it is called a "torn cartilage".
There is another type of cartilage in the knee called hyaline cartilage. This cartilage is a smooth shiny material that covers the bones in the knee joint. In the knee, hyaline cartilage covers the ends of the femur, the femoral groove, the top of the tibia and the underside of the patella. Hyaline cartilage allows the knee bones to move easily as the knee bends and straightens.
Tendons connect muscles to bone. The large quadriceps muscles on the front of the thigh attach to the top of the patella via the quadriceps tendon. This tendon inserts on the patella and then continues down to form the rope-like patellar tendon. The patellar tendon in turn, attaches to the front of the tibia. The hamstring muscles on the back of the thigh attach to the tibia at the back of the knee. The quadriceps muscles are the muscles that straighten the knee. The hamstring muscles are the main muscles that bend the knee.
Bursae are small fluid filled sacs that decrease the friction between two tissues. Bursae also protect bony structures. There are many different bursae around the knee but the ones that are most important are the prepatellar bursa in front of the knee cap, the infrapatellar bursa just below the kneecap, the anserine bursa, just below the joint line and to the inner side of the tibia, and the semimembranous bursa in the back of the knee. Normally, a bursa has very little fluid in it but if it becomes irritated it can fill with fluid and become very large.
Is it bursitis... or tendonitis...or arthritis?
Tendonitis generally affects either the quadriceps tendon or patellar tendon. Repetitive jumping or trauma may set off tendonitis. The pain is felt in the front of the knee and there is tenderness as well as swelling involving the tendon. With patellar tendonitis, the infrapatellar bursa will often be inflamed also. Treatment involves rest, ice, and anti-inflammatory medication. Injections are rarely used. Physical therapy with ultrasound and iontopheresis may help.
Bursitis pain is common. The prepatellar bursa may become inflamed particularly in patients who spend a lot of time on their knees (carpet layers). The bursa will become swollen. The major concern here is to make sure the bursa is not infected. The bursa should be aspirated (fluid withdrawn by needle) by a specialist. The fluid should be cultured. If there is no infection, the bursitis may be treated with anti-jnflammatory medicines, ice, and physical therapy. Knee pads should be worn to prevent a recurrence once the initial bursitis is cleared up.
Anserine bursitis often occurs in overweight people who also have osteoarthritis of the knee. Pain and some swelling is noted in the anserine bursa. Treatment consists of steroid injection, ice, physical therapy, and weight loss.
The semimembranous bursa can be affected when a patient has fluid in the knee (a knee effusion). The fluid will push backwards and the bursa will become filled with fluid and cause a sensation of fullness and tightness in the back of the knee. This is called a Baker’s cyst. If the bursa ruptures, the fluid will dissect down into the calf. The danger here is that it may look like a blood clot in the calf. A venogram and ultrasound test will help differentiate a ruptured Baker’s cyst from a blood clot. The Baker’s cyst is treated with aspiration of the fluid from the knee along with steroid injection, ice, and elevation of the leg.
Knock out knee arthritis... simple steps you can take! Younger people who have pain in the front of the knee have what is called patellofemoral syndrome (PFS). Two major conditions cause PFS. The first is chondromalacia patella. This is a condition where the cartilage on the underside of the knee cap softens and is particularly common in young women. Another cause of pain behind the knee cap in younger people may be a patella that doesn’t track normally in the femoral groove. For both chondromalacia as well as a poorly tracking patella, special exercises, taping, and anti-inflammatory medicines may be helpful. If the patellar tracking becomes a significant problem despite conservative measures, surgery is need.
While many types of arthritis may affect the knee, osteoarthritis is the most common. Osteoarthritis usually affects the joint between the femur and tibia in the medial (inner) compartment of the knee. Osteoarthritis may also involve the joint between the femur and tibia on the outer side of the knee as well as the joint between the femur and patella. Why osteoarthritis develops is still being scrutinized carefully. It seems to consist of a complex interaction of genetics, mechanical factors, and immune system involvement. The immune system attacks the joint through a combination of degradative enzymes and inflammatory chemical messengers called cytokines.
Patients will sometimes feel a sensation of rubbing or grinding. The knee will become stiff if the patient sits for any length of time. With local inflammation, the patient may experience pain at night and get relief from sleeping with a pillow between the knees. Occasionally, locking and clicking may be noticed. Patients with osteoarthritis may also tear the fibrocartilage cushions (menisci) in the knee more easily than people without osteoarthritis.
So how is the arthritis treated? An obvious place to start is weight reduction for patients who carry around too many pounds.
Strengthening exercises for the knee are also useful for many people. These should be done under the supervision of a physician or physical therapist.
Other therapies include ice, anti inflammatory medicines, and occasionally steroid injections. Glucosamine and chondroitin supplements may be helpful. A word of caution... make sure the preparation you buy is pure and contains what the label says it does. The supplement industry is unregulated... so buyer beware!
Injections of the knee with viscosupplements – lubricants- are particularly useful for many patients. Special braces may help to unload the part of the joint that is affected.
Arthroscopic techniques may be beneficial in special circumstances. Occasionally, a surgical procedure called an osteotomy, where a wedge of bone is removed from the tibia to “even things out,” may be recommended. Joint replacement surgery is required for end stage knee arthritis.
Research is being done to develop medicines that will slow down the rate of cartilage loss. Targets for these new therapies include the destructive enzymes and/or cytokines that degrade cartilage. It is hoped that by inhibiting these enzymes and cytokines and by boosting the ability of cartilage to repair itself, that therapies designed to actually reverse osteoarthritis may be created. These are referred to as disease-modifying osteoarthritis drugs or “DMOADs.” Genetic markers may identify high risk patients who need more aggressive therapies.
Newer compounds that are injected into the knee and provide healing as well as lubrication are also being developed. And finally, less invasive surgical techniques are also being looked at. Recent technological advances in “mini” knee replacement look very promising.
Dr. Wei (pronounced “way”) is a board-certified rheumatologist and Clinical Director of the nationally respected Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine and has served as a consultant to the Arthritis Branch of the National Institutes of Health. He is a Fellow of the American College of Rheumatology and the American College of Physicians. For more information go to: Arthritis Treatment
Easy Steps You Can Take Today
to Erase Hip Pain
By
Nathan
Wei
“More than 100,000 Americans are unable to get from their bed to the bathroom without assistance because of problems related to their hip or knee.” So says Dr. Nathan Wei, Clinical Director of the Arthritis and Osteoporosis Center of Maryland. He adds, “Too many people put up with pain when there are so many treatments available.”
The hip joint plays a major role in weight-bearing and walking.
It’s a ball-and-socket joint that combines great stability and a wide range of motion. This joint is comprised of the head of the thigh bone (femur) which is shaped like a ball. This sits inside a cup-like area of the pelvis called the acetabulum (“socket”). It is surrounded by powerful muscles that help maintain the body in an upright posture and also help with walking. Many ligaments also help support the structure of the hip.
The most common symptom with hip problems is pain
Pain due to hip problems may be felt in the groin, on the outside of the hip region, the buttock, inner part of the thigh, the front of the thigh, and even the knee. In fact, there have been patients who’ve had knee surgery... when the problem was really in the hip. NOT a good thing! Pain coming from the hip joint also needs to be distinguished from low back disorders as well as knee disorders. Activities of daily living that are affected by hip pain include going up and down stairs, getting out of chairs, getting out of bed, getting shoes and socks off and on, and sexual intercourse.
Hip pain is often aggravated by weight-bearing.
Besides arthritis, hip pain can be due to bursitis. The most common is trochanteric bursitis. Trochanteric bursitis is inflammation of the large bursa that sits on the side of the hip. It tends to come on in middle-aged people. The major symptom is a deep aching pain over the upper outer thigh. It is made worse by walking. It is often bad at night and is aggravated by lying on the affected side. The treatment consists of anti-inflammatory medication, physical therapy, steroid injection, and stretching exercises.
Another potentially serious condition is avascular necrosis of the hip.
Here, a patient will have severe pain- usually in the groin. Weight-bearing is excruciating and the pain may also be present at night. Avascular necrosis is a condition where the blood supply to the head of the femur (”the ball”) is interrupted... ...and the head of the femur actually dies! The bone collapses. Remember the great athlete, Bo Jackson... he had avascular necrosis. The diagnosis is confirmed by MRI scanning and the treatment involves surgical procedures. In patient with an arthritis condition, treatment modalities should include anti-inflammatory medication, physical therapy, exercises, and weight reduction, if necessary.
Specific stretching exercises are helpful.
Dr. Wei says, “One of my favorite is called thread-the-needle. You cross one leg across the thigh of the other. Reach down through the hole formed by this crossing over maneuver with the same side hand as the leg you’re using to cross over. Clasp fingers with the other hand behind the thigh and gently pull. You’ll feel the stretch! Hold for 10 seconds. Repeat with the other side.”
Joint replacement- known as hip arthroplasty- is still the resort of choice in patients with end-stage arthritis.
Indications for arthroplasty include:
•loss of function in the hip.
In the past, the limiting problem was that the replaced hip was only good for 10 to 15 years with “normal” use.
Problems that limit the lifespan of hip replacements are
•wear and...
•inflammatory response to particles that eventually cause loosening in some patients.
Dr. Wei (pronounced “way”) is a board-certified rheumatologist and Clinical Director of the nationally respected Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine and has served as a consultant to the Arthritis Branch of the National Institutes of Health. He is a Fellow of the American College of Rheumatology and the American College of Physicians. For more information on arthritis and related conditions, go to: Arthritis Treatment
My Arthritis is Killing Me - It Must be
Springtime
By
Nathan Wei
It turns out that patients with rheumatoid arthritis appear to have higher disease activity during the spring season relative to the fall season, based on subjective and objective disease measures.
To determine whether a seasonal fluctuation in disease severity exists among patients with rheumatoid arthritis (RA), researchers examined data from 1,665 patients with RA who participated in a large, observational cohort study conducted in Japan from October 2000 to April 2005. The majority of the patients (81.7%) were female, the mean age of the patients was 57.2 years, and the mean disease duration was 9.9 years.
Ten criteria were used to assess disease activity, including objective, subjective, patient-assessed, and physician-assessed measures. Evaluations were made each spring and fall during the study period.
The results showed higher disease activity in the spring for almost all measures.
In addition to clinical measures of disease, laboratory measures of disease activity including the erythrocyte sedimentation rate (sed rate), C-reactive protein, and rheumatoid factor were also significantly elevated in the spring compared with the fall.
The implications of the research are difficult to fully establish. However, it is clear that examining patients during different times of the year may lead to different results. Seasonal variations in symptoms should be taken into account when planning changes in treatment. Patients with RA should be warned about the possible seasonal variations that can occur.
(N. Iikuni, A. Nakajima, E. Inoue, E. Tanaka, H. Okamoto, M. Hara, T. Tomatsu, N. Kamatani and H. Yamanaka. What's in season for rheumatoid arthritis patients? Seasonal fluctuations in disease activity. Rheumatology. January 2007).
Nathan Wei, MD, FACP, FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland (http://www.aocm.org). He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine and consultant to the National Institutes of Health. For more info: http://www.arthritis-treatment-and-relief.com/arthritis-treatment.html Arthritis Treatment
Green Tea for Rheumatoid
Arthritis?
By
Nathan Wei
A new study from the University of Michigan Health System and the University of Michigan School of Medicine was presented at the national Experimental Biology meeting in Washington, D.C.
Lead researcher, Salah-uddin Ahmed, stated that "it's too early" to fully recommend green tea to ease rheumatoid arthritis (RA), but the “study is a starting point."
In the study, Ahmed isolated cells called synovial fibroblasts from the joints of patients with rheumatoid arthritis. These cells form the inside lining of tissue inside the capsule of a joint. This synovial lining becomes inflamed in patients with rheumatoid arthritis. The inflammation leads to joint destruction and crippling deformity.
The researchers cultured these cells and exposed them to the active ingredient in green tea, a compound named epigallocatechin-3-gallate (EGCG). Next, the cells were stimulated with a protein called interleukin-1B. Interleukin -1B is a cytokine. Cytokines are chemical messengers that promote joint inflammation and destruction through the production of damaging proteins and enzymes.
In an earlier study, Ahmed's team found that fibroblasts pretreated with EGCG and then stimulated with cytokine IL-1B were better able to block IL-1B's ability to produce the damaging proteins and enzymes that cause the cartilage breakdown seen in people with rheumatoid arthritis.
In the current study, the researchers also looked at whether EGCG had the ability to block the activity of two potent molecules, IL-6 and cyclooxygenase-2 (Cox-2), which also play a role in joint inflammation in RA.
The two molecules were suppressed by the EGCG significantly, Ahmed reported.
EGCG also blocked the production of prostaglandin E2, another compound that can promote joint inflammation.
The new research by Ahmed is one of the first to focus on rheumatoid arthritis and green tea. Ahmed cautioned that while it's too soon to advise rheumatoid arthritis patients to drink green tea, drinking green tea certainly wouldn't hurt, he said. Green tea is known to have many health benefits and no known side effects.
Nathan Wei, MD, FACP, FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland (http://www.aocm.org/). He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine and consultant to the National Institutes of Health. For more info: http://www.arthritis-treatment-and-relief.com/
Eliminate
Agonizing Hand Pain Quickly and Easily!
By
Nathan Wei
According to Dr. Nathan Wei, “The hand and wrist are the mirrors of disease.” While the cause of hand pain can be a localized problem, hand pain can also be the presenting sign for other diseases.
The wrist and hand are capable of power and precision. As a result, pain and swelling are often accompanied by weakness of grip in hand disorders. A careful history and a complete physical examination are important. The presence of symptoms elsewhere in the body is important to establish.
Two serious hand problems are:
• Reflex sympathetic dystrophy (RSD). This is caused by a disorder of the sympathetic nervous system. Typically, it is described as a burning pain. The precipitating factor may be trauma Color changes including purplish discoloration of the fingers may occur. The treatment involves a special procedure called stellate ganglion block. Usually performed by an anesthesiologist, this procedure is often very effective.
• Hypertrophic osteoarthropathy. The hand becomes swollen and painful. This picture occasionally occurs in patients with underlying cancers.
Other hand problems that point to other diseases:
• Psoriasis may also cause pitting or lifting up (onycholysis) of the fingernails.
• Abnormal blood vessel patterns near the fingernails may signify auto-immune diseases like lupus.
• Raynaud's phenomenon... When fingers blanch (turn white) this may be a sign of an underlying autoimmune problem such as systemic lupus erythematosus or scleroderma.
• Bumps, called “nodules” can develop as a result of osteoarthritis, gout, and rheumatoid arthritis.
• Depuytren’s contracture is a problem where the skin in the palm may become thickened and shortened. A cord of tissue develops and causes fingers to bend into the palm. Treatment for this problem may be steroid injection, splinting, and physical therapy. Surgery is often needed. This condition occurs with other medical diseases.
Virtually all types of arthritis can affect the wrist and hand.
Arthritis when untreated or poorly treated will lead to deformity. Tendonitis is another common problem in the wrist and hand. In the wrist, tendonitis usually causes pain and localized swelling. Tendonitis can be confused with arthritis.
Tendonitis in the hand is most common in the palm. This causes locking or triggering of the fingers. Steroid injection and physical therapy are usually effective treatments. Treatment consists of anti-inflammatory medication, steroid injection, splinting, and occasionally physical therapy.
Tips to make your hand pain better...
• Wear splints if you’re going to be doing a lot of repetitive motions
• Use your whole arm instead of just your hand and wrist
• Enlarge the handles on your tools. You can get kitchen utensils and writing implements with enlarges handles. They’re worth it.
• Make sure to take rest breaks.
• Avoid repetitive movements when possible.
• Carry objects with the palms open and flat. This will take the pressure off your wrists and fingers.
A common cause of hand pain is carpal tunnel syndrome
... pinching of the median nerve in the wrist. Carpal tunnel syndrome is a symptom- much like fever... it is not a disease! It is the most common cause of tingling in the hands. Besides tingling, burning pain may also occur. Patients often have discomfort at night that is relieved by hanging the affected hand over the side of the bed or vigorously shaking the hands. The discomfort of carpal tunnel syndrome can also be brought on by holding up the newspaper while reading, or by driving. Causes of carpal tunnel syndrome include arthritis, endocrine problems, pregnancy, trauma, infection, tumors, and overuse. Treatment of carpal tunnel syndrome depends on the severity. Mild to moderate carpal tunnel syndrome is treated with splinting, sometimes steroid injection, and avoidance of overuse. For patients with carpal tunnel syndrome that doesn’t respond to conservative measures or where the carpal tunnel syndrome is severe, surgery is indicated.
Radial nerve damage leads to wrist drop. Radial nerve pressure in the wrist can occur as a result of repetitive motion, tight pressure (handcuffs, watchbands, bracelets), diabetes, and trauma. Ulnar nerve damage and compression in the wrist can cause a "claw hand." Treatment consists of anti-inflammatory medication, rest, splinting, injection, and sometimes surgery.
Treatment of hand disorders is entirely dependent on making an accurate and specific diagnosis.
Doctor - How
Serious Are The Risks Of Arthritis Pain Relievers To My Stomach?
By
Nathan Wei
Non-steroidal-anti-inflammatory drugs (NSAIDS) are anti-inflammatory pain relievers. Approximately twenty different NSAIDS are available by prescription. Three NSAIDS (ibuprofen, naproxen, and ketoprofen) are also available over-the-counter as Advil, Motrin IB, Aleve, and Orudis. Aspirin is also an NSAID. NSAIDS are also found in many common cold preparations such as Advil Cold and Sinus, Dimetapp Sinus, and Aleve Cold and Sinus.
The most common side effect associated with these drugs is stomach problems. These problems can range from mild stomach upset to ulcers and bleeding. NSAIDS cause this situation because the same mechanism that allows them to block inflammation also causes them to block the secretion of substances that protect the stomach lining.
The magnitude of this problem is enormous. Significant stomach side-effects from NSAIDS result in 103,000 hospitalizations and 16,500 deaths each year in the United States.
While anyone who takes an NSAID can be at risk for stomach problems, there are some high risk factors that significantly increase the chance of problems developing. These include:
• Age greater than
60
• History of previous ulcers
• Taking steroid medicines such as prednisone
• Using blood thinners like coumadin, Plavix, or heparin
• Regular alcohol consumption
• Taking higher than the recommended dosage of NSAID
• Taking more than one NSAID at the same time (such as taking an NSAID along
with aspirin)
• Taking NSAID for a prolonged period of time
A 2003 survey revealed that about half of all Americans who took over-the-counter NSAIDS took more than the recommended dose. This can happen when the dose is taken before the recommended time for dosing, taking more than the recommended number of tablets, taking more than the recommended dosage per day, and taking more than one NSAID at a time.
Small amounts of over-the-counter NSAID including low-dose aspirin to prevent stroke, heart attack, and colon cancer also increase risk.
Warning signs that a
significant problem may be occurring include:
• Stomach pain
• Tarry black stool or blood in the stool
• Vomiting up material that looks like coffee grounds
One unfortunate issue is that more than 80 per cent of people who have a life-threatening stomach problem have no warning symptoms. Symptoms can occur quickly also. Serious medical events have occurred in people taking NSAIDS for less than one week.
To reduce your
risk:
• Check to see if you have risk factors.
• Discuss potential side-effects with your prescribing physician.
• Read the warning label and follow dosing instructions.
• Don’t use prescription NSAID and over-the-counter NSAID at the same time.
• When you see your doctor let him or her know about all the medicines,
including nutritional supplements, you are taking.
• Limit your alcohol intake while on these medicines.
• Recognize that low dose aspirin is an NSAID.
• Let your physician know if you’re experiencing any symptoms that suggest a
stomach problem.
• Ask about other medicines that might reduce your risk of a stomach
side-effect. Medicines called proton pump inhibitors (PPIS) can reduce the risk
of stomach side-effects. Examples of PPIS include Nexium, Protonix, Prilosec,
and Axid.
Another medicine, Cytotec, may also protect your stomach. Sometimes using an analgesic that is not an NSAID can relieve arthritis symptoms sufficiently. Analgesics include Tylenol or Ultram (tramadol).
Cox-2 medicines such as Celebrex may also reduce your stomach risk. However, adding low dose aspirin to Celebrex apparently removes the protective effect of the Celebrex.
Viscosupplements for My Knee Arthritis - What are They?
By
Nathan Wei
In osteoarthritis, the cartilage in the joint gradually wears away. During the course of cartilage degeneration, there is inflammation and resultant stiffness and pain. Osteoarthritis may be caused by or aggravated by excess stress on the joint from deformity, repeated trauma, or excess weight. It most often affects middle-aged and older people.
A younger person who develops osteoarthritis may have an inherited form of the disease or may have experienced problems as a result of injury.
In rheumatoid arthritis, the joint becomes inflamed and cartilage may be destroyed as well. Arthritis not only affects joints, it can also affect supporting structures such as:
• muscles
• tendons
• ligaments
Rheumatoid arthritis often affects people at an earlier age than osteoarthritis. Regardless of the type of arthritis causing knee symptoms, the end result is often the same. A person who has arthritis in the knee may experience pain, swelling, and a decrease in knee motion. A common symptom is morning stiffness that gets better as the person moves around. Sometimes the joint locks or clicks when the knee is bent and straightened, but these signs may occur in other knee disorders as well. The doctor may confirm the diagnosis by performing a physical examination and examining magnetic resonance (MR) scans, which reveal the inner architecture of the knee.
Most often arthritis in the knee is treated initially with pain-reducing medicines, such as analgesics and anti-inflammatory medicines.
Exercise is essential to restore joint movement and strengthen the knee. Losing excess weight can also help people with osteoarthritis.
Glucocorticoid injections are helpful when there is evidence of inflammation.
The normal knee joint produces synovial fluid, a thick slippery substance that nourishes cartilage and allows smooth gliding of the cartilage surfaces. With arthritis, the amount of synovial fluid made by the joint is reduced.
In instances when other therapies do not provide the desired relief, viscosupplements are sometimes used. These are gel-like substances (hyaluronates) that mimic the properties of naturally occurring joint fluid.
These hyaluronates actually supplement the viscous properties of synovial fluid. Injection of hyaluronates is done using either fluoroscopic or ultrasound needle guidance.
Currently, hyaluronate injections are approved for the treatment of osteoarthritis of the knee in those who have failed to respond to more conservative therapy. The number of injections performed varies with the type of viscosupplement used. Usually 5 injections are required for the best response.
Currently, there are five FDA approved hyaluronates:
• Hyalgan
• Synvisc
• Euflexa
• Supartz
• Orthovisc
Sometimes, a physician will perform an arthroscopy before providing viscosupplement. Also, a special type of brace to help unload the narrowed part of the knee may be used to help the viscosupplement work better.
Use for other joints is being studied. Studies have shown effectiveness for the shoulder, hip, and ankle. We published a study a few years ago showing these viscosupplements are effective for osteoarthritis affecting the base of the thumb.
How You Can Erase Low Back
Pain Using the Latest Medical Techniques!
By
Nathan Wei
“If you’re one of the nine out of ten adults in the United States who suffers from low back pain, I have good news for you!” states Dr. Nathan Wei, a board-certified rheumatologist and Clinical Director of the Arthritis and Osteoporosis Center of Maryland.
“Low back pain is the most expensive work-related injury as well as the third most common reason for a surgical procedure,” Dr. Wei adds.
The spine is a complex collection...
It consists of bones, called vertebrae, and the joints that allow them to
interact; discs that separate the vertebrae from each other; the spinal cord and
nerves; the soft tissues such as muscles and ligaments that help hold the spine
together. Your spine has 3 major functions including protecting the spinal cord,
supporting the body in an upright position, and allowing the body to move
freely.
The four major categories of low back pain are:
• Mechanical- arising from either trauma or repetitive motion
• Degenerative- usually from arthritic causes
• Systemic- arising from medical illnesses
• Stress-induced
Mechanical causes are responsible for more than 90% of back pain and the most common cause of back pain is probably muscle injury due to strain or sprain. Other common causes include disc herniation, spondylolisthesis (a condition where the vertebra slips on the one below it), spinal stenoiss (narrowing of the canal that carries the spinal cord), scoliosis (curvature of the spine), osteoporosis (a disease where the bones become fragile and break), and arthritis. Bone tumors are another potential cause.
“Treatment is entirely dependent on
diagnosis!”
Dr. Wei says, “There are simple ways to help your back. For instance use the log
roll technique to get into and out of bed. Think of your body as a log, and make
sure you move it as a unit... rolling into and out of bed.”...He says, “use the
same idea when getting into and out of your car. Don’t twist or stick one leg
one way and the other leg a different way. Move your body as a unit...”
Check your work area
Make sure your computer, chair, and other parts of your work environment are
“friendly” to your back. Good support for your low back as well as your legs is
important.
Exercise regularly
Dr. Wei reminds us, “...Stretching is important for your spine…Since rotation is
a key movement and the upright position is part of our daily routine, we need to
incorporate exercises that stretch and strengthen those muscles that are
important for twisting and for posture.”
Space Age Treatment
“A new addition to our low back pain tool kit is a procedure device called
intervertebral disc decompression or IDD. It helps decompress the vertebrae
non-surgically, and non-invasively. Studies to date have shown a response rate
of up to 86%,” adds Dr. Wei
Dr. Wei concludes, “Surgical procedures are a last ditch effort...and should be reserved for patients who have pain unresponsive to conservative treatment or who have a progressive neurologic problem.”
My Son Has A Stiff Back When
He Gets Up in the Morning - Is It Ankylosing Spondylitis?
By
Nathan Wei
Ankylosing Spondylitis is one of the more common forms of arthritis affecting about 0.5% of the population. It affects men more often than women in a ratio of about 2.4-5:1. The disease is categorized as a "spondyloarthropathy"... a type of arthritis that preferentially affects the spine. It usually starts in the sacroiliac joints- the joints that join the pelvis to the low back- and spreads upwards to involve the rest of the spine. Peak age of onset is between 15 and 30 years.
Typically, a patient will complain of stiffness in the low back or neck or both that is worse with rest and better with activity. Often, a young person will pursue sports as a way to relieve the pain they have! Stiffness during the day after inactivity is also common. Other joints affected include the hip, knee, wrists, shoulders, elbows, and ankles. Typically, patients will have not only joint symptoms but they will also have enthesopathy... meaning inflammation at points where tendons connect to bones. Fatigue is a very common symptom. Occasionally low grade fever, appetite loss, and weight loss may be seen.
Patients will sometimes present with the extra-articular (outside of the joint) symptoms. Examples include inflammation of the eye, lungs, and rarely, the heart. The most common extra-articular symptom is eye inflammation which occurs in about 40% of patients and must be diagnosed and treated aggressively. Blindness is a dreaded complication.
The physical exam will show limitation of range of motion in the low back. Chest expansion is also restricted since many patients with AS will have limited ability to expand their lungs due to involvement of the thoracic spine.
Occasionally, women with AS will have more symptoms in the neck than the low back.
Laboratory testing will show abnormalities that indicate the presence of inflammation. Patients with AS will also have the genetic marker HLA B27 in about 90% of cases.
Imaging studies such as magnetic resonance imaging will show the presence of inflammation in the sacroiliac joints. Inflammation of the tendon insertions at different affected joints will also be evident.
Treatment goals consist of relieving pain and stiffness as well as maintaining function.
A comprehensive program consists of a combination of anti-inflammatory medicines to help with symptoms as well as disease-modifying therapy to slow down the rate of progression. Examples of anti-inflammatory drugs are drugs such as ibuprofen (Motrin), naproxen (Naprosys), nabumetone (Relafen), etodolac (Lodine), meloxicam (Mobic), and celecoxib (Celebrex). Disease-modifying drugs that are used extensively for this condition are sulfasalazine (Azulfidine) and methotrexate. Biologic therapies like etanercept (Enbrel), adalimumab (Humnira), and infliximab (Remcade) are considered important for inducing remission. A solid program of physical therapy to help with range of motion is also mandatory.
For patients with suspected eye disease, close supervision by an experienced ophthalmologist is also recommended.
Patients with far-advanced disease may suffer complications including compression of the spinal cord (cauda equina syndrome), and fractures of the neck. In particular, care should be exercised in preparing patients with AS for surgery. Intubation (placing a breathing tube into the airways) for general anesthesia carries the risk of inadvertent spine fracture.
Surgery is reserved for far advanced cases that have not responded to medical therapy.
The clinical course and prognosis is highly variable and also highly dependent on the rapidity of diagnosis and the effectiveness of therapy.
Do You Suffer from
Osteoarthritis? Here's How to Tell!
By
Nathan Wei
The most common type of arthritis is osteoarthritis (OA). This type of arthritis is commonly referred to as wear and tear arthritis or degenerative arthritis.”
While this condition probably begins in the early teen years, it does not become symptomatic until a person reaches their 40’s.
Osteoarthritis affects cartilage, the slippery elastic tissue that covers the ends of long bones. Cartilage functions to absorb shock from movement and also to provide a gliding surface for the joints. With OA, the cartilage begins to wear away and the underlying bones begin to rub against each other. This leads to pain. As OS progresses, it causes swelling and loss of motion. Bone spurs develop and the joint starts to deform. Microscopic particles of cartilage and bone flake off and cause irritation of the joint lining leading to more inflammation which leads to pain and more damage.
Symptoms of OA include pain or stiffness in a joint particularly after getting out of bed or after sitting for a prolonged period of time. Some people have “flares” of their symptoms with weather changes. Stiffness and pain in the joints with movement may occur as may “crunchiness”.
Some people report no symptoms. One study done at the National Institutes of Health showed that one third of patients with osteoarthritis on x-ray had no symptoms.
While any joint may be affected, the most common areas of involvement are weight-bearing parts of the skeleton such as the neck, low back, hips, and knees. The great toe and the base of the thumb are also common locations. In older women the last row of finger joints and the next to last row of finger joints may be affected. Less common sites are the shoulders, elbows, ankles, and jaws.
Many factors including the way people use their joints. Occupational experiences also play a role. For instance, miners and dockworkers may develop knee OA while farmers have a higher incidence of OA of the hip. Ballet dancers can also develop OA in the feet, ankles, and hips. Athletes also fall into a high risk category with women soccer players being more likely to develop knee OA as a result of prior injury. Other athletic activities which cause joint trauma also can be a trigger for the development of OA.
Obesity is a major risk factor for OA of the hips and knees. The famous Framingham study showed that obese women had the most severe OA.
People with other types of arthritis such as rheumatoid arthritis or gout are at increased risk for developing OA also.
Probably the most significant risk factor is genetic. Patients with a strong family history of OA are at high risk themselves for developing OA. This is most likely a result of defects in cartilage metabolism which hastens wear and tear.
A Fresh Start Plan for People
With Neck Pain!
By
Nathan Wei
If you have to deal with chronic neck pain, it can be a real struggle. I know… because I’ve had to do it myself,” states Dr. Nathan Wei, a board-certified rheumatologist and Clinical Director of The Arthritis and Osteoporosis Center of Maryland.
How arthritis causes neck pain...
The neck is an interesting structure. It's made up of 7 bones stacked on top of
each other. Each is separated from each other in the front by fibrous cushions
called discs, and from each other in the back by special joints called facet
joints. “The maximum movement of the neck occurs between the 4th and 6th
cervical vertebrae...and this is where the most wear and tear in arthritis is
seen,” says Dr. Wei
Pain can come from anywhere!
Dr Wei adds, “… anything in the rear part of the brain can cause referred pain
to the neck….This includes aneurysms, infections, and tumors….
Also, neck pain can be referred from the shoulder, the upper chest, or even the heart! …Problems in the soft tissues of the neck such as growths or tumors affecting the thyroid gland, esophagus (food pipe) or trachea (wind pipe) can also lead to neck pain
Injury to the muscles and ligaments (example= whiplash auto accident) can cause neck pain. Dr. Wei declares, “This is the type of problem I have had for many years. I’ve been rear-ended a few times and I have degenerative arthritis in the neck at the C5-6 level. Patients I have talked with agree with me when I report popping or grinding in the neck with movement. Other patients say it “feels like sand back there” when they move their head…”
Pain from whiplash can radiate up the back of the head and cause headache. It may also radiate into the shoulders or between the shoulder blades.
Dr. Wei also adds, “Some types of neck pain are dangerous. When neck problems are associated with pressure on the spinal cord, this is called myelopathy and is a neurosurgical emergency!”
What are the most effective treatments?
Treatment obviously depends on making the correct diagnosis. According to Dr.
Wei, the goals of treatment are to relieve pain, improve range of motion,
prevent weakening of muscles, and restore function. Among the common treatments
are non-steroidal-anti-inflammatory medicines or NSAIDS, topical agents such as
Myorx, soft neck collars, neck support pillows, and exercises. Dr. Wei firmly
reminds us, “… evidence of instability or cord compression is a ticket to see
the neurosurgeon stat…”
22 Inside Tips on How You Can
Make Your Arthritis Medicines Work Twice as Effectively
By
Nathan Wei
This report will give you 22 important tips to make sure that you’re getting the very best out of your arthritis treatment program.
1. Make absolutely sure that the nurse or doctor knows what allergies you have. Also, make sure that they know what other medicines you’re taking and ask specifically about drug interactions and side effects.
2. Ask how the arthritis medicine should be taken. Sometimes arthritis medicines are taken best on an empty stomach and sometimes they’re taken best on a full stomach. Also ask what time of day is best to take the medication. Some arthritis medicines should be taken in the morning and some should be taken in the evening.
3. If you have other medical illnesses, let the doctor or nurse know about that. If you have a previous history of ulcers, they should be informed.
4. Ask whether there is literature such as an Arthritis Foundation pamphlet available on the kind of medicine that you’re going to be receiving. If not, ask if there are any other printed handouts. At the very least, the nurse should go over the medication with you.
5. Ask if the medicine comes as a generic. If it does not, at the very least, ask for a two-week supply of free samples.
6. If you have a common arthritic condition, ask whether any arthritis clinical trials are available in the area. This is a great way to get free medical care for your arthritis along with free medication for your arthritis.
7. Ask about other types of therapies that can be used along with the medicine. For instance, ice or heat to a painful area for 15-20 minutes two or three times a day can be quite effective.
8. Sometimes moist heat also can be effective. Ask your nurse or doctor which is better for you, ice or moist heat. If you’re going to use moist heat, make sure it is moist heat rather than dry heat.
9. Sometimes assistive devices such as braces, splints, neck support pillows, canes, etc. may help your medicine work more effectively. Ask whether that’s the case.
10. If no specific handouts or pamphlets are available from your doctor, ask whether you can have a photocopy of the pages from the Physician’s Desk Reference made available to you. This is difficult to get through because of the vocabulary used, but contains a lot of important information that you may want to know.
11. Remember to ask about how the medicine should be monitored. Most arthritis medicines need to be monitored fairly frequently because of side effects. This is especially true in people over the age of 60.
12. Sometimes, as your arthritis gets better, it’s possible to cut back on the amount of medicine you take. Ask about that.
13. Ask whether physical therapy modalities might be helpful in your case.
14. Make sure you let your nurse or doctor know whether you’re taking any natural or vitamin supplements. These sometimes can interfere with the effectiveness of your arthritis medication.
15. If you see an article in a magazine about your medication, bring it into your nurse or doctor. Sometimes these articles contain good information. However, sometimes these articles contain misleading, or even worse, wrong information.
16. Ask about generic drugs. Sometimes generic drugs, while cheaper than brand name drugs, may not be as effective. Sometimes though, they can be just as effective. You need to ask.
17. Make sure that you periodically ask your nurse or doctor whether there are any new drugs available for your condition. Sometimes the new drugs are more effective, safer, and more convenient.
18. If, after you start taking your medicine, you notice anything that could be a side effect, call your physician immediately.
19. Ask if there are any Internet web sites that provide good information about the medication that you are taking.
20. Do not share medications with friends or relatives. Remember the medication that has been given to you is specific for your problem. To share your medication with another person can be extremely dangerous. Likewise, if you borrow some of your relatives or neighbors medication, you may run into a terrible problem.
21. If you smoke or drink alcohol, ask about potential problems with your arthritis medicines.
22. Make sure you get the proper monitoring. Many arthritis medicines need careful evaluation of blood and urine on a regular basis.
Winning the War Against
Rheumatoid Arthritis
By
Nathan Wei
RA is a condition that forces half of patients to become disabled from the work force within five to ten years… and reduces life expectancy by as much as 18 years. RA affects about one per cent of the world’s adult population, most commonly women between the ages of 30 and 50.
The good news is that a tremendous amount of progress has been made within the last ten years in identifying patients earlier and treating the disease more aggressively. Patients with RA, if treated appropriately, can lead a relatively normal life. This is in stark contrast to the wheel-chair bound existence common as recently as 20 years ago!
Experts in the field consider early rheumatoid arthritis to be a medical emergency with mortality and morbidity equal to that for diabetes, asthma, heart disease, and other life-threatening conditions.
Rheumatoid arthritis attacks the joints in a symmetric fashion (both sides of the body affected equally) with the most common areas being the hands, wrists, ankles, knees, and feet. In addition to the swelling and pain, patients with RA often have profound fatigue and stiffness.
Rheumatoid arthritis is an autoimmune disease that attacks not only joints, but internal organs such as the blood vessels, lungs, heart, and eyes. Patients with RA are at increased risk for heart attack, stroke, and lymphoma.
Since many other types of arthritis such as gout, lupus, and osteoarthritis can look like RA a careful diagnostic approach is needed.
Laboratory testing has its pitfalls. The rheumatoid factor, a blood test found to be positive in about 80 per cent of individuals with RA, may also be positive in other disease conditions. Couple that with the fact that 20 per cent of patients with RA will be rheumatoid factor negative, then it becomes clear a diagnosis should not hinge on the results of blood tests alone.
Imaging procedures can also be misleading. Conventional x-rays often miss the erosions found with early disease. Newer imaging technologies such as magnetic resonance imaging (MRI) and ultrasound are much more sensitive.
After the diagnosis is made, there is even more hope for a patient today. In the past, non steroidal anti-inflammatory drugs (NSAIDS) used to be considered a cornerstone of therapy. That is no longer true.
Disease-modifying anti-rheumatic drugs (DMARDS) are being used earlier. Among the DMARDS currently being used are methotrexate, leflunomide (Arava), azathioprine (Imuran), sulfasalazine (Azulfidine), cyclosporine, and hydroxychloroquine (Plaquenil). These drugs attack the immune cells responsible for chronic inflammation. While DMARDS alone in combination are effective, they are relatively non-specific. Often, combinations of DMARDS are required.
Biologic Response Modifiers (BRMS) can target the disease more specifically than DMARDS. RA is a disease that is dependent on the signaling that occurs between immune cells. The signaling takes place through the use of special chemical messengers called cytokines. BRMS act at both the cytokine (chemical messenger) as well as the cellular level allowing the disease to be better controlled and in some instances put into remission.
Biologic response modifiers, which include drugs that suppress tumor necrosis factor (TNF), appear to be particularly effective.
Tumor necrosis factor is a protein that is produced by the immune cells. TNF is the major culprit responsible for inflammation-inducing damage. By block the effects of TNF, better control of RA can be achieved.
Three anti-TNF drugs are currently available: etanercept (Enbrel), adalimumab (Humira), and infliximab (Remicade). Another biologic drug, anakinra (Kineret) blocks interleukin, a different cytokine.
These drugs allow patients to have their disease controlled to such an extent that most are able to enjoy a normal work and leisure existence.
Second line biologic agents such as Rituxan and Orencia allow rheumatologists to treat patients who have failed anti-TNF drugs.
On the horizon are other biologic drugs that work at different points in the immune system- on different cytokines and on different pathways- to allow even greater as well as more specific control of disease. Since rheumatoid arthritis is a disease with many different cytokine and cellular mechanisms responsible for damage, attacking the disease at different points makes sense. In the future it may be possible to identify patients through specific tissue signals (called “biomarkers”). These biomarkers will allow physicians to type patients and give patients the specific therapy that will work best for them. Once that is achieved, the possibility of a cure becomes a reality.
Everything, though, starts with early accurate diagnosis. If damage is allowed to occur the chances for remission drop dramatically!
The 7 Most Dangerous Mistakes
You Can Make When You See a Doctor for Arthritis!
By
Nathan Wei
1. Seeing a doctor who’s not board-certified or a doctor who isn’t really an arthritis specialist. A lot of doctors will tell you they’re “board-eligible.” That’s nonsense! What “board-eligible” means is that they did the training for the specialty but either haven’t taken or- heaven forbid- failed the examination for board-certification. Don’t trust your health to one of those doctors. And worse yet, some specialists don’t pass on the first attempt. They keep taking the board exam over and over in the hopes they’ll finally pass. Ask the doctor how many times it took them. Would you rather see somebody who passed the first time or some idiot who took three and four times to pass?
Are they American trained? While some specialists have completed a residency or fellowship in the U.S., they’ve gotten their medical degree elsewhere. The medical schools overseas do not compare to the medical schools in the United States.
How long have they been practicing? It takes a good ten years or longer of real world experience to really be able to take good care of patients.
And are they specialists in the field of arthritis (rheumatology)? Orthopedic surgeons claim to be able to take care of arthritis. But they’re not rheumatologists. They haven’t received formal training in the medications used to treat arthritis. They don’t know about the newest developments in the field of arthritis. They don’t know about the side effects and about proper monitoring techniques for medications. They’re trained to cut and to operate. Why should they want to stop arthritis from destroying your joints? Since they are surgeons, they can always do surgery and replace your joints. Having an orthopedic surgeon take care of your arthritis is like putting the fox in charge of the chicken coop.
2. Waiting too long to be seen. Arthritis causes the most damage in the first six months. That’s a fact from the Arthritis Foundation. It you have to wait a couple of months just to see a doctor... guess what... the cat is out of the bag. Damage has already been done. You can’t afford to wait. And if you’re thinking, “Well, this doctor participates in my insurance...” Is that really a good reason to risk crippling and loss of independence? Participating in managed care is bad for your health. Insurance companies, not the doctor, dictate what kind of care you receive. Think about it…do you really think insurance company executives stay up at night worrying about your arthritis? Is that really good for you?
3. Rude staff and doctor. If you can’t get along with the staff and doctor, do you think your arthritis is going to take top priority? No way!!! Look for a practice where they treat you the way you want to be treated. Like a real human being.
4. Doctor rushes. Hey... you’re paying good money. Make sure the doctor knows what you’re there for and what is worrying you. Are your calls returned? Do they schedule timely follow-up visits? Are they interested in you as a whole person ... or are you just a number... a body part. Are they open-minded about alternative treatments? Do you feel comfortable discussing them?
5. They don’t care if you’re educated or not. You have to know about your disease and the medicines you’re being treated with. You’ve got to know about the side-effects and what type of follow-up is needed. These are your rights! And do these doctors know their P’s and Q’s? Have they done clinical research? What kind of reputation do they have in their field? Are they recognized as a leader in the field of arthritis? Do you want to see a leader or a follower?
And that goes double for proper follow through. If the doctor and his staff drop the ball, you could be in for a bad time. Not only is the disease going to cause problems but the medicines need to be monitored carefully. You’ve got to be seen on a regular basis!!! And what if the doctor is a medication freak? He or she gives you a medicine and that’s the end of it. And you go back and you get another medicine... and then another without any explanation. You deserve better.
6. Your doctor doesn’t refer. If you’re seeing a primary care doctor for your arthritis and you’re not getting any better and he’/she doesn’t refer, you’re making a big mistake. Remember... the damage is done in the first six months of disease. It’s important to be seen by a specialist as early as possible! The amount of medical information a doctor has to know has increased 20 times since 1950. Can you really expect a family doctor or internist to know about the latest developments on arthritis? Remember...arthritis causes most of its damage in the first six months. You’ve got to get the right treatment early!!!!!
7. Not getting a diagnosis. This is key. You need to know what you have and what can be done. There are always many treatment options available!
Doctor... What Do I Do Now
That They've Taken Away My Vioxx!
By
Nathan Wei
Ever since the huge tidal wave of publicity that surrounded COX-2 drugs hit the American public, patients with arthritis have had to deal with the consequences. While some deaths possibly could have been attributed to cardiovascular side-effects, there has been a huge downside. This has been the radical removal of medicines which had been the source of better quality of life for thousands of patients.
So what are the options?
Well for one, there is still one COX-2 drug available. Celebrex has been shown to be effective for pain associated with osteoarthritis and rheumatoid arthritis. The down side is that patients with a history of allergy to sulfa should not take it because of cross-reactivity. Also, despite the touted safety for patients with prior peptic ulcer disease, the benefit of COX-2 drugs has been negated when patients have had to take concomitant aspirin therapy. Nonetheless, Celebrex remains a viable option for patients who are in need of the benefits of COX-2 inhibition.
Older non-steroidal drugs also remain on the market. These include drugs like Relafen, Lodine, Mobic, Daypro, Motrin, Naprosyn, and Voltaren. Unfortunately, data has indicated that all non-steroidal drugs share an increased risk of cardiovascular events. In fact, it appears that many of the older drugs such as Clinoril, Voltaren, and Indocin probably have a higher cardiovascular risk than many of the newer medications.
A new plant-based cyclooxygenase inhibitor called Limbrel appears to be both effective as well as safe. Clinical trials in osteoarthritis are ongoing.
Interest in nutritional supplements has also offered a possible alternative. The recent NIH GAIT (Glucosamine/Chondroitin Arthritis Trial) has been called a “negative” study by some. Nonetheless, 66% of patients taking glucosamine/chondroitin benefited vs. 60% in the placebo group. While the numbers may not be statistically significant, no one can explain why the actual treatment group did better than the placebo group and why animal studies also show a benefit. (It’s hard to fake placebo effect in animals).
Non-drug therapies such as weight loss, thermal modalities (heat and cold), topical agents (rubs), and exercise play an important role in the management of arthritis.
Integrative therapies such as acupuncture, various herbal supplements, and hypnosis might benefit some people.
Newer therapies such as electrical pulsed coils might also help. This type of therapy has drawn much interest because of its non-invasive, non-drug properties.
It’s important that patients consult knowledgeable rheumatologists to assist them in their quest for safe, effective relief from arthritis pain.
The Top Seven Myths About
Arthritis
By
Nathan Wei
Myth #1: “Nothing can be done about arthritis...”
You don’t have to put up with arthritis. Now more than ever, there are excellent medicines that can not only treat the symptoms but also, in many cases, get the disease into remission. Arthritis when diagnosed and treated properly can be controlled.
Myth #2: “It’s all due to getting old...”
Arthritis affects all age groups. Arthritis can even affect children. Three out of every 5 people with arthritis are younger than 65 years!
Myth #3: “If I wait, it’ll go away...”
Six million Americans believe they have arthritis but have never seen a physician! A proper diagnosis and treatment are important! Who doesn’t want to see their children graduate or play with their grandchildren? It’s a choice many Americans make every day.
Myth #4: “Arthritis medicines have too many side-effects...”
Yes... Many of these medicines do have potential side-effects! Witness the latest flap over the COX 2 drugs. But...When properly monitored by an arthritis specialist, the chances for severe side-effects are much much lower! Let’s face it... any medicine you take has potential side-effects. What you and your physician have to determine is this: Are the potential side-effects- which by the way are relatively uncommon despite what the media would have you believe- worth my quality of life?
Myth # 5: “I’ll never get arthritis...”
Seventy million people in the United States (25% of the population) suffer from arthritis!” Also, arthritis strikes 750,000 new people a year. More than 97% of people over 50 will get arthritis. Just because you don’t have symptoms now doesn’t mean you won’t get symptoms soon.
Myth # 6: It’s just aches and pains... Nothing I can’t live with...
Arthritis is the #1 cause of loss of personal freedom. More than 100,000 Americans can’t walk independently from their bed to the bathroom because of arthritis. Ten million Americans are limited in their daily activities because of arthritis. Arthritis is the:
* leading cause of physician visits in adults over 65
* most common chronic disease
* most common cause of crippling
* most common cause of impairment and functional limitation in adults
Myth # 7: “My doctor can take care of arthritis...”
Unless your physician is a rheumatologist who remains active on the cutting edge of new research, there is no way he or she can “take care” of this condition. There has been a literal explosion of new treatments in the last three years. These treatments can make the difference between a life filled with joy and a life filled with dread.
"Foot Pain Relief At Last!"
By
Nathan Wei
“As an arthritis specialist, one area that I see people complain about more often than almost any other, is their feet.” So says Dr. Nathan Wei, Clinical Director of The Arthritis and Osteoporosis Center of Maryland. “This is too bad because there are many treatments that can be helpful,” Dr. Wei adds.
The foot is made up of 26 bones and 39 muscles...
The foot and ankle are designed to bear weight. The multiple joints in the feet are capable of adjusting to almost any terrain and the padding in the feet are designed to absorb shock.. The ankle joint allows the foot to move up and down, side to side, and inward and outward (inversion and eversion).
Not All Foot Pain Comes From The Foot!
Careful examination of the low back, hip, and knee should be performed because pain from these areas may affect the foot and ankle. In particular, pinched nerves in the low back can cause foot pain and weakness.
Ankle sprains are common- 25,000 people sprain an ankle every day! The goal of treatment is to relieve pain and prevent instability.Treatment of an acute sprain consists of rest, ice compression and elevation ("RICE”). Exercises to help stabilize and strengthen the ankle should be started.
Arthritis of the ankle may cause recurrent pain and swelling.Pain from arthritis typically is made worse by weight-bearing particularly on uneven ground. What this means is you should try to avoid excessive walking or running on uneven ground. Anti-inflammatory medication and proper foot support can do wonders.
Pain in the ball of the foot has many causes...
Other common causes of foot pain include:
Muscle strengthening exercises and orthotics are helpful. Two other common problems are:
Well fitted orthotics (arch supports) can alleviate not only foot and ankle pain but pain in the knees, hips, low back, and neck!!
We often take the ability to walk for granted. This ability involves the use of two engineering marvels- our feet and ankles. Because of the tremendous amount of force transmitted to the feet with walking, unique problems may develop. Attention to proper preventative care, i.e., comfortable shoes, sox, hygiene, support, along with proper prompt medical care can really put the brakes on foot pain.
So... Which One Do I Use for
My Arthritis, Doctor... Heat or Ice?
By
Nathan Wei
Heat has long been used to provide temporary relief of arthritis pain, and is used in many different forms. Contrast baths, whirlpools, electric pads, microwaveable gel packs, hydrocollator packs, infrared lamps, and hot showers are some of the different techniques used. Even warm tap water probably will meet some of your needs for heat therapy at home.
Heat can provide temporary relief of pain and stiffness, and can prepare you for physical activity or exercise. For example, morning stiffness is a common problem for many people with rheumatoid arthritis. Because your body has been still during the night you may need special help to get going in the morning. The following combination of techniques using heat can reduce the length and the severity of morning stiffness:
1. Sleep in a sleeping bag (which helps retain body heat) or with an electric blanket (following the manufacturer’s instructions).
2. Take your aspirin or other anti-inflammatory medication an hour before you get out of bed in the morning. (Keep a few crackers at your bedside to take with the medication to avoid stomach irritation.)
3. Take a warm shower or bath immediately after you get up.
4. Then do limbering-up exercises after your shower or bath while you still feel warm.
Safety is important in choosing the form of heat you use. You should take great care to avoid burns or electric shocks. Heat must be used with much caution on any area of the body with poor circulation or where you cannot feel heat or cold normally. It should not be used over areas where your skin is fragile or broken.
Only mild heat is necessary to get results. You are aiming for a temperature just slightly above body temperature, and you do not have to apply heat for a long time. You will get full benefit by using heat for 20 minutes each time.
Moist heat is any technique in which water is used to conduct the heat, such as a bath or shower or hydrocollator packs. People with arthritis prefer moist rather than dry heat, such as a heating pad. Moist heat penetrates more deeply than dry. You will have to try both and see which is more effective and convenient for you.
Heating pads are available which provide either moist or dry heat, but they should be chosen and used with care. Make sure the pad is approved by the Underwriter’s Laboratory. Look for those which have temperature control switches; those without temperature settings get hotter and hotter until you switch them off.
When using a pad, never lie on top of it and make sure you do not fall asleep while it is on. Severe burns can result! It may be wise to use a timer during the treatment. Check the instructions on use carefully. Regularly inspect the pad for any cracks in the plastic cover.
Hydrocollator packs are canvas bags containing silicone gel which retain heat for a long time. You can buy them in different shapes at pharmacies. Some people like them because they lose heat more slowly than most wet compresses. The pack is heated in water, wrapped in 8 to 10 layers of heavy toweling and placed over the painful joint.
The pack is heated in a large pot of water and placed on heavy towels. Place the surface with the thickest layer of toweling over the part to be treated.
Keep in mind that hydrocollator packs do have drawbacks. They are not practical if heat is needed for several joints, because each pack can be used for only one part at a time. They are also cumbersome to use and may be too heavy placed over a painful joint. If your hands are affected by your arthritis, it may be difficult for you to remove the heavy pack from the water with the tongs. So you may need help. Again, you must be very careful about burns. If you decide to try such a pack, follow the manufacturer’s instructions carefully.
Microwaveable gel packs are popular. Follow the instructions carefully or else the bag containing the gel may leak… or even worse explode and cause serious burns!
Physical therapists sometimes use melted paraffin as a means of applying heat, particularly to the hands. There are units available for home use as well. Because they involve high temperatures, paraffin baths should be used with caution. Patients with osteoarthritis or rheumatoid arthritis involving the hands often find paraffin to be helpful.
You can buy nylon and spandex gloves which can reduce morning stiffness of the hands for some people when worn at night. The gloves are available in both men’s and women’s sizes.
It is important to wear adequate, warm clothing in cold weather. Some people find that knitted, woolen or fleece pullover cuffs on painful joints, especially the knees, ankles and elbows are helpful in keeping the joints warm and more comfortable in cold weather.
Some people with arthritis find that heat does not help them. In fact, the reverse is often best-cold compresses. Cold may be especially effective when active inflammation produces severe pain and joint swelling. Only trying different modalities will enable you to find out which is best for you.
It is easy to make a cold pack by filling a small plastic bag with a few ice cubes. A bag of frozen vegetables wrapped in a towel can be used. Place any cold pack over the painful joint with a layer of terry cloth toweling in between. The same precautions that apply to the use of heat should be observed when using cold. The maximum benefit is achieved in less than 20 minutes. You may wish to repeat this application several times a day.
For many people with arthritis an effective approach is alternating warm and cold water applications, a process called contrast baths. It is most useful for a hand or foot which can be dipped in a large pot filled with water. If you decide to give it a try, use a thermometer to check temperatures.
1. Fill one container 2/3 full with 110 degree F water.
2. Fill a second container 2/3 full with 65 degree F water.
3. Put your hands or feet completely into the warm water for three minutes; then put them into the cold water for one minute.
4. Repeat step #3 two more times.
5. End the treatment with three more minutes in the warm water; then carefully dry the hands or feet.
Finally…and very importantly… with acute musculoskeletal pain, and particularly with injuries, always use ice. The formula to remember is RICE...
Rest
Ice
Compression
Elevation
My Dermatologist Told Me to
See An Arthritis Doctor... I Have Psoriasis and My Joints Hurt
By
Nathan Wei
Psoriatic arthritis is a distinct disease, different from rheumatoid arthritis and ankylosing spondylitis- another common type of arthritis- but sharing similar features to each. The disability and functional impairment in psoriatic arthritis can be as severe as that occurring from rheumatoid arthritis.
Typically, a patient will have had psoriasis for a number of years before the arthritis develops. A small proportion of patient will develop the arthritis concurrently with the skin disease and an even smaller percentage will develop the skin disease after the joint disease.
Psoriatic arthritis may affect most joints in an oligoarticular pattern, meaning a few scattered joints are affected and the joint inflammation does not have the symmetrical pattern seen in rheumatoid arthritis. Enthesitis, which is inflammation of the tendons that attach to bone, is common in psoriatic arthritis. “Sausage digits” – swelling of the fingers and toes so that they look like little sausages is frequent. Nail changes are also common. These include "pitting" and separation of the nail from the nailbed. Some patients will develop carpal tunnel syndrome because of inflammation in the wrist. Inflammation of the eyes is a serious complication, as is involvement of the aortic valve of the heart.
Joint deformity is frequent and affects 40% of patients with the disease. Psoriatic arthritis has a significant impact on quality of life. The skin disease is a tremendous burden and often leads to depression.
The inflammatory process that causes both the skin disease as well as the joint disease is driven by elevated levels of a substance called tumor necrosis factor, or TNF.
A patient with psoriasis who complains of joint pain, swelling, morning stiffness, and fatigue should raise a high level of suspicion for the diagnosis of psoriatic arthritis.
Laboratory testing will show evidence of inflammation and imaging procedures such as magnetic resonance imaging (MRI) can help confirm the diagnosis.
Treatments that improve the skin disease do not necessarily improve joint symptoms and vice versa.
Treatment goals include symptomatic relief and control of disease progression.
Non-steroidal anti-inflammatory drugs are helpful for relieving some symptoms. However the majority of patients with psoriatic arthritis will require a combination of methotrexate and anti-TNF biologic therapy. Anti-TNF therapies have provided a significant advance in the treatment of both the skin as well the joint disease in patients with psoriatic arthritis.
Doctor, What Kind Of
Anti-inflammatory Medicine Should I Take For My Arthritis?
By
Nathan Wei
The process of inflammation starts with arachidonic acid which is a key ingredient in cell walls. Arachidonic acid is produced when cells are subjected to stress from aging, trauma, or wear and tear. Arachidonic acid is then converted into prostaglandins which are the primary mediators of inflammation. The process of arachidonic acid conversion to prostaglandins is through two enzyme pathways - cyclooxygenease (COX) or lipoxygenase (LOX).
Cyclooxygenease is an enzyme pathway that has two components. The first is COX 1 and the second is COX-2. COX-1 is responsible for the inflammatory response but also plays a role in helping to protect the stomach from ulcers and promoting normal kidney function. COX-2 also has a large role in the inflammatory response. Traditional anti-inflammatory medicines block both COX-1 and COX-2. Examples include ibuprofen, naproxen, sulindac, indomethicin, nabumatone, etc. By doing this they inhibit inflammation but also make the body vulnerable to certain conditions such as stomach ulcers, high blood pressure, and kidney problems.
Drugs that block COX-2 alone also block inflammation. There has been concern that blockade of COX-2 may also have deleterious effects such as elevated blood pressure, reduced kidney function, and possibly an increased tendency for heart attack and stroke. Vioxx was removed from the market after concerns regarding the possibility of an increase in cardiovascular problems related to this drug. Celebrex is the only COX-2 drug that remains on the market. It is currently undergoing extensive trials to further evaluate its safety profile. Interestingly, it appears now that all anti-inflammatory drugs share a similar risk for causing cardiovascular events to occur.
Another important cause of inflammation are Reactive Oxygen Species. These are also known as “oxygen free radicals.” These oxygen free radicals lead to the production of pro-inflammatory proteins.
One medication undergoing clinical trials is a plant-derived anti-inflammatory product called flavocoxid. This medication apparently has effects on COX-1, COX-2, as well as LOX. Clinical data so far has shown that the side-effect profile is significantly lower than that for other anti-inflammatory drugs. Flavocoxid is a blend of phytochemical compounds derived from fruits and vegetables. The advantage is that this compund appears to have many fewer side-effects than currently available prescription non-steroidal anti-inflammatory drugs. Clinical trials are ongoing.
I Hurt All Over... How to
Ease Away the Pain of Fibromyalgia!
By
Nathan Wei
At one moment, a life of activity consumed with enjoyable activities like biking, golfing, going to the movies, out to dinner. Then one day, it’s gone. Replaced with constant pain and fatigue. Here’s the lowdown on fibromyalgia.
Fibromyalgia is one of the most common forms of arthritis seen in a rheumatology practice. It is actually a soft tissue form of rheumatism. Typically, a patient will complain of feeling achy all over, being chronically tired, and feeling like they’re walking around in a constant fog. Often a patient will complain of short term memory problems.
The American College of Rheumatology has set criteria by which fibromyalgia symptoms can be classified. These consist of a history of widespread pain for three or more months and pain in 11 of 18 tender point sites when 4 kilograms (about 9 pounds) of pressure is applied. When accompanied by a history of chronic fatigue and non-restorative sleep (waking up and feeling as if you haven’t slept), there is a strong suspicion that fibromyalgia is to blame.
People affected by fibromyalgia experience two unique responses to stimuli. They perceive normal stimuli as being painful and they perceive painful stimuli as being more painful than it should be.
These abnormal responses are thought to be due to an abnormality involving pain-processing pathways within the central nervous system.
History and physical examination is the first step in evaluation. Unfortunately, there are no specific laboratory tests that confirm the diagnosis. However, the tests can be helpful in excluding other conditions that can mimic fibromyalgia such as hypothyroidism, lupus, and rheumatoid arthritis.
Treatment consists of a combination of four approaches. The first is patient education. Talking with the patient about the diagnosis and presenting what he options are. The second is institute medications. These may include one or more of the following:
• Analgesics which help to control pain. An example would be a drug such as tramadol
• Antidepressants which are used for their ability to elevate serotonin and nor-epiephrine levels in the brain. Examples include amitryptiline, fluoxitene, and duloxitene.
• Muscle relaxants like cyclobenzaprine
• Anti-seizure medicines like gabapentin
• Anti-fatigue medicines (modafinil)
The third therapy is non-impact aerobic exercise which helps to increase endorphin production in the brain and helps to recondition muscles.
Finally, the fourth is cognitive behavioral therapy which helps with goal-setting, coping and other measures which reduce the sense of victimization that people with fibromyalgia often have.
Fibromyalgia can be treated effectively. It is important that a patient seek out a qualified and empathetic rheumatologist to help them.
Wrist Arthritis - What Could
it Be?
By
Nathan Wei
Arthritis of the wrist may not sound like a big deal... until you need to open a door, type on your computer, or shake hands. Then you realize how much a role your wrist plays in these simple activities.
The wrist is like many other joints. It’s enclosed in a synovial membrane. It consists of the ends of the radius and ulna- two long bones- that articulate with a row of eight carpal bones. The carpal bones in the wrist also articulate with the metacarpal bones of the hand. The entire wrist complex is stabilized by tendons and ligaments and encased in a synovial membrane.
When arthritis develops, the wrist complex is affected by inflammation of the synovial membrane as well as by any other problem that causes the cartilage that surrounds all the bones in the wrist to wear away.
While wrist pain may occur as the first sign of a problem, the inability to perform simple activities of daily living follows shortly.
The pain may be dull initially but then becomes sharper and more constant.
Grip strength diminishes. Inflammation progresses, then there may be pressure on the other structures that pass through the wrist such as the median nerve. This leads to carpal tunnel syndrome.
The treatment of wrist arthritis is dependent on the cause. Forms of arthritis that commonly affect the wrist include rheumatoid arthritis, psoriatic arthritis, gout, and pseudogout. When inflammatory forms of arthritis affect the wrist, there is wearing away of cartilage as well as damage to the supporting structures. Wearing away of the cartilage leads to misalignment and deformity as well as wrist dysfunction. Swelling and fluid accumulation may occur.
When wrist arthritis occurs, there is a benefit in that wrist involvement by arthritis generally is often a tip off to diagnosis. For instance, rheumatoid arthritis is one of the more common forms of arthritis that affect the wrist. By allowing an earlier diagnosis, early intervention can lead to remission.
Physical therapy and specific exercise may be beneficial as are splinting and anti-inflammatory medicines. Sometimes, injection with glucocorticoids may be necessary.
In advanced cases, surgery may be necessary. Surgical procedures include excision arthroplasty where the end of the ulna bone is removed. This often helps with some forms of arthritis since it allows more freedom of movement.
Joint fusion and joint replacement may be called for in extreme cases. Wrist replacement currently lasts about ten to fifteen years depending on the amount of activity.
What's a Good Arthritis
Medicine for Me, Doctor?
By
Nathan Wei
Pain is the body’s warning signal that something is wrong. If the pain is due to overuse or arthritis there are many things to consider. In all likelihood, one of the first things a person will reach for is an over-the-counter anti-inflammatory medicine.
Non-steroidal anti-inflammatory medicines work by blocking the synthesis of cyclooxygenase, the enzyme responsible for the production of pro-inflammatory prostaglandins. The two different pathways that are blocked are COX-1 and COX-2.
Despite the negative publicity surrounding COX-2 drugs, it is clear that all anti-inflammatory drugs have potential cardiovascular risks. These drugs also may inhibit bone and tendon healing. They may also block the absorption of nutrients... So the weekend warrior needs to take notice.
Nonetheless, anti-inflammatory drugs remain a bulwark for the treatment of painful episodes.
Here are some simple suggestions:
If you’re going to undertake an activity that you’re sure will cause a problem, it’s OK to pop a small amount... say 200 mgs of ibuprofen before you do whatever you’re going to do. Unless it’s a marathon. Dehydration and anti-inflammatory drugs do not mix!
After your activity, it’s also OK to pop a bit of ibuprofen or naproxen (200 mgs). Just make sure you’re well hydrated. Also do not take these medicines if you have any underlying liver, kidney, or heart disease!
If you already take anti-inflammatory drugs on a regular basis, remain well-hydrated, and avoid alcohol when exercising or undertaking strenuous activity. With the recent data regarding cardiovascular risk, it’s a good idea to get your heart checked out.
Make sure you take your anti-inflammatory medicines with food. Sometimes people who develop indigestion with anti-inflammatory medicines but who do not have an ulcer will benefit from taking a proton pump inhibitor medicine such as Nexium or Protonix.
If you absolutely can’t take anti-inflammatory medicines because of a true allergy or if you have an ulcer- or another valid reason- you can try acetaminophen (Tylenol). The primary concerns here are that you not take this drug with alcohol (liver toxicity is increased) and you should not take this drug if you have significant liver or kidney disease.
An interesting new drug is Limbrel, a food-based COX-2 inhibitor. It has good effectiveness and appears to be well-tolerated by most patients.
Another option is tramadol (Ultram) which is a pure analgesic. Ask your physician about this.
Always consult with your physician prior to taking these medicines on a regular basis. Anti-inflammatory drugs may affect the metabolism of other prescription drugs.
Amazing Shoulder Pain
Reversing Secrets!
By
Nathan Wei
Whether you’re a weekend athlete, or a gardener that overdid it, or a person with arthritis, there’s hope for you. According to Dr. Nathan Wei, Clinical Director of the Arthritis and Osteoporosis Center of Maryland, “Shoulder problems are one of the most common afflictions of modern times. Fortunately, there are many ways of helping people feel better.”
The shoulder is the largest, most complex, and most mobile joint in the body
Four muscles and their tendons (ropes attached to the top of the humerus), collectively known as the rotator cuff allow the shoulder to move as it does. The rotator cuff also plays a role in stabilizing the arm bone to the shoulder blade.
Shoulder pain doesn’t always come from the shoulder!
Examples include pain referred from arthritis of the neck, diseases of the chest such as pneumonia and diseases of the abdomen like gall bladder problems can cause pain to be referred to the shoulder. Even ectopic pregnancies have caused shoulder pain!!!Finally, heart conditions can cause referred pain to the shoulder, particularly on the left side. A specialist’s physical exam is important. Dr. Wei relates this story. “I saw a patient who had shoulder pain. The pupil of the eye on the same side of the shoulder was enlarged. That set off alarm bells so I got a chest x-ray. He tuned out to have a lung cancer. This combination is called Horner’s syndrome.”
Most causes of true shoulder pain fall into 3 categories
• tendonitis/bursitis- With repetitive motion, the bursae (small fluid-filled sacs) surrounding the shoulder joint can become inflamed. This condition is called bursitis.
• injury/instability- Keeping your arms extended above your head; chronic compression , ie. forcing the shoulder into its socket; muscle imbalance- if one of the muscles is extra weak, that can cause the rotator cuff to function poorly.
• arthritis- Usually a function of aging.
Patient tips:
• Try to limit the number of overhead reaches.
• If you’re wheelchair-bound, tuck your arms a bit closer to your body as you push.
• Avoid repetitive motion.
• Work on rotator cuff strengthening. Range-of-motion exercises are important!
• Use correct posture!
One tip that might help if you have chronic shoulder pain and have a “frozen shoulder” is to use a broomstick for stretching and range-of-motion exercises.
Oral anti-inflammatory medicines are sometimes, but not always, helpful. Patients may require a steroid injection. For people who don’t respond to medicines, injections, and physical therapy, another option is surgery. Any type of surgery should be done by a skilled shoulder surgeon. “The shoulder is the most complex joint so make sure whoever works on your shoulder is an expert with shoulders,” advises Dr. Wei.
Get Rid of Tendonitis ...
Now! Advice From An Expert
By
Nathan Wei
Tendons are ropes of fibrous tissue that connect muscles to bones. It is this connection that permits joint motion. When muscles contract, they pull on the tendons which cause the bones to move. In order for tendons to glide they move inside a lubricated sheath of tissue that is lined with synovial tissue. This synovial tissue is the same type of tissue that lines the inside of joints. Tendonitis refers to a condition where the sheath through which a tendon glides becomes inflamed. This leads to severe pain. The pain usually gets worse with use of the affected joint. However, when tendonitis becomes severe, there may be pain at rest.
Since muscles and tendons surround most joints, tendonitis is rather common. The diagnosis of tendonitis is relatively simple for the experienced clinician. Genrally, the diagnosis is made by history and physical examination. In difficult diagnostic cases, magnetic resonance imaging is helpful in confirming the diagnosis.
Some of the more common types of tendonitis are:
Shoulder tendonitis. The tendons in the shoulder that are most often affected are the rotator cuff and the biceps tendon. The rotator cuff consists of four tendons that sit on top of the upper arm bone. The location of these tendons and the muscles they attach to are what give the shoulder such an expansive range of motion. Rotator cuff tendonitis may occur as a result of repetitive activity or tendon degeneration. Pain is felt with most movements and is located on the outside part of the shoulder. The biceps tendon allows the arm to be flexed at the elbow. Biceps tendonitis also occurs due to repetitive activity and pain is felt in the front of the shoulder. Shoulder tendonitis can be treated successfully with anti-inflammatory medication, physical therapy, and occasionally glucocorticoid injection.
Tendonitis in the elbow is usually located either on the outside and is called lateral epicondylitis or tennis elbow. It may also occur along the inside part of the elbow- medial epicondylitis. This is called golfer’s elbow. Treatment consists of physical therapy, stretching and strengthening exercises, splints, and injections. Rarely, surgery is required.
Tendonitis in the wrist arises because of repetitive motion. A special type of tendonitis, called Dequervain’s tendonitis, is felt on the out side of the thumb. Tendonitis in these areas is managed with glucorticoid injections and immobilization with a splint. Other physical therapy modalities may be helpful. Sometimes surgery is required. Tendonitis in the fingers can lead to catching of the fingers. This is termed “trigger finger.” Trigger finger usually responds to injection but may require operative intervention.
Tendonitis in the knee may affect the patellar tendon. This is the tendon that connects the knee cap to the tibia (lower leg bone). Patellar tendonitis usually occurs because of excessive jumping and is actually called “jumpers knee.” This is treated with rest, anti-inflammatory medications, and physical therapy.
Tendonitis in the ankle can occur along the outside of the ankle (peroneal tendonitis), the inside of the ankle (posterior tibial tendonitis), or at the back of the ankle (Achilles tendonitis). The tendonitis that occurs along the outside or inside of the ankle can occur because of trauma or because of mechanical instability. Another potential cause is an underlying arthritis condition. Achilles tendonitis often occurs as a result of excessive stress and repetitive trauma. The Achilles tendon is the thick cord at the back of the ankle that connects the heel bone to the calf muscle. Treatment involves rest, elevation of the heel to take the tension off the Achilles tendon, and physical therapy. Glucocorticoid injection should be avoided because of the danger of Achilles tendon rupture. Anti-inflammatory medication may be helpful.
Balance Exercises for People
with Arthritis
By
Nathan Wei
Patients with arthritis are often caught in a vicious cycle. They hurt. As a result they reduce their activity level which leads to weakness and atrophy of muscles. When muscles no longer are strong enough to protect joints, pain intensifies. And so on.
Often neglected is the role of the muscles that help us in our quest to remain upright against the forces of gravity. Achieving balance is important because it helps strengthen the muscles that protect our weight-bearing joints. It also helps prevent falls.
The first exercise is the assisted leg raise. Stand with a chair to one side of your body. Make sure the chair is sturdy While holding onto a chair with one hand, slowly lift the opposite leg with the knee bent. As the knee approaches hip height, hold the position for 10 seconds. Then slowly straighten the knee and hold for another 10 seconds before letting the leg down slowly straighten the leg out in front and hold for 10 seconds. Repeat this two times then do the opposite leg.
Another exercise is to stand with a chair to the side. Hold onto the back of the chair with the nearest hand. Than rock up onto your toes. Hold for ten seconds. Then slowly rock back onto your heels and hold for ten seconds. Repeat 5 to 10 times.
The “sobriety walk” is another good balance exercise. Walk heel to toe along an imaginary straight line for 10 steps forward. Then do ten steps backward.
The Swiss ball is another good balance tool. The advantage of using a Swiss ball is that it strengthens the core muscles at the same time it helps with balance. You should only think about using this after you have been working on other balance exercises. Contact a physical therapist who will help you use this properly.
T’ai chi, an ancient Chinese form of exercise, is another form of exercise that is helpful. This modality involves a series of slow rhythmic movements that move joints through a range of motion. The body remains centered while gentle shifts of weight take place. There is very little impact and almost no stress on joints. Yoga is another form of exercise that can help with balance.
What is the Risk of Infection
With Anti-TNF Drugs in Rheumatoid Arthritis?
By
Nathan Wei
A recent study has demonstrated that rheumatoid arthritis (RA) patients who use tumor necrosis factor (TNF) blockers are up to four times more likely to develop a serious bacterial infection than those who use only methotrexate. While the risk is not tremendously high, it is still a factor that needs to be taken into consideration by both patients as well as prescribing rheumatologists.
Infections are common in patients with rheumatoid arthritis and related disorders, but it is unclear if this is due to the treatments or the underlying disease process. Previous studies examining the impact of TNF blockers on infection have yielded variable results.
The goal of this most recent study was to determine if TNF inhibition raised the risk of serious bacterial infections compared to the use of methotrexate alone.
The study examined 2393 patients treated with TNF antagonists who were also on DMARDS, most often, methotrexate, and 2933 patients taking methotrexate alone. The most common TNF- blocker used was etanercept (Enbrel), followed by infliximab (Remicade).
During a median follow-up period of 17 months, infection-related hospitalization rates were 2.7% and 2.0% for the TNF blocker group and methotrexate-only group, respectively.
In order to calculate relative risk, researchers often use multivariate analysis to develop a number called a hazard ratio. If the number is less than one, then it means the substance in question is less hazardous than the control. If the number equals one, then the substance has the same risk as the control. And if the ratio is greater than one, it means the substance is more hazardous than the control.
TNF blocker use was associated with a hazard ratio of 1.9 for serious bacterial infection. So, TNF therapy combined with DMARD therapy is more hazardous than methotrexate alone as far as risk of infection.
The incidence of infections was highest within 6 months of initiating TNF inhibition therapy.
The most common serious infections in both groups were pneumonia/ lung abscess (empyema) followed by cellulitis/soft tissue infection.
The efficacy of TNFantagonist therapy for most rheumatoid arthritis patients needs to be balanced against the potential harm of an increased risk of infection associated with these agents. Vigilant monitoring for infection is recommended when using these agents.
(Curtis JR, Patkar N, Xie A, Martin C, Allison JJ, Saag M, Shatin D, Saag KG. Risk of serious bacterial infections among rheumatoid arthritis patients exposed to tumor necrosis factor α antagonists. Arthritis Rheum 2007;56:1125-1133).
Doctor...What Are The Effects
Of Alcohol On Rheumatoid Arthritis?
By
Nathan Wei
Could a glass of wine at dinner time be the next major arthritis breakthrough?
Possibly… according to a recent Swedish study. A diet of 10% ethanol had a protective effect on mice that would otherwise have developed collagen-induced arthritis (CIA), Swedish researchers report in Proceedings of the National Academy of Sciences. CIA is often used as an animal model of human rheumatoid arthritis (RA.)
Andrej Tarkowski, MD, the senior author and a faculty member in the department of rheumatology and inflammation research, Goteborg University, in Sweden, stated that the primary finding was that, in male mice, long term consumption of 10% ethanol delayed the onset and progression of CIA.
The underlying mechanism appears to be a reduction in inflammation due to decreased NF-kB activation (a primary inflammatory pathway) caused by upregulation- or increased production -of testosterone secretion.
The research team fused a CIA model in mice by immunizing male DBA/1 mice with collagen type II (CII). To determine whether drinking ethanol has any impact on the development of CIA, the mice were provided with either 10% ethanol or water alone to drink. Mice were sacrificed after 5 to 6 weeks. All four paws from DBA/1 mice were sectioned, stained, and examined for inflammation of the joint including damage to the joint lining and erosion of bone and cartilage.
The investigators report that development of arthritis due to inflammation was markedly reduced in the ethanol-drinking mice. Ethanol had no such effect on mice with arthritis induced by injection with a mixture of four monoclonal anti-CII antibodies. “These data suggest that ethanol affects the start or initiation rather than the perpetuation of immune responsiveness during CIA,” mentioned the researchers.
Joints from the water-drinking mice developed
frequent bone and cartilage erosions. Those from the ethanol-drinking mice were
“histologically …intact,” meaning no significant damage occurred. In addition,
ethanol prevented the arthritis-induced loss of bone mineral density associated
with CIA.
“The major surprise in this study was the outstanding effect of ethanol on
saving cartilage and bone, suggesting that apart from regulation of inflammatory
mediators, matrix metalloproteinases (i.e., tissue destroying enzymes) might be
a direct target for ethanol,” commented Dr. Tarkowski.
Dr. Tarkowski cautions, “This dose of ethanol was chosen for mice with an exact knowledge regarding the toxicity. This was further confirmed by intact liver function at the end of experiments. In contrast, exchanging water for 10% ethanol in humans eventually will lead to liver disease (cirrhosis). Thus, the optimal dose of ethanol in the human setting to prevent/delay RA is presently unknown. For practical purposes, one could speculate on the use of doses of ethanol similar to those sometimes suggested for prevention of cardiovascular diseases—i.e., something in the range of 1 to 2 glasses of wine per day,” he suggested.
“We are presently analyzing whether female mice
with arthritis have the same effect from ethanol.
The investigators also compared castrated to intact male mice and found that
mice drinking 10% ethanol had significantly elevated levels of testosterone and
decreased levels of IGF1 and cortisol. “These observations, considered together
with the cellular anti-inflammatory properties of testosterone that lead to a
decrease of NF-kB activation, point to testosterone as a potential link
mediating the anti-inflammatory effects of ethanol.”
So… what are the implications for patients with RA?
The first is that perhaps, a prescription of a glass or two of wine a day is not necessarily bad.
However, there are cautions. The first is that patients who are taking methotrexate need to absolutely limit their consumption of alcoholic beverages because of the danger of developing cirrhosis. Second, patients taking non-steroidal anti-inflammatory drugs are at increased risk for developing stomach ulcers and alcohol increases that risk.
(Jonsson I-M, Verdrengh M, Brissiert M, et al. Ethanol prevents development of destructive arthritis. PNAS. 2007;104:258–263)
Low Back Pain in the
Workplace... Do Those Low Back Belts Really Work?
By
Nathan Wei
Back injuries are the leading cause of disability in the United States for people younger than 45 years of age and have been the most expensive health care problem for the 30-50 year old age group [Bureau of Labor Statistics. Lost work time injuries and illnesses: Characteristics and resulting time away from work. U.S. Department of Labor, Washington, D.C., 1998.].
There is evidence that low back belts are helpful in protecting the worker from low back injury. However, there is a pervasive feeling that wearing these belts confers absolute protection. That is not the case. Workers need to be instructed in proper lifting techniques. The back belts need to be part of a comprehensive program of back care stressing proper ergonomics, correcting potential back overload situations, and educating workers on injury avoidance.
At the same time workers need to be screened for cardiovascular risk. Mounting data indicates these back belts are responsible for significant increases in blood pressure and heart rate. Obviously, this poses a hazard for patients who already have other risk factors for cardiovascular disease.
Finally, the worker should be told not to wear the belt for extended periods of time. This is because the persistent use of these belts eventually leads to weakening of the body's natural "corset" of core muscles.
In addition, workers should be instructed in proper core strengthening techniques along with general overall fitness.
“Back school” education and assessment of the job site for proper ergonomics is also recommended.
Summary tips:
• Maintain ideal weight
• Exercise regularly
• Maintain proper body mechanics and core strengthening
• Learn proper lifting techniques and make sure the work area is ergonomically
“friendly”
• Use back belts judiciously
• Get your heart and blood pressure checked out.
I Have Arthritis in My Knee
and My Doctor Told Me I Need a Knee Replacement - What Do I Do?
By
Nathan Wei
People with arthritis will eventually need a total knee replacement if they fail the other more conservative measures. These treatments include medications (anti-inflammatory medicines and analgesics), physical therapy, topical agents (arthritis rubs), intraarticular glucocorticoid injections (cortisone shots given into the knee joint), viscosupplements (lubricant injections into the knee joint), arthroscopy, and bracing.
Patients who have received the full gamut of conservative medical treatment and who continue to have either severe pain or loss of function, are considered candidates for total knee replacement.
The traditional method of total knee replacement involves making an incision through the large muscle located at the lower end of the inside of the thigh and slightly above the inside part of the knee- the vastus medialis obliquus (VMO). This large muscle is a stabilizer of the patella (kneecap) and one complication of knee replacement is patellar instability.
More recently, minimally invasive techniques using a smaller incision are becoming popular.
Prior to surgery, a careful evaluation of the patient’s medical history is made. Since there is the chance that there will be blood loss, the patient may require either “banking” of their own blood or injections of erythropoietin (a hormone) to help stimulate red blood cell production.
What occurs with knee replacement is that the surface of the femur (upper leg bone) and the surface of the tibia (lower leg bone) are replaced with metal and plastic implants which are cemented in. For the operation to be successful, the surgeon will require adequate visualization of the operative site, proper sizing of the components, and proper alignment of the limb.
The postoperative period involves extensive rehabilitation and takes anywhere from four to ten weeks before a patient will be "as good as they’ll be." Complications of the procedure include patellar instability, infection, blood clots, excessive blood loss, prolonged pain, and loosening of the replacement parts.
In patients who have two bad knees, it is a good idea to get them both done at the same time, if possible.
Finally, it is important that there is coordination between the patient’s primary physicians and the orthopedic surgeons. This is particularly true in patients with other medical problems that require attention. oftentimes, medicines will have to be montored, discontinued temporarily, or changed before surgery.
Careful attention to detail including the preoperative management, the actual surgery, and the post-operative rehabilitation will ensure a good result in most cases.
Arthritis Cure? Is It True Or
Is It A Quack Remedy?
By
Nathan Wei
The federal watchdog that guards against rip-offs in any commercial venue is the Federal Trade Commission (FTC). One area that is particularly filled with claims for unproven treatments is arthritis.The FTC and the Arthritis Foundation report that quack remedies for arthritis can be harmful in two different ways. First, one in every ten people who try these unproven remedies report side effects. Second, any remedy, even if it contains no harmful can be detrimental if it stops or delays someone from seeking an effective treatment program from their physician.
Why do quack cures appear to work for some people? There is a scientific term called the “placebo effect.” This refers to the ability of the mind to create the belief that a sham treatment- a sugar pill- is really working to make symptoms better. How does this happen? It has been proven that when people believe strongly in a treatment, endorphins and other natural pain mediators in the brain are produced. This placebo effect can be deceptive. It can cause people to believe a treatment has true value. Another factor to consider is that arthritis characteristically has periods of flares and remissions. People may think that they are feeling better because of a remedy when it is actually just the disease going through its natural cycle.
So if you’re a patient with arthritis, how do you spot a potential quack cure?
First, pay attention to the words used to describe the remedy. These words have emotional power and impact and are used by clever marketers to heighten desire.
Examples: “magic”, “exclusive”, “astonishing”, “secret”, “proven”, “miracle”,” breakthrough”, “special”, “overnight”, “works while you sleep”, or “cure”.
The use of testimonials from satisfied users is an age-old tool used to provide proof of effectiveness. Often, these are not people who have used the product but are paid actors. Beware of celebrity endorsements because these are, in almost all cases, paid endorsements. The only time you can rely on the use of testimonials is if the person’s full name, address, and occupation are provided. If a phone number or other means to contact the person directly is given, that is also a sign that the testimonial is a real one and not a fake.
Another ploy that is used is to make the medical establishment the bad guy. It’s the age-old “conspiracy theory” tactic. A variant of this is when the arthritis treatment is touted to be "natural" and described as a sensible alternative to dangerous drugs and surgery.
There is no cure for arthritis yet so if the product makes the claim of a cure, stay away.The words “no side-effects” are another tip off to a bogus cure. In controlled scientific trials, even patients receiving placebo get side-effects.
There is the temptation to believe that something developed in a far-away locale may be better than what we have here. This is a version of the “grass is always greener” phenomenon. Just because a “mystic healer discovered an arthritis miracle lying under a rock in Borneo”, doesn’t mean it is effective.
Use caution when buying products online. The Internet has created an arena where products marketed with fraudulent health claims are legion.
Another tactic is the use of confusing terms couched as “scientific explanations”. This is often used to lure the unsuspecting buyer with what is termed “pseudoscience.” Any arthritis treatment that can’t be backed up with proof through testing with well-designed scientific clinical trials is probably not worth buying.
There is one website that may give you an example of what I’ve been talking about.
The FTC has created what it calls a “teaser page.” This is a page with examples of bogus ads that help to alert consumers to distinguish unproven medical treatments.
The ArthritiCure teaser page shows you the common list of claims and marketing ploys which make unproven arthritis remedies and quack cures easily recognizable.Go to: http://www.wemarket4u.net/arthriticure/index.html
Super Secret Exercise Tips
for People with Arthritis
By
Nathan Wei
People with arthritis should exercise … but they need to keep some valuable information in mind. Here are some important tips to follow:
1. Make sure you warm up. Warming up increases blood flow and helps muscles loosen up. Five minutes of simple walking or riding a stationary bike will do it.
2. Stretching improves flexibility which helps a patient prepare for aerobic activity. Stretching the hamstrings and quadriceps muscles is important.
3. Start out easy. If you exercise too hard you switch from aerobic to anaerobic activity. This can lead to potentially painful and dangerous injury. To determine where you need to be, find your target heart rate by subtracting your age from 220, then aim for 40 to 70% of that rate.
4. You need to push a bit. Make sure you are working inside the 40 to 70% range to improve energy, lose weight, and build muscle. If you push too hard you’ll be in a lot of pain and may need to back off a bit.
5. Do not eat within two hours of exercising. Digestion causes blood flow to go to the gut instead of the muscles. This could cause abdominal cramps and nausea.
6. Make sure you don’t overdo it. When lifting weights, the temptation is to push too hard. If you are lifting the proper amount of weight you will feel fatigue by the 15th repetition. When you find that a certain weight becomes too easy, go up a bit in weight. Weight training helps improve stamina, energy, and strength.
7. Cool down properly. Stretch, breathe deeply, and don’t stop abruptly. You may even want to ice down areas prone to injury.
8. Drink plenty of water. The rule of thumb is drinking 8 ounces of water for every fifteen minutes of exercise. After you’re done, drink more. Proper water intake will help with your cool down, circulation, and injury prevention.
9. If you’re using a stair climber or elliptical machine, the temptation is to lean on the arm rests. This could lead to bad posture and low back problems. Stand straight.
10. Use proper form. Improper form leads to injury.
11. If you hurt, skip your exercise that day. Trying to work through the pain may lead to injury. You may notice some muscle soreness the day after a good workout. The soreness should not last longer than a day or two.
12. Consider seeing a physical therapist prior to starting an exercise program. They can give you a set of “do’s and don’ts”.
13. “Custom fit” your exercise. For instance, if you have bad shoulders, then swimming is probably not the right exercise for you. Consider biking or walking. On the other hand, if you have bad knees, swimming might be better for you than walking. Avoid rowing if you have a bad back.
Why Is My Arthritis Not
Getting Better?
By
Nathan Wei
There are more than 100 different types of arthritis. The treatment for each of these types is different. Therefore, one of the first questions to ask when you aren’t getting better from your arthritis is this:
What is the diagnosis? Is it the correct diagnosis? A misdiagnosis could explain why you’re not getting any better. For instance, if you have rheumatoid arthritis, you will need a very different set of treatments than if you have osteoarthritis.
Another question is this… Are you seeing an arthritis specialist, a rheumatologist? A rheumatologist is the type of person to see if you have arthritis. They are specially trained to make the diagnosis and start appropriate treatment. If you’re just taking over-the-counter medicine and you have arthritis that isn’t letting up, you need to see a rheumatologist. If your primary doctor is treating you and you aren’t getting any better, you need to see a rheumatologist.
Another question to ask if you already are seeing a rheumatologist is this: Are you seeing the right rheumatologist? Patients often make the mistake of seeing the specialist that is part of their insurance plan. Big mistake! Insurance plans try to sign up doctors at the lowest price possible. To them a doctor is a doctor is a doctor. Would you go see the brain surgeon who advertised the cheapest price? Or how about the heart surgeon who’s getting ready to cut on you… would you try to negotiate a low price? Of course not! Then why would you do it for a specialist in a disease that can not only cripple you but can also significantly shorten life span (mortality statistics similar to untreated diabetes, heart attack, stage 4 Hodgkin’s disease!) You need to see an arthritis expert who will take the time to evaluate your case and put you on the treatment program that’s right for you.
Another reason why you may not be doing better: Are you on the right medicines and the right dose of medicines? Sometimes a more aggressive approach is needed. If you’re not getting better, you need to consider the fact that stronger medicines may be required. And here is where insurance companies sometimes place barriers. Sometimes the right medicine isn’t “approved” by your insurance company. If your doctor says you should be on a certain medicine and you insurance company gives you the run around, fight back!
Finally- and this is something that will vary a lot- are you giving it enough time? I recently had a patient come in who had seen two other rheumatologists over a 3 year period of time. She then came to see me and complained she wasn’t getting any better within the first 7 weeks. Sometimes patience from patients is called for. Don’t be afraid to discuss this with your doctor.
Will the Cost of Arthritis
Care Bankrupt the US Economy?
By
Nathan Wei
Arthritis medical costs in the U.S. topped $80 billion in 2003, up from nearly $65 billion in 1997.
Researchers from the University of California, San Francisco reviewed medical cost data on 22,000 U.S. adults in 1997 and 23,000 U.S. adults in 2003.
In 1997, nearly 37 million people in the U.S. had arthritis. That figure rose to 46.1 million people in 2003, many of whom are baby boomers.
Part of the increase in spending has been driven by prescription drugs. Americans spent twice as much on arthritis medications in 2003 as they did in 1997.
Prescription drug costs rose from about $33 billion in 1997 to roughly $75 billion in 2003. Average arthritis prescription costs per person were $141 in 1997 and $338 in 2003, the study shows.
Thus... at least two major factors account for these staggering numbers: First, the fast-rising number of people with the disease; second, increases in the number of medications they take each month. Finally another contributor is the inflation-adjusted cost per prescription.
One bright spot: The in-patient treatment costs dropped during the same period, the study shows. In 1997, average inpatient costs per arthritis patient totaled $508, dropping to $352 per person in 2003.
Because the number of persons with arthritis and other rheumatic conditions is projected to increase steadily to more than 70 million by 2030, the economic impact is likely to continue to grow.
And for people with arthritis, this is often money they are having more problems affording. The study reveals that, due to their health problems, people with arthritis earn around $40 billion less each year than people without the condition.
The six-year study was performed in response to a growing concern about the escalating costs of arthritis care as the U.S. population ages, said professor Edward Yelin, lead author of the study.
“Arthritis can be a highly debilitating disease that, as this study shows, presents a substantial cost to our society,” Yelin remarks. “We are also seeing a shift in the burden of that cost onto patients who rely on Medicare to cover a large fraction of their inpatient care, but pay for a relatively larger share of their drug treatments from their own pockets,” he adds.
(Yelin E, et al. Arthritis Rheum, May, 2007)
The message this study sends is a troubling one because of the demographic shift that is occurring. While the baby boomers are into or approaching Medicare age, there will be a much smaller working population that will be able to support entitlement programs. Something’s got to give. And it may be the U.S. economy.
I Have Rheumatoid Arthritis
and My Doctor Has Told Me I Need to Go on Biologic Treatment
By
Nathan Wei
The immune system is the body’s defense mechanism. It is capable of recognizing foreign invaders such as bacteria and viruses, and destroying them. It does this through the process of inflammation. In inflammation, white blood cells are attracted to the area of invasion. The cells then are stimulated to release chemical messengers, called cytokines which help destroy the foreign invaders. The cytokine with the greatest importance in this process is tumor necrosis factor or TNF. The problem in diseases like rheumatoid arthritis is that the immune system can no longer distinguish between foreign invaders and the body’s normal cells. The immune system then begins to attack the body. TNF plays a significant role in this aberrant behavior. For a disease like rheumatoid arthritis (RA), inflammation affects the joints as well as other organ systems.
Drugs that block the effects of TNF have been found to be very effective in reducing inflammation and in slowing down the rate of disease progression in rheumatoid arthritis.
The first anti-TNF drug to be approved by the FDA in the United States was etanercept (Enbrel). This drug is actually a receptor protein that binds to circulating TNF and prevents TNF from stimulating white blood cells to produce more inflammation. It is given subcutaneously by the patient. Side effects include injection site reactions, an increased tendency for infections, rare blood cell effects, rare liver function test abnormalities, and rare neurological side-effects.
Another anti-TNF drug is infliximab (Remicade). It is an antibody that is part human and part mouse protein. This antibody is directed against TNF and removes it from the system. Remicade is given intravenously. Side effects include infusion reactions (side-effects during the intravenous infusion), increased susceptibility to infection, and reactivation of tuberculosis. Some people begin to lose their response to Remicade over time.
The third anti-TNF drug is adalimumab (Humira). This is a human antibody directed against TNF. It, like Enbrel, is administered subcutaneously by the patient. Side-effects are similar to that for Enbrel.
Patients should be counseled about the potential side-effects of these drugs prior to administration. PPD skin tests to screen for tuberculosis are advised. A chest x-ray is also something to consider. Recent data suggests that PPD skin tests should be done annually in patients receiving anti-TNF therapy.
These drugs work best when combined with methotrexate. There is increasing evidence that these drugs not only slow down the progression of RA but also reduce the incidence of cardiovascular events such as heart attacks and strokes that may occur in these patients.
Monitoring for side effects is important and a patient should be followed by an experienced rheumatologist.
It should be mentioned that these drugs don’t work for everyone. Nonetheless, they are a major advancement in our arsenal of weapons against rheumatoid arthritis.
Are The New Biologic Drugs
For Rheumatoid Arthritis Worth The Cost?
By
Nathan Wei
The standard beginning therapy for rheumatoid arthritis (RA) consists of methotrexate as a disease modifying anti-rheumatic drug (DMARD) and either a non-steroidal anti-inflammatory drug (NSAID) or low dose prednisone. While these drugs do work to a certain extent, they rarely induce remission.
TNF- inhibitors such as Enbrel, Humira, and Remicade have revolutionized our approach to RA and have enabled rheumatologists to get patients into remission.
The high cost of biologic agents has brought “pharmacoeconomic” considerations as a factor to deal with in the care of patients with rheumatoid arthritis. There is an increasing amount of data confirming the substantial cost implications of various arthritic conditions. For the TNF inhibitors, the clinical effectiveness needs to be factored into an assessment of their value.
In RA, there is a growing body of data addressing the potential cost-effectiveness of TNF inhibitors. As a result of their remarkable clinical efficacy, it appears that TNF inhibitors may have an incremental cost efficacy in RA.
Much of the data upon which this is based come from follow up of patients participating in clinical trials of these agents over the past decade. In general, changes in health states, using specific quantifiable measures of performance of activities of daily living have provided proof of cost effectiveness.
Using anti-TNF drugs and then measuring their effect on ability to function has provided the ability to define the level of response to treatment in terms of quality-adjusted life years (QALYs) gained.
A number of studies have shown improvements in
work status with treatment.
Other studies have begun to explore the effect of TNF inhibitor treatment on
employability; in one study, such treatment significantly improved employability
and reduced days missed from work.
In addition, ongoing studies are developing models comparing the outcomes of patients who are capable of productive work versus what would happen in the event of progressive disease and crippling. A patient who doesn’t have access to an anti-TNF drug and becomes crippled can’t be a positive producer to the economy. On top of that, there would be a negative impact on the economy in terms of dollars needed for health care support of that patient.
Unfortunately, insurance companies who set up barriers to the access of these medicines have a very shortsighted view of the picture. Hopefully, further studies that document the value to society and to the individual of remaining productive and having a better quality of life will change this situation for the better.
My Rheumatologist Wants Me to
Take Rituxan… What is It?
By
Nathan Wei
Rituxan is the trade name for rituximab. This a human/mouse monoclonal antibody It targets a marker called CD20 which is located on the cell surface of B lymphocytes, white blood cells that are felt to be important in promoting the inflammation of rheumatoid arthritis (RA). By binding to CD20, Rituxan causes depletion of B cells by destroying them. Destruction is achieved through two mechanisms. One is lysis or cell disruption. The other is apoptosis which is programmed cell death. Through this removal of B cells, it is felt that the events that start and perpetuate RA are disrupted.
The effectiveness of Rituxan has been evaluated in a number of clinical trials. These clinical trials led to the FDA approval of Rituxan for the treatment of RA that has been unresponsive to other therapies such as the anti-TNF drugs (Enbrel, Humira, Remicade).
The safety of Rituxan has been demonstrated through the RA clinical trials and also through the experience accumulated since 1997 when Rituxan was approved for treatment of Non-Hodgkins lymphoma.
Rituxan is administered intravenously. It is dosed as 1,000 mgs given intravenously with a second 1,000 mg dose given two weeks later. These two treatments last approximately 6 to 12 months… sometimes longer. Most patients receive Benadryl and intravenous methylprednisolone prior to their Rituxan and this seems to reduce the frequency of side-effects. Infusions last approximately 6-8 hours the first time and about 4-6 hours for subsequent infusions.
The side effects of Rituxan include infusion reactions and increased susceptibility to infection.
Currently, Rituxan is approved for use in combination with methotrexate for the treatment of adult patients with RA who have had an inadequate response to one or more anti-TNF drugs.
Remicade:
Doctor, I Have Rheumatoid Arthritis and I Want to Know More About Remicade
By
Nathan Wei
TNF alpha is a protein that is produced during the inflammatory response. It both starts as well as perpetuates inflammation. Increased levels of TNF are found in several inflammatory conditions including rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. Drugs that block tumor necrosis factor (TNF) have been found to be particularly effective for the treatment of these serious types of inflammatory arthritis.
Infliximab (Remicade) is a monoclonal chimeric antibody (part human, part mouse) directed against TNF alpha.
Infliximab is approved for use alone or combined with methotrexate for treating moderate to severe rheumatoid arthritis. It also is approved for the treatment of active psoriatic arthritis and ankylosing spondylitis.
Infliximab is administered intravenously. The recommended dose for the treatment of rheumatoid arthritis is 3 mg/kg as a single dose. The initial dose should be followed by additional 3 mg/kg doses two and six weeks after the first dose. The maintenance dose depends on the patient’s response. It can be increased to a maximum of 10 mg/kg every 4 weeks.
The most common side effects of infliximab are upper respiratory tract infections, urinary tract infections, cough, rash, back pain, nausea, vomiting, abdominal pain, headache, weakness and fever. Infusion reactions, which are sometimes severe, may occur.
Side effects such as blood pressure changes, chest pain, shortness of breath, rash, itching, fever and chills may occur during or shortly after administration. These reactions could possibly be due to an allergy to the drug. They are more common among patients who develop antibodies to infliximab and are less likely to occur in patients who are taking drugs that suppress the immune system, such as methotrexate. Infliximab should be discontinued if serious reactions occur.
Serious infections have been reported with other drugs that block TNF- alpha, and infections have been reported during treatment with infliximab. Therefore, infliximab should not be used in patients with serious infections. Infliximab should be discontinued if a serious infection develops during treatment.
Before starting infliximab, persons should have tuberculosis skin testing, because of reports of reactivation of tuberculosis in patients taking infliximab.
There have been rare cases of serious liver injury in people taking infliximab. Screening for hepatitis B may be a good idea.
Infliximab should not be used in patients with congestive heart failure or other significant heart disease.
Approximately half of infliximab-treated patients in clinical trials developed a positive ANA during the trial compared with approximately one-fifth of placebo-treated patients. Anti-dsDNA antibodies were newly detected in approximately one-fifth of infliximab-treated patients compared with 0% of placebo-treated patients. Reports of lupus and lupus-like syndromes, however, remain uncommon.
Decreased white and red blood cell and decreased platelet counts have been reported with infliximab. Vasculitis (inflammation of arteries) also has been reported.
Patients with rheumatoid arthritis, particularly patients with very active disease and/or chronic exposure to immunosuppressive therapies, may be at a higher risk (up to several fold) than the general population for the development of lymphoma. It is not known whether anti-TNF therapy raises this level of risk.
Infliximab should not be used in combination with anakinra (Kineret).
My Doctor Wants
Me to Take Enbrel For My Rheumatoid Arthritis-What Can You Tell me About it?
By
Nathan Wei
TNF alpha is a cytokine, a protein that is produced during the inflammatory response. TNF alpha is involved in inflammation from two perspectives. It is not only the product of inflammation; it also helps perpetuate and promote inflammation. Increased levels of TNF are found in several inflammatory conditions including rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. Drugs that block tumor necrosis factor (TNF) have been found to be particularly effective for the treatment of these serious forms of inflammatory arthritis.
The first anti-TNF drug approved for such use was etanercept (Enbrel).
Etanercept is a synthetic (man-made) protein that binds to TNF alpha. It acts like a sponge to remove most of the TNF alpha molecules from the joints and blood. This prevents TNF alpha from perpetuating inflammation and the pain, tenderness and swelling of joints in patients with different types of arthritis.
Etanercept reduces the signs and symptoms of rheumatoid arthritis, the arthritis of psoriasis, and ankylosing spondylitis. It also prevents the progression of joint destruction in patients with rheumatoid arthritis and the arthritis of psoriasis.
Etanercept is usually used in combination with methotrexate in patients who do not respond adequately to methotrexate alone.
Etanercept comes in two different preparations. The first is a powder that must be reconstituted (mixed) with a diluent. This comes as a 25 mg dose. The second is as a premixed syringe containing 50 mgs of etanercept. Etanercept must be refrigerated. The drug is given as a subcutaneous injection. Dosing will vary according to disease severity and body size.
Because etanercept reduces the immune response,
it should not be administered with live vaccines.
Etanercept is not recommended for use in pregnant or nursing women.
The most common side effects are mild to moderate itching, pain, swelling and redness at the site of injection. Headache, dizziness, nose and throat irritation also occur.
TNF alpha has an important role in the response of the immune system to infections. Blocking the action of TNF alpha with etanercept may worsen or increase the occurrence of infections, and patients with serious infections should not receive etanercept. Etanercept should be discontinued if a patient develops a serious infection. It should not be given to patients with active infections or who have an allergy to its components. Etanercept should be used with caution in patients prone to infection, such as those with poorly controlled diabetes.
Since etanercept has entered the market, there have been reports of multiple sclerosis, myelitis, optic neuritis in patients using the drug. Etanercept is not recommended for persons with preexisting disease of the central nervous system (brain and/or spinal cord) or for those with multiple sclerosis, myelitis, or optic neuritis. Rare cases of potentially serious low blood counts (pancytopenia) have been reported in patients using etanercept.
Monitoring should be done according to guidelines set by the rheumatologist.
Doctor, Should
I Take Humira for My Rheumatoid Arthritis?
By
Nathan Wei
TNF alpha is a cytokine, a unique protein that is produced during the inflammatory response. TNF alpha is not only the result of inflammation, it is also a substance that promotes the inflammation. Increased levels of TNF are found in several inflammatory conditions including rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. Drugs that block tumor necrosis factor (TNF) have been found to be particularly effective for the treatment of these serious forms of inflammatory arthritis.
Adalimumab (Humira) is constructed from a fully human monoclonal antibody. It binds to TNF alpha, preventing it from activating TNF receptors.
It acts like a barrier to the interaction between TNF alpha and receptors for TNF alpha on immune cells. This prevents TNF alpha from perpetuating inflammation and the pain, tenderness and swelling of joints in patients with different types of arthritis.
Humira reduces the signs and symptoms of rheumatoid arthritis, the arthritis of psoriasis, and ankylosing spondylitis. It also prevents the progression of joint destruction in patients with rheumatoid arthritis and the arthritis of psoriasis.
Humira can be used alone or in combination with methotrexate. The drug has been approved for use in rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis.
It comes in a 40 mg prefilled syringe and is administered subcutaneously every two weeks. The syringe must be kept refrigerated.
Serious infections, including tuberculosis, have occurred in patients receiving Humira. In some cases, these infections have been fatal. Before starting the drug, a patient should be tested for TB. Any medication prescribed for the treatment of TB should start before beginning Humira and should be continued until the full course of medication is completed.
Since Humira suppresses important parts of the immune system, a patient should not receive vaccines containing live virus.
Having an infection could put a patient at risk for serious side effects from Humira.
TNF-blocking agents have been associated with reactivation of hepatitis B. Some cases have been fatal.
Rare cases of demyelinating syndromes such as multiple sclerosis have been reported.
Anti-TNF drugs should be used with caution in patients with congestive heart failure.
Combining Humira and Kineret (anakinra) is not recommended
Humira is contraindicated in pregnancy as well as for use in nursing mothers.
There have been rare cases of severe allergic reactions after taking Humira. Lymphoma and pancytopenia (low blood counts) have also been rarely reported in patients taking anti-TNF therapy.
The most common side-effects are injection site reactions, upper respiratory tract infections, headache, and nausea.
Doctor, I Am
Treated With Rituxan For Rheumatoid Arthritis. What Is This Serious Brain
Side-Effect?
By
Nathan Wei
The United States Food and Drug Administration issued an alert on December 19, 2006, regarding the use of rituximab (Rituxan) in patients with certain arthritic conditions. This was based on two reports of fatal progressive multifocal leukoencephalopathy (PML) in patients with systemic lupus erythematosus who had received rituximab therapy.
PML is a rare, generally fatal demyelinating
disease of the central nervous
system similar to multiple sclerosis. It is caused by reactivation of JC polyoma
virus infection. Exposure to JC virus is endemic meaning that approximately 80%
of healthy adults have been exposed to the virus and actually still carry the
virus around. However, PML is rare (approximately 1 in 200,000 persons), and is
almost always seen among very immunocompromised individuals, for example AIDS
patients and organ transplant patients receiving strong immunosuppressive drugs.
There have been approximately 20 cases of PML
reported in the medical
literature among patients with systemic lupus erythematosus (SLE) not receiving
rituximab. More than 85% of patients reported were receiving one or more
immunosuppressive drugs and/or high dose corticosteroids. The outcome was fatal
in approximately two thirds of cases. Although rituximab has not yet received
regulatory approval for use in SLE, it is estimated that approximately 8,000 SLE
patients worldwide have received therapy with rituximab to date.
The symptoms of PML include paralysis, thinking
difficulty, memory lapses, and
problems with coordination.
Diagnosis can be difficult. Magnetic resonance imaging (MRI) findings consistent with PML include multiple spots in different parts of the brain with the lesions limited to the white matter. The presence of JC virus in the central nervous system (CNS) can be established by a test called the polymerase chain reaction (PCR) on samples of cerebrospinal fluid. Biopsy of brain tissue also will be abnormal. Measurement of the viral load of JC virus in the blood can also be done.
Among AIDS patients, antiretroviral therapy has
resulted in a decreased prevalence of PML, indicating that improved immune
function can improve outcome. It is not clear whether discontinuation of
immunosuppressive therapy might improve the outcome in other conditions. Several
anti-viral agents have been tried in patients with PML (interferon, cidofovir,
cytarabine), but only cytarabine, which penetrates
the central nervous system poorly, has shown activity against JC virus.
PML has been reported among patients with
rheumatic diseases, including SLE
and Wegener's granulomatosis. There are a handful of reports of PML among
patients with rheumatoid arthritis. No cases of PML have been reported to date
among RA patients treated with rituximab. Among patients with
immunodeficiencies, patients with AIDS have a greater prevalence of PML
than those with other immune deficiencies.
PML is a rare condition. So far two cases of PML
have been described in
patients with SLE treated with rituximab. The overall and long-term risk of
PML in patients with rheumatic diseases treated with rituximab is unknown.
Patients should be counseled about the potential risk. As with any
treatment, the potential risks must be weighed against the potential
benefits of therapy.
I Have
Rheumatoid Arthritis - Why Is My Rheumatologist Concerned About My Heart
By
Nathan Wei
Women with rheumatoid arthritis (RA) have high rates of non fatal heart attacks. This occurs even without traditional risk factors being present. (Solomon, et al. Circulation 2003; 107: 1303-1307). The same is probably true for men with RA as well.
Methotrexate appears to lower the mortality suggesting that some RA treatments might help reduce cardiovascular risk.(Choi, et al. Lancet. 2002; 359: 1173-1177)
Another study used carotid ultrasound to detect atherosclerotic plaque (hardening of the arteries) in patients with RA. They found atherosclerosis was three times more common in RA patients compared with controls at all ages. The difference was even more striking for younger RA patients. (Roman, et al. Ann Intern Mede. 2006; 144: 249-256)
The conclusions drawn from multiple studies are that RA is an extremely potent risk factor for the development of atherosclerosis. More aggressive goals for risk factor modification should be instituted.
Practically speaking, it’s important to assess all risk factors in patients with RA. Control of hyperlipidemia and high blood pressure is mandatory. Dietary measures are primary. If dietary changes don’t work, then statin therapy maybe needed. These drugs lower LDL cholesterol (“bad” cholesterol) and reduce levels of C-reactive protein. If a patient has diabetes, tight control of blood sugar is extremely important. Discontinuation of cigarette smoking, proper weight management, and a regular exercise program are all valuable. While aspirin therapy has been shown to be effective prophylaxis for men, it has not been shown to be effective for primary prevention in women.
The controversial role of non-steroidal anti-inflammatory drugs (NSAIDS) as far as being risk factors themselves is another dilemma that has not been fully resolved. One European study presented at the American College of Rheumatology meeting in Washington, D.C. in November 2006 indicated that NSAIDS might even be protective in some instances because of their anti-inflammatory effect.
What is clear is that chronic inflammation is an important force in causing premature hardening of the arteries. Whether or not more aggressive means of systemic control of RA- such as with anti-TNF drugs and other biologic therapies- will be helpful in reducing atherosclerosis is the subject of continuing study. Preliminary evidence suggests that tighter control of RA is helpful for reducing atherosclerosis.
Until more is known, it is important for patients with RA to know that their rheumatologists will be paying closer attention to their arterial status. Perhaps the use of surrogate methods of detection of atherosclerosis such as carotid ultrasound may be useful in detecting patients at high risk.
Rheumatoid
Arthritis: A Life-threatening Condition?
By
Nathan Wei
Rheumatoid arthritis is the most common inflammatory form of arthritis and affects approximately two million Americans. It is an autoimmune disease. Autoimmune diseases are characterized by abnormal function of the immune system. For whatever reason (and that reason is still unknown), the immune system attacks healthy tissue. In rheumatoid arthritis, joint tissues such as ligaments, tendons, and muscles, are attacked and become inflamed. Symptoms that develop include painful, swollen, tender joints. The small joints in the hands and feet are the most commonly affected. Other prominent symptoms include fatigue and stiffness.
Rheumatoid arthritis is a systemic disease meaning it attacks many different organ systems. One organ system that can be affected are the blood vessels. This inflammation of blood vessels is called vasculitis. It is especially dangerous because vessels carry blood throughout the body: to the brain, lungs, skin, kidneys, and heart. ”Shutdown” of organs occurs. Why? As the inflammation of the blood vessels progresses, the blood vessels are no longer able to transport blood.
Vasculitis due to rheumatoid arthritis can lead to heart attack and stroke. (Roman MJ, et al. Preclinical Carotid Atherosclerosis in Patients with Rheumatoid Arthritis. Annals Int Med 2006; 144: 249-256)
A sidebar to this is the eye involvement that can occur. Inflammation of the sclera- the white part of the eye- can lead to blindness as a result of perforation or hemorrhage.
An interesting side light to this is that several studies provide evidence that long-term smoking contributes to the immune system’s malfunctioning. This most likely explains why smoking is associated with increased severity of the disease. This is also why smoking and rheumatoid arthritis make a terrible combination. Smoking causes premature atherosclerosis and rheumatoid arthritis does also.
If untreated, rheumatoid arthritis significantly
shortens life span by an average seven to eight years. It increases the risk for
heart attack and stroke. Sixty percent of untreated patients are disabled and
dependent on others to take care of them within 10 years.
One other factor that contributes to the shortened lifespan is the increased
incidence of lymphoma that occurs in patients with RA.
Doctor…My Body
Hurts. There’s Pain In Every Joint… What’s Causing It?
By
Nathan Wei
Joint pain causes can be divided into several categories.
Infections such as viruses (in particular, parvovirus) can cause a type of arthritis. Bacteria such as gonococcus (the bug that causes gonorrhea) and Borrelia, the organism that causes Lyme disease, are well known infectious causes for joint pain.
Trauma is an obvious cause. This can range from an athletic injury occurring more than 30 years ago leading to osteoarthritis in the knee to a whiplash injury that happened yesterday accounting for total body stiffness and pain today!
Disorders of the blood are an uncommon but important cause of joint pain. Leukemia and lymphoma can present as aches and pains. Often fever, sweats, and weight loss accompany the pains… but not always. Multiple myeloma- a malignancy that affects the plasma cells in the blood- causes ill-defined joint pains. Sickle-cell anemia and hemophilia both are associated with arthritis. A blood disorder due to excess iron in the blood- hemochromatosis- is responsible for causing both cirrhosis of the liver as well as an unusual type of arthritis.
Endocrine problems can cause aches and pains. For example, growth hormone excess is called acromegaly. This is a cause of terrible arthritis. Thyroid hormone deficiency also causes aches and pains that mimic the symptoms of fibromyalgia
Closely related to endocrine causes are the metabolic disease like gout and pseudogout which cause inflammatory types of arthritis.
The largest category of causes of aches and pains is arthritis. Wear and tear arthritis- termed osteoarthritis- is the most common form of arthritis. This arthritis is due to premature wearing away of cartilage, the gristly that protects the end of long bones. Osteoarthritis most often affects weight bearing areas such as the neck, low back, hips, and knees. It also affects the hands and feet. More autoimmune types of arthritis such as systemic lupus erythematosus, scleroderma, polymyalgia rheumatica, psoriatic arthritis, and rheumatoid arthritis can cause severe total body aches and pains in the joints. These autoimmune diseases have more inflammation associated with them. In addition, constitutional symptoms such as low grade fever, weight loss, sweats, and fatigue are common.
Finally soft tissue rheumatism – termed fibromyalgia- is a very common reason for a person to have "total body joint pain". While not a life-threatening disorder, fibromyalgia, which is often accompanied by fatigue, short term memory loss, "fibro fog", and bladder and bowel disturbance is can be debilitating.
Effective Remedies for
Arthritis - Eight Treatment Techniques Anyone Can Use!
By
Nathan Wei
Arthritis is the most common disorder leading to crippling and deformity. It affects about 70 million Americans. Because there are more than 100 different kinds of arthritis, it is important to know what type of condition you’re dealing with. There are some general treatment principles that apply to most people with arthritis.
Effective methods for dealing with arthritis include the following:
• Medicines: Both over-the-counter and prescription anti-inflammatory medicines will help with symptoms. More specific disease-modifying medicines may be needed. The physician best suited to determine this is a rhuematologist.
• Exercise: This “treatment” helps to reduce fatigue, increase range-of-motion and movement, and also helps with self-esteem!
• Rest: Proper amounts of rest help to conserve energy and allow the body to heal. A good balance between exercise and rest is necessary.
• Thermal modalities: Heat and cold applied judiciously give short-term relief of pain and stiffness. These are also important adjuncts to an arthritis exercise program.
• Self-help aids: These devices help patients with arthritis perform activities of daily living in a more efficient and less painful manner.
• Joint protection: This helps patients perform tasks easier with less stress on the joints. Physical and occupational therapists are useful resources.
• Self-help: This method of empowering the mind can help patients manage their symptoms better.
• Surgery: When more conservative measures have failed, surgery may be required. Fortunately, this is becoming less and less of a need.
Despite everything, people with arthritis can lead a productive and less painful existence. Proper attention to detail and individualized therapy can make a big difference!
Doc, My Mouth is So Dry All
the Time, What Could Be the Problem?
By
Nathan Wei
Sjogren’s syndrome is an autoimmune disorder – a disorder in which your body attacks its own tissues because it thinks they are foreign. It prevents your body’s exocrine (moisture-producing) gland from producing enough moisture for different areas of your body. This leads to chronic and lifetime dryness. Sjogren’s syndrome affects many areas of your body. In addition to the mouth and eyes, other affected areas include the skin, vagina, respiratory tract (lungs), and gastrointestinal tract (stomach and intestines).
Even the pancreas and sweat glands may be affected.
People at risk include:
• Females who constitute about 90 per cent of patients
• People over the age of 40 years
• Those who have other autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, and scleroderma
• People on medications for allergies, high blood pressure, and depression
• People who have undergone radiation therapy
• Patients who have had bone marrow transplant
A common symptom of Sjogren’s syndrome is dryness that losts a long time. Dryness may lead to other serious medical conditions including:
• Eyes (corneal ulceration, serious infections)
• Mouth (increased incidence of cavities, bronchitis, pneumonia)
Rarely, in patients who have serious autoimmune Sjogren’s problems, the kidneys may be affected. A small percentage of patients will develop lymphoma.
The symptoms of Sjogren’s syndrome are sometimes hard to recognize because they take a long time to develop and may look like signs of other medical conditions.
Fortunately, treatment involving symptomatic therapies as well as disease-modifying drugs are available.
Evaluation by an experience rheumatologist is recommended.
Doctor I'm Having A Flare of
My Arthritis What Should I Do?
By
Nathan Wei
The first thing to do is remain calm. The flare will end. It can be controlled. Sometimes something simple like an ice pack can help relieve the pain of a localized flare in a joint. Make sure to place a towel between the ice pack and the skin.
After a day, it may be helpful to switch to moist heat. This will help increase blood flow to the area and help with healing. It can also help loosen up tight muscles. A heating pad, a hot bath or shower, or even a not moist towel can be used.
Another trick is to use massage. Massage can also reduce the pain associated with muscle spasm that can be a part of a flare. Be careful though. Hard massage may make things worse!
Sometimes, over-the-counter (OTC) analgesics such as acetaminophen (Tylenol) or anti-inflammatory drugs like ibuprofen (Advil) or naproxen (Aleve) might help. Be careful! If you already are on a non-steroidal anti-inflammatory drug or a blood thinner, you should not take these medicines without consulting your physician.
Rub it out! Occasionally topical ointments and creams can provide short-term soothing relief. In our office we use Myorx (Contact the Arthritis and Osteoporosis Center of Maryland by emailing us at aocm@adelphia.net to find out more). Our patients love it.
Call your rheumatologist. He or she can give you the best information because they know your case. They will make medication adjustments or ask you to come in for an evaluation.
Don’t worry. Flares can be beaten!
Doc, I Know My Arthritis Will
Get Better If I Lose The Weight.... But How Do I Do It?
By
Nathan Wei
First… establish realistic goals. Start with a target you can hit…say… “OK, I’d like to lose five pounds in one month.” Make it easy on yourself. Then once you hit that goal, set another one. Achievable goals will help you get the confidence you need to keep on going. Another tip: reward yourself (not with food) for hitting your goals.
Second… Get support. If you have a spouse or friend to act as a buddy while you’re doing this, you’ll get much needed help. Groups like Weight Watchers are also an option.
Third…Change the way you eat. Frequent small meals are better than three large ones. Eat most of your calories early in the day so they’ll be burned off as the day progresses. Start your meal with a big salad- one that is a lot of bulk but few calories. That’ll prevent you from eating a larger main meal.
Fourth… Change what you eat. Replace refined carbohydrates with carbohydrates that have a heavy fiber content. Definitely lower the amount of carbs you have in your diet.
Fifth…Reduce your portion size. Something simple like this can markedly reduce your caloric intake but you’ll eat less.
Sixth… Eat with your non-dominant hand. It sounds crazy but it works.
Seventh…Increase your exercise. Try cross-training. Consider both weight-training as well as cardio exercises to boost your metabolism. By doing a variety of exercises, you won’t get stuck on a plateau or stop because you’re bored.
Eighth…Watch less television as a completely passive activity. Not only is this the prototypical sedentary activity but it’s much better for you if you can get your TV fix while exercising. Set up a TV in front of your treadmill.
So there you have it... Now let's lose some weight!
Prednizone Side Effects -
Should I Be Worried if I Take this Drug?
By
Nathan Wei
Prednizone- the correct spelling is “prednisone”- is a commonly used oral glucocorticoid medicine.
The adrenal glands manufacture a natural form of glucocorticoid. Glucocorticoids are responsible for many functions in the body including maintenance of blood pressure, proper use of sugar, protein, and fat metabolism, response to stress, and many other tasks.
Glucocorticoids manufactured by the body are referred to as endogenous steroids- meaning a person’s own body makes these steroids.
When steroids are taken in from the outside either by mouth, intramuscularly or intravenously, they are referred to as exogenous steroids. Taking glucocorticoids orally or intravenously can reduce the ability of the person’s own adrenal glands to continue to manufacture glucocorticoids.
Without the ability to increase steroid production in the face of stressors such as injury, infection, and surgery, a patient can go into shock.
The chances of the adrenal glands being suppressed increase as the dose of “outside” steroid exceeds the average daily equivalent output of the adrenal glands which is about 5.0-7.5 mg prednisone, therapy continues for more than a few weeks or months, doses are given late in the day or in split doses, or long-acting corticosteroid preparations are used.
Patients who require high doses of prednisone (more than 20 mgs a day) for extended periods of time often will develop side-effects.
Taking steroids on an alternate day (every other day) schedule lessens the chance of adrenal insufficiency but does not do away with it altogether.
Other side-effects include:
• Increased risk of bacterial or opportunistic
infections such as fungi, tuberculosis, pneumocystis carinii
• Elevated blood sugar
• Fat distribution changes leading to moon face, buffalo hump
• Elevated blood lipids
• Aggravation of hypertension
• Electrolyte abnormalities such as low blood potassium
• Fluid retention leading to edema
• Easy bruisibility
• Increased body hair
• Increased sweating
• Purple stretch marks
• Impaired wound healing
• Glaucoma
• Cataracts
• Muscle wasting
• Stomach ulcers
• Pancreatitis
• Accelerated hardening of the arteries
• Osteonecrosis (bone death)
• Psychiatric disturbance
• Insomnia
• Bowel perforation
• Masking of infection
The use of prednisone for different diseases such as arthritis needs to be assessed with the potential benefits vs. the risks. These benefits and risks need to be discussed with your rheumatologist.
Bottom-line Kitchen Tips for
Arthritis Sufferers
By
Nathan Wei
First of all, let’s make it easier on you in the kitchen. Let’s face it… cooking a meal that’s good for you from a nutrition point of you is difficult when you hurt.
Here are a few simple tips to help you:
• When you’re preparing your food, pull up a high barstool and sit down to chop, mix, or stir, instead of standing at the counter.
• Use cooking utensils with built-up or padded handles to help you with grip.
• Use an apron with pockets to carry things you can use instead of having to make more frequent trips.
• Use the microwave to heat up leftovers or defrost frozen vegetables.
• Consider using pre-cut vegetables, fruits, and meats.
• Use a crock pot. By putting meat, poultry, pre-sliced vegetables along with broth and spices you can use a crock pot to create a hot nutritious meal- with only one pot to clean afterwards!
• Prepare large batches of food at one time and refrigerate or freeze the leftovers for later.
And as far as the types of foods, here are the important nutrients to consider…
• Vitamin C. Studies have shown that vitamin C may slow progression of osteoarthritis. Vitamin C can be found in citrus fruits and juices as well as berries.
• Vitamin D. Patients with rheumatoid arthritis may benefit from immunomodulatory effects of this vitamin. Vitamin D also is important in preserving healthy bone mass. Vitamin D can be found in dairy products, cereals, and eggs.
• Omega-3 fatty acids. This anti-oxidant has been shown to reduce inflammation in patients with rheumatoid arthritis. Omega-3 is found in cold water fish such as salmon and mackerel.
• Gamma-linoleic acid. GLA is found in foods like flaxseed and carry the same potent anti-oxidant effect as foods that are high in omega-3 fatty acids.
Bottom line: Cooking with arthritis can be healthy and shouldn’t hurt!
Doctor, I've Been Told I Have
Osteoporosis - What Is It?
By
Nathan Wei
Roughly 10 million people in the United States suffer from osteoporosis. Postmenopausal women are the most commonly affected individuals; however, men also face an increased incidence of the disease as a result of advancing age.
Fractures due to osteoporosis are deadly. Mortality rates are increased more than 7-9 times normal after osteoporosis related fractures of the hip or spine. And of those people who survive, more than half lose the ability to function normally and 25% end up in nursing homes.
Risk factors for osteoporosis include: female gender, advancing age, family history of the disease, Caucasian or Asian race, small body structure, chronic kidney disease, poor health, lack of mobility, alcoholism, cigarette smoking, high caffeine intake. Other risk factors include low calcium intake or reduced calcium absorption from the intestine, chronic steroid or blood thinner use, and history of falls.
The major determinant of risk of fracture is the strength of bone. Bone strength is a function of both the quantity as well as quality of bone.
Bone formation starts as the fetus develops and continues throughout childhood and adolescence. Peak bone mass is achieved in early adulthood, around the age of 30.
Bone is a living tissue that is continually being renewed. Old bone is removed and new bone takes its place. The structure of bone can be viewed as being like a house. A framework, called the matrix, is filled in with “bricks” consisting of minerals such as calcium and phosphorus.
In healthy adults the rate of removal of old bone is matched by the laying down of new bone. With aging, though, the amount of new bone formation slows and there is a net loss of bone mass over time.
Osteoporosis occurs when there is an excessive amount of bone removal so that the bone develops small cavities. This leads to a loss of bone strength and increased risk for fracture.
The diagnosis and treatment of osteoporosis will be discussed in other articles.
Doctor, Could My Child Really
Have Arthritis? I Thought Only Old People Got Arthritis!
By
Nathan Wei
Rheumatoid arthritis (RA) is a chronic inflammatory disease that damages and eventually destroys joints. What many people don’t realize is that this disease may affect children... not just adults!
Though inflammation is a normal response of the body’s immune system, in arthritis, the inflammation is excessive and targets normal tissue leading to damage and destruction. The inflammation in the joints causes pain, stiffness, and swelling as well as many other symptoms. The inflammation often affects other organs and systems of the body as well.
Juvenile rheumatoid arthritis (JRA) is not one disease, but a group of diseases. What they all have in common is chronic joint inflammation. Besides this common feature, these diseases are very different in their symptoms, their treatments, and their outcomes.
• Pauciarticular disease affects only a few joints, fewer than 5. The large joints, such as the shoulder, elbow, hip, and knee, are most likely to be affected. This type of JRA is most common in children younger than 8 years of age. Children who develop this disease have a 20-30% chance of developing inflammatory eye problems and need frequent eye examinations. Children who develop this disease when older than 8 years have a higher-than-normal risk of developing an adult form of arthritis. About 50% of all children with JRA have this type.
• Polyarticular disease affects 5 joints or more, sometimes many more. The small joints such as those in the hands and feet are most likely to be affected. This type can begin at any age. In some cases, the disease is identical to adult-type RA. This type accounts for about 30% of cases of JRA.
• Systemic disease affects many systems of the body. Children may have high fevers, skin rashes, and problems caused by inflammation of the internal organs such as the heart, spleen, liver, and other parts of the digestive tract. It usually, but not always, begins in early childhood. Physicians sometime call this Still’s disease. This type accounts for about 20% of cases of JRA.
Children with JRA may experience complications specific to their type of JRA.
The most common complications in children with JRA relate to adverse effects of medications taken to treat the disease, particularly non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin). When taken chronically, these drugs can cause irritation, pain, and bleeding in the stomach and upper intestine. They also can cause problems in the liver and kidneys that often produce no symptoms until they are very severe. In some cases, the child must undergo frequent blood tests to screen for these problems.
Eye inflammation- iritis- occurs in about 30 per cent of children. It must be treated aggressively in order to prevent blindness.
Some children with JRA have emotional or psychological problems. Bouts of depression and problems functioning in school are the most common.
The mortality (death) rate in children with JRA is somewhat higher than in healthy children. The highest death rate in children with JRA occurs among patients with systemic JRA who develop systemic symptoms (eg, pleural and pericardial disease- disease affecting the lining of the lungs and heart). JRA can also evolve into other diseases, such as systemic lupus erythematosus (SLE) or scleroderma, which have higher death rates than pauciarticular or polyarticular JRA.
Treatment for JRA, like that for adult-type rheumatoid arthritis, has improved dramatically in the last 30 years, thanks mainly to the development of new medications.
These include the use of sulfasalazine, methotrexate, and biologic medications such as etanercept (Enbrel). Other biologic agents are also being studied. Regular exercise is also therapeutic.
Doctor, What Do I Do If I
Think I Have Osteoporosis?
By
Nathan Wei
Bone is a living tissue that undergoes constant change. This series of changes is called “remodeling.” Old bone is removed and new bone is formed.
The structure of bone consists of a matrix composed of a framework of collagen and minerals. While the character of bone is different in different areas of the skeleton, the common thread is that if the collagen framework or the minerals aren’t properly remodeled, then bone quality is compromised. This leads to an increased risk for fracture. The typical situation- and the one that is responsible for post-menopausal osteoporosis- is that too much bone tissue is removed and not enough is built. When this abnormal bone is subjected to daily wear and tear, “microcracks” in the bone accumulate leading to fracture.
The first place to start if you suspect you may be at risk for osteoporosis is to find the right kind of doctor. This is usually a rheumatologist who specializes in osteoporosis.
He or she will take a careful history looking for risk factors. Among the most common are: female gender, advancing age, family history, small body frame, Caucasian or Asian race, chronic kidney or bowel disease, cigarette smoking, alcoholism, high caffeine intake, and chronic steroid or blood thinner therapy.
Other medical conditions which may be associated with osteoporosis are diabetes, overactive thyroid disease, lung disease, alcoholism, and hormone (estrogen or testosterone) deficiency.
Ideally, a careful history evaluating a patient’s risk for falls should also be taken. Impaired vision and environmental hazards such as poor lighting in the home, etc. should be looked into.
After the history, a careful physical examination looking for specific causes of bone loss such as thyroid disease, vitamin deficiency, or other conditions should be performed.
Then, a full laboratory workup consisting of complete blood count, erythrocyte sedimentation rate (ESR), thyroid blood tests, blood chemistries, urinalysis, serum vitamin D levels, and 24 hour urine tests measuring calcium and phosphorus should be obtained.
If there is evidence of fracture in the spine, x-rays may be obtained. Some people may have what are called insufficiency fractures. These are fractures that develop spontaneously in people with very low bone strength. Often these types of fractures will not show up on regular x-ray. Bone scans and magnetic resonance imaging (MRI) may then be required. Special urine tests for bone markers may also be ordered. These urine tests may yield a clue that bone is undergoing improper remodeling.
A bone density scan (also called a dual-energy x-ray absorptiometry scan or DEXA) is mandatory! These scans should be interpreted by a trained rheumatologist. This scan measures the actual “thickness” of bone. DEXA scans are also an excellent method for evaluating the effectiveness of drug therapy… once the patient has been started on the proper medication.
In some instance, a bone biopsy may be required. This procedure involves the extraction of a plug of bone from the pelvis. This is done using local anesthetic and provides a specific look at bone architecture.
In future articles, treatment of osteoporosis will be discussed.
At Last! Good News For Gout
Sufferers!
By
Nathan Wei
Gout, an arthritis affliction with its roots in antiquity, has not always been easy to treat. The traditional medicines employed for gout have been non-steroidal anti-inflammatory drugs (NSAIDS), colchicines, probenicid (Benemid), and allopurinol (Zyloprim).
Unfortunately, while effective, these drugs have their drawbacks. NSAIDS cause gastrointestinal complications; colchicines has been linked to severe neurologic and gastrointestinal problems; probenecid cannot be used in patients who do not have normal kidney function or who excrete too much uric acid in the urine; and allopurinol has been associated with severe side effects including liver, skin, and blood toxicity.
Interestingly, drugs you may take for other medical conditions may help you with gout. Losartan (Cozaar), a blood pressure medication, and fenofibrate (Tricor), a triglyceride-lowering drug, works as mild uricosuric drugs. This means these agents help the kidneys get rid of excess uric acid- the major ingredient in the crystals that cause gout pain.
By the same token that some medicines taken for different conditions may help gout, others may hurt it. For instance, certain diuretics may elevate blood uric acid. The same is true for low doses of aspirin.
A new medicine, febuxostat, has recently undergone clinical trials. This medication is being heralded because of its general safety profile. Unfortunately, there have been some concerns raised about cardiovascular issues.
Uricase, an enzyme found in all animals but not in humans has been evaluated. It tends to induce allergfic reactions and has not been found to be of practical use to date.
Obviously, all medicine decisions should be made in concert with your physician.
Arthritis Diet Myths - Don't
Be Fooled By These Food Fables!
By
Nathan Wei
One of the most popular myths I hear from my patients is that eating golden raisins soaked in gin will cure arthritis. There is no good research to support this notion. Save your money.
A recent popular diet, the Dong diet, advocates the elimination of fruits, red meats, and dairy foods. Not only is there no scientific evidence to support this diet but there may be potential harm. By eliminating so many potentially nutritious foods, there is the danger of causing a deficiency of important nutrients. Elimination diets though, have their supporters and selective elimination under the strict supervision of a registered dietician may be something to explore if you’re absolutely convinced your symptoms are food-related.
Another diet advocates the removal of dairy products. There are some who claim that dairy products make arthritis worse. The concern here is that total purging of dairy foods can lead to severe calcium deficiency and subsequent weakening of bones.
For years, there has been a myth that states the elimination of nightshade vegetables such as tomatoes, potatoes, eggplant, and peppers will cure arthritis. The theory is that these plants produce a harmful toxin that causes arthritis. To date there is no scientific data indicating that these foods produce the supposed destructive ingredient that is responsible for inducing arthritis. Nightshade vegetables actually are low-calorie and contain important nutrients that might help arthritis sufferers.
Another popular “tonic” is the combination of vinegar and honey. Again, no reliable concrete evidence backs this as a “cure” for arthritis.
The advice: Thoroughly check out any story you hear. Don't be fooled. Talk with a reputable rheumatologist and dietician before embarking on a food "experiment."
The Arthritis Pain
Reliever... A New Program That Just Might Make You Younger!
By
Nathan Wei
For years, it's been known that regular daily exercise is one of the most important activities that people can engage in to promote good health.
The Centers for Disease Control and Prevention (CDC) and the United States Department of Agriculture (USDA) are trying to help people follow through with exercise prescriptions written by their physicians. A new program, in conjunction with the Arthritis Foundation, called the Arthritis Pain Reliever will include public service announcements, posters, and brochures which encourage people to engage in exercise. Whether it’s swimming, biking, or walking, all of these can help people with arthritis decrease their symptoms.
A number of published studies have provided important insight into the role of exercise...
A recent study indicated that exercise can help increase the efficiency of insulin and that inactivity leads to more sugar in the blood stream, potentially setting up a person for diabetes.
Researchers also demonstrated that women who exercised before breakfast and then ate burned 20 per cent more calories than if they rested before eating.
To go along with that study, another study showed that caffeine may help produce better exercise tolerance by reducing the amount of pain due to muscle strain.
Finally, another study demonstrated that the ability to sustain aerobic exercise may be genetic but can be improved. Low aerobic capacity strongly predicts the eventual development of cardiovascular problems. Genes may impair the energy generating ability of cells. These results stress the need to maintain regular exercise to increase aerobic capacity.
All of these findings... and your doctor can’t be wrong. It’s important to get into the habit of exercise. Make it so it’s like brushing your teeth!
Doc, My Tummy Aches and My
Joints Hurt! Is there a Connection?
By
Nathan Wei
Inflammatory disease of the bowel- regional enteritis (Crohn’s disease) and ulcerative colitis- are often associated with arthritis. This occurs because inflammation in the bowel and the joints may share a common immunological abnormality.
Patients can present with abdominal pain, weight loss, and diarrhea.
Clinically, the arthritis that accompanies inflammatory bowel disease occurs in two different ways. The first pattern typically affects the larger joints of the lower extremities such as the ankles and knees. The heels may also be affected. Sometimes the fingers or toes can swell and look like little sausages. This type of “peripheral” arthritis occurs in about 20 per cent of patients who have inflammatory bowel disease. The activity of the arthritis parallels the gut activity.
In the second type, the arthritis can affect the low back- the sacroiliac joints that join the pelvis to the lower spine. This type of arthritis occurs in about 15-20 per cent of inflammatory bowel patients. A genetic marker called HLA-B27 is present (found through a blood test) in 50 per cent of patients who have inflammation of the sacroiliac joints. Stiffness in the low back along with limited range of motion is seen. This type of arthritis does not parallel the gut activity.
The diagnosis is usually suspected from the presence of bowel symptoms such as diarrhea and abdominal cramping. Rarely, the arthritis may precede the bowel symptoms.
The diagnosis is confirmed by laboratory testing, x-rays, bowel visualization (colonoscopy), and magnetic resonance imaging (MRI).
The treatment for the arthritis associated with inflammatory bowel disease is remarkably similar to that involving other types of arthritis. Typically anti-inflammatory drugs and disease-modifying drugs are both used. Anti-inflammatory drugs should be used with caution since they may cause the bowel disease to flare up. More recently, biologic drugs have been used with success to treat inflammatory bowel disease. The arthritis not surprisingly, also responds.
Who Else
Wants General Information on Arthritis?
By
Nathan Wei
Today there are about 70 million Americans with arthritis…that’s one person out of every four who suffer both pain and the expense of this crippling disease. In one year alone, arthritis will be responsible for over half a billion dollars in lost wages. The economic consequences of arthritis are important to review because each year, arthritis takes a devastating financial toll on our society.
Over the course of ten years, arthritis related work loss has been associated with a 37% drop in income for arthritics – all those without arthritis had a 90% rise in income over the same period of time!
If you…a friend…or a relative has arthritis, it’s important to know that early treatment can help sufferers continue with their normal daily lives and remain productive members of the community.
The term “arthritis” is derived from the Greek: “arthron” meaning “joint” and “itis” meaning inflammation. Arthritis is a word that describes over 100 different conditions, some involving inflammation and others not.
Arthritis is not a single disease. It encompasses about 100 different conditions, that affect joints and that pose unique problems for diagnosis and treatment.
Some common types of arthritis include osteoarthritis, rheumatoid arthritis, gout, pseudo-gout, ankylosing spondylitis, polymyalgia rheumatica, psoriatic arthritis, Reiter’s disease, systemic lupus erythematosus, and fibromyalgia.
Most types of arthritis involve joint inflammation. Inflammation is the body’s natural response to injury or infection.
For an example of inflammation, take a simple scratch…your body automatically releases chemicals that cause fluids to accumulate and white blood cells to gather around the area of the scratch. As your body fights foreign substances and bacteria, inflammation…redness…heat…swelling…and pain occur at the sight of the injury.
In arthritis, unfortunately, this natural defense mechanism goes awry. Elements from the blood designed to fight infection and repair injury attack the body instead.
And, unless this inflammatory process is halted, it will continue to attack the body and cause joint destruction.
So you can begin to see how treatments that just relieve the pain associated with arthritis – but that do not reduce inflammation – may not adequately treat this disease.
Getting proper treatment early on is important…because proper care can help arthritis sufferers lead more active and comfortable lives.
Yet many people with arthritis delay going to a physician. Either they have fear about going to a doctor or they feel that nothing can be done for arthritis. Other reasons include the notion that all arthritis medicines are harmful or arthritis is just a normal part of aging.
Some people try unproven remedies which also delay proper diagnosis and treatment.
Since arthritis may evolve gradually, people often ignore its early warning symptoms or signs. These include persistent pain, tenderness, or swelling in one or more joints…symptoms that should not be dismissed as signs of age.
Other warning symptoms are joint pain and stiffness…especially when they appear in the morning.
Low back pain is one of the earliest symptoms of arthritis. For people over the age of 60, arthritis is the most frequent cause of low back pain.
The activity of arthritis varies unpredictably. Symptoms are cyclic in nature and seem to come and go.
Therefore, it is important to remember that any symptoms or signs of arthritis that last for more than six weeks – no matter how mild – should be checked by a physician. And, if symptoms are severe, then even waiting six weeks might be too long.
The two most common types of arthritis are osteoarthritis and rheumatoid arthritis. Joint inflammation is involved in both.
But, these types of arthritis differ in terms of…age of patients who are affected…the joints involved…the pattern of stiffness…and the potential for disability.
Close to 16 million Americans have osteoarthritis – the most common type of arthritis. Although osteoarthritis can occur at any age, it most often begins in people in their 50’s and 60’s.
Osteoarthritis or degenerative disc disease is a disorder of cartilage – the gristle that covers the ends of long bones. Cartilage is made of cell called chondrocytes which sit inside a framework made up of collagen and proteoglyens. Under normal conditions, chondrocytes make collagen and proteoglycens – in other works – they make the framework they sit inside. With osteoarthritis, chondrocytes behave abnormally and begin to make destructive enzymes such as collagenasese, stromelysin and others. These enzymes degrade cartilage…these enzymes also attract inflammatory cells which secrete substances called cytokines which cause further inflammation and damage to cartilage, underlying bone, and the joint lining.
This process results in progressive pain, stiffness, and loss of function.
Joint pain and stiffness are the most noticeable symptoms of osteoarthritis. Morning stiffness is usually brief lasting less than 15 minutes. Osteoarthritis usually affects weight bearing areas particularly the neck, low back, hips and knees.
It may also affect the fingers and hands and bony knobs may appear at the finger joints. The base of the thumb may also be affected. The typical pattern of osteoarthritis in the hands involves the distal and proximal interphalangeal (DIP and PIP) joints of the fingers, and the carpometacarpal (CMC) joint of the thumb.
Osteoarthritis is considered to be a degenerative joint disease. Along with inflammation, there is wear and tear on the inside of the joint.
This causes damage to the cartilage (the substance that forms the surface of the joints and works as a shock absorber). As the cartilage wears thin, the underlying bone is damaged. This process results in progressive pain, stiffness, and loss of function.
Osteoarthritis does not need to be disabling and with the proper medical care can be managed easily.
Rheumatoid arthritis is the other most common type of arthritis. It is more common in women and affects 7 million Americans…or one out of every five arthritis patients. It may affect any age group, although onset is most common in middle age.
Rheumatoid arthritis is usually characterized by heat, swelling, and pain in multiple joints in both the right and left sides of the body, including the hands, wrists, elbows, hips, knees, ankles, and feet. Spinal involvement also occurs on occasion.
The typical pattern of rheumatoid arthritis in the hands involves the proximal interphalangeal (PIP) joints, the metacarpal phalangeal (MCP) joints, the wrists, and the elbows.
Unlike osteoarthritis, rheumatoid arthritis can affect the entire body. People with this disease may feel sick all over…tire easily…lose their appetite…and lose weight.
In rheumatoid arthritis, the tissue that surrounds and nourishes the joints is attacked by the body’s immune system. The body mistakenly perceives its own tissue as foreign, and it reacts by sending special white blood cells and toxic chemicals called cytokines to destroy the foreign material. (The cytokine abnormalities that cause the damage in rheumatoid arthritis are different from the abnormalities seen in osteoarthritis.) This process of white cell migration and cytokine release damages the joint.
Although we do not know the cause of rheumatoid arthritis, researchers are investigating several possibilities.
Another interesting point about rheumatoid arthritis is that this disease can affect the internal organs including the lungs, skin, blood vessels, spleen, heart, and muscles.
If rheumatoid arthritis is not well controlled it can damage the joints irreversibly and cause serious disability.
To diagnose rheumatoid arthritis, the rheumatologist establishes the presence of joint pain and inflammation lasting at least six weeks and then looks for signs of the course of the disease that are characteristic for rheumatoid arthritis.
There are also blood tests that aid in the diagnosis of rheumatoid arthritis.
Patients with rheumatoid arthritis have a series of flare-ups followed by a period where there are mild or no symptoms. Usually, the pain and disability of rheumatoid arthritis progresses gradually.
Morning stiffness generally lasts longer than half an hour and may last several hours depending on the severity of the condition.
Most forms of arthritis persist for the patient’s lifetime. Medication cannot usually reverse the bone and soft tissue damage caused by arthritis.
However, new methods of measuring inflammation and its response to medication and other treatments offer valuable information to physicians…and can help to evaluate the arthritis sufferer’s discomfort.
Magnetic resonance imaging is one such technique. This method using the effects that strong magnets have on water molecules to provide exquisite images of the interior of the body. MRI has been used to diagnose and also assess the degree of damage within joints of patients suffering from arthritis. It is also helpful for evaluating the effect of new drugs.
Although there is no cure for arthritis, proper treatment can help tremendously. The goal of arthritis treatment is to relieve the pain and stiffness due to the progressive destruction caused by inflammation, and to maintain or increase freedom of movement.
Among the advancements that have taken place in the medical treatment of arthritis are various disease-modifying medications that not only relieve symptoms but also help slow down the progression of disease.
Other advances include various cartilage sparing drugs, cartilage growing drugs, and also biologic remedies. These drugs act by blocking the destructive effects of enzymes such as metalloproteases in osteoarthritis and cytokines in rheumatoid arthritis. By targeting specific processes, relief of symptoms and healing of damage can take place with presumably fewer side effects.
What can you do if you think you have arthritis?
First, you can consult your doctor. This is important because medical issues are complicated and your doctor, who understands your health needs, can prescribe the best treatment for you.
The type of doctor who can best evaluate arthritis is called a rheumatologist. These are physicians who have completed four years of medical school, three years of internal medicine residency, and three years of rheumatology fellowship.
While arthritis can be a serious disease that can progress and cause disability, science has come up with some new answers for arthritis sufferers. It is now up to the arthritis sufferer to recognize early warning signs and symptoms and to see a rheumatologist. With proper medical care, the course of this crippling disease may change and people can help to be returned to fully active lives – without pain and crippling disability.
Doctor - Will
Meditation Help My Arthritis?
By
Nathan Wei
Many alternative or complementary therapies have been examined to determine their effectiveness for arthritis. The problem is that research studies often present with conflicting results. Some studies are positive and others are negative. That has been found to be the case for treatments such as acupuncture, nutritional supplements, homeopathy, etc.
A recent research study concluded that meditation reduced psychological distress and led to a small reduction in rheumatoid arthritis (RA) disease activity. The improvement in disease activity was accompanied by a statistically significant fall in the erythrocyte sedimentation rate (ESR), a blood marker of inflammation.
The study was conducted at the University of Maryland’s Center for Integrated Medicine. And the results were presented at the 2005 annual meeting of the American College of Rheumatology held in San Diego, California.
Trial design had patients meditating for an hour each day for six days a week. Patients were compliant, with 85% still using the program at six months. The intervention was safe with no adverse events.
The actual treatment group had classes lasting 2.5 hours once a week for eight weeks and were asked to practice for 45 minutes to an hour each day for six days a week. The control group did not have “treatments.” Both groups continued with all their usual medications and were well-matched as far as drug therapy (75% were on disease-modifying anti-rheumatic drugs, 16% on biologics, 32% on steroids, and 51% on non-steroidal anti-inflammatory drugs). There were a total of 63 patients, mostly female and well educated.
At the beginning of the study, both groups had similar levels of psychological distress (measured by the Symptom Checklist-90, which covers symptoms of depression, anxiety, anger, hostility, and interpersonal relationships). Both groups also had a similar level of RA disease activity.
The treatment group showed a 30% reduction in psychological distress at 10 weeks (compared with a 10% reduction in the control group) and a 33% reduction (compared with 2%) at 24 weeks. Both reductions in the intervention group were statistically significant.
RA disease activity showed no change in either group at week 10, but by week 24 the intervention group showed a reduction of 11%, compared with no change in the control group. What was deemed particularly interesting was that the fall in disease activity was accompanied by a reduction in ESR—this fell by 23% by week 10 and by 33% by week 24, while the control group members showed a worsening for this specific test.
All in all, meditation is cheap, safe, and appears to be effective (until the next study comes along...) Obviously, a person needs to be receptive to this form of treatment.
Doctor - I Have
Symptoms of Pain and Swelling in My Hands and Feet - What Could It Be?
By
Nathan Wei
While there are multiple causes of swelling and pain in the hands and feet, arthritis is probably the most common cause.
The term "arthritis" is derived from the Greek and means "joint inflammation". It refers to more than 100 different diseases that can cause pain, swelling, and stiffness in the joints. Joints are where the ends of long bones connect and interact. The end of each bone inside a joint has a thin layer of cartilage and is held in place by ligaments, tendons, and muscles. A joint is lined with synovial tissue (synovium) that helps to nourish the joint. It is the synovium that often becomes inflamed in arthritis.
Arthritis may also affect other supporting structures around joints such as the muscles, tendons, ligaments, and bones. Some serious forms of arthritis can affect internal organs.
The common symptoms of arthritis are due to inflammation (swelling, heat, redness, pain):
• Swelling in one or more joints
• Stiffness in the joints in the morning or with prolonged inactivity
• Joint pain or tenderness
• Restricted mobility in the joints
• Warmth or redness
Diagnosing arthritis can be difficult because some symptoms are often common to many different diseases. A rheumatologist will first do a complete physical exam, looking for clues. The eyes, ears, nose, throat, heart, lungs, and other parts of the body will be examined along with the joints. Lab tests and imaging procedures such as x-ray, ultrasound, or magnetic resonance imaging (MRI) may also be ordered.
The most common forms of arthritis are:
Osteoarthritis (OA) is also referred to as degenerative joint disease. This is the most common type of arthritis. When it affects the hands, it can cause painful swelling in the last row (Heberden's nodes) and middle row (Bouchards nodes) of finger joints. In the feet it will affect the toe joints as well as the mid-foot. This disease affects cartilage, the tissue that cushions and protects the ends of bones in a joint. With osteoarthritis, the cartilage starts to wear away prematurely. The swelling of the fingers and toes may lead to bony deformity.
Rheumatoid arthritis (RA) is an autoimmune disease; the body's immune system (defense mechanism against infection) attacks normal tissues. This autoimmune reaction causes inflammation of the synovium. RA symptoms include pain, stiffness, swelling, rapid loss of joint function, and crippling. When severe, rheumatoid arthritis can also affect internal organs. This is the type of arthritis that most commonly causes severe inflammation in the hands and feet.
Rheumatoid arthritis tends to be symmetric- one side of the bodt being affected just like the other.
Fibromyalgia is a chronic disease characterized by generalized aches and pains. The pain is accompanied by stiffness that is worst in the morning but tends to last all day long. Patients may have localized tender points occuring in the muscles and tendons, particularly in the neck, spine, shoulders, and hips. These tender points are called trigger points. Fatigue and sleep disturbances may also occur. There is subjective swelling along with pain in the hands and feet.
Gout and pseudogout are inflammatory forms of arthritis due to deposits of crystals in joints and other body tissues. Uric acid is the culprit in gout and calcium pyrophosphate is the villain in pseudogout. Both diseases cause painful attacks of arthritis affecting the hands and feet.
Infectious arthritis is a type of arthritis caused by either bacteria or viruses. A relatively common form of infectious arthritis is Lyme disease. Infectious forms of arthritis can cause swelling and pain in the hands and feet. A diagnosis is often difficult to establish. Antibiotics will often be used to treat bacterial infectious arthritis.
Reactive arthritis is an autoimmune arthritis that develops after a person has an infection in the urinary tract or intestine. This problem is often referred to as Reiter's disease. People who have this disease often have eye inflammation (iritis), rashes, and mouth sores. Inflammatory arthritis involving the hands and feet leading to a toe or finger that looks like a sausage (dactylitis) is common.
Psoriatic arthritis. Some people who have psoriasis also have arthritis. This disease often affects the hands and feet. It is usually asymmetric. It also causes deformity of the fingernails and toenails (onycholysis) that is often misdiagnosed as a fungal problem. Sometimes the spine- neck and low back-can be affected. As with Reiter's disease, dactylitis often occurs.
Systemic lupus erythematosus is another autoimmune disease. Lupus can affect many organ systems including the joints, skin, kidneys, lungs, blood vessels, heart, and brain. This is a cause of swelling and pain involving the hands and feet.
Juvenile rheumatoid arthritis is the most common type of arthritis affecting children. It leads to pain, stiffness, swelling, and loss of function in the joints. A patient can also have rashes and fevers with this disease. Hands, wrists, ankles, and feet are often affected.
Polymyalgia rheumatica. Symptoms include pain, aching, and morning stiffness in the shoulders, hips, thighs, and neck. It is sometimes the first sign of giant cell arteritis, an inflammatory disease of the arteries characterized by headaches, scalp tenderness, weakness, weight loss, and fever. The hands and feet may be affected although less often than other joints. The erythrocyte sedimentation rate (sed rate), a blood test that measures inflammation, is often greatly elevated.
Bursitis is inflammation of the bursae- the small, fluid-filled sacs that help cushion joints. The inflammation may accompany arthritis in the joint or injury or infection of the bursae. Bursitis produces pain and tenderness and may limit the movement of joints.
Tendinitis is inflammation of tendons (the fibrous cords of tissue that connect muscles to bones) caused by overuse, injury, or arthritis. Tendinitis produces pain and tenderness and may restrict movement of joints.
Not all conditions that cause symptoms of pain and swelling in the hands and feet are due to arthritis. Here are some non-arthritis causes...
Polycythemia vera (PV) is a disorder that is due to excessive production of red blood cells, white blood cells, and platelets. Some patients with PV will not have any symptoms at all, but many will experience easy bruising or bleeding with minimal trauma. Also, the blood may become thick, causing it to clot in tiny blood vessels. If clotting does occur in the small blood vessels of the fingers and toes, a patient may experience numbness or burning. Swelling and pain in the hands and feet may also occur.
Some medical conditions cause edema…swelling of the hands, ankles, feet, face, abdomen, or other areas of the body. Swelling is most often seen in the hands, in the feet, or around the eyes. The swelling often causes pain.
Edema is due to excessive fluid accumulation. It can be caused by abnormal kidney function, chronic kidney disease, congestive heart failure, varicose veins, phlebitis, protein or thiamine deficiency, sodium retention, or cancer.
Other reasons for edema are pregnancy, standing for prolonged periods of time, premenstrual syndrome, oral contraceptives, an injury (sprain), hypothyroidism (low thyroid), anemia, adrenal disease, deficiencies of potassium and B vitamins, or allergic reactions.
The cause of the edema needs to be determined. Diagnoses such as congestive heart disease, kidney disease, or liver disease should be ruled out.
Insect stings can lead to swelling and pain in the hands and feet. The same type of reaction may occur with medications, such as penicillin or sulfa. This is referred to as serum sickness.
Acromegaly is a disease where a tumor in the pituitary gland causes an overproduction of growth hormone. This leads to swelling and pain in the hands and feet.
Frostbite is another cause of swelling and pain in the hands and feet.
Blood clots in the veins are another cause of swelling and pain in the limbs. This rarely affects the upper extremities (arms). If it does, diseases associated with clotting abnormalities should be suspected.
Reflex sympathetic dystrophy (causalgia) is an unusual disorder that leads to swelling and pain in an affected limb. Generally it occurs in an arm or a leg, rarely both at the same time. The preceding event is usually some type of trauma.
How Do You
Treat Carpal Tunnel Syndrome?
By
Nathan Wei
Once the diagnosis of carpal tunnel syndrome has been established and underlying diseases associated with the condition have been dealt with, then it is time to treat the condition.
Medication such as acetaminophen and non-steroidal anti-inflammatory drugs can be used for symptom relief. Splinting the wrist, especially at night, helps keep the wrist straight during the night and thus decreases the pressure on the median nerve. These splints, which are available in your rheumatologist’s office or at many pharmacies, may relieve symptoms, especially in milder cases.
A cortisone injection into the carpal tunnel area is often helpful in relieving symptoms for weeks to months and can be repeated. Injections should be done using ultrasound guidance. If there is an underlying disease, such as hypothyroidism (under active thyroid) or rheumatoid arthritis, causing the carpal tunnel syndrome, then treatment of the specific disease may also relieve symptoms.
Carpal tunnel syndrome occurring during pregnancy is often treated wtih splints and occasionally diuretics. These drugs should be used sparingly. Carpal tunnel symptoms usually resolve after delivery.
When the above measures fail to relieve symptoms, surgical opening of the tunnel to relieve the pressure on the median nerve, known as a carpal tunnel release, is probably indicated. In severe cases, early surgery may be considered. If there is significant muscle atrophy, surgical release is indicated over more conservative measures. However, if the carpal tunnel syndrome is very severe and has been present a long time, even surgery may not work. The surgery may be an open surgical procedure or an endoscopic procedure, and can be often done on an outpatient basis.
I Was Just
Diagnosed With Arthritis and I Want to Keep Exercising
By
Nathan Wei
A proper exercise program should consist of stretching, strengthening, and non-impact or low impact aerobic exercises. Neglecting one of these components not only makes your program incomplete, it also may lead to unnecessary injury.
Patients should start out slow depending on their level of conditioning. People who are used to exercising can probably maintain and improve upon what they already have been doing while people who aren’t used to exercise may want to start out with 5 minutes a day and build up.
Proper stretching both before and after exercise is critical. Stretching improves flexibility and prepares stiff joints for the work out. Warming up is very important because this increases blood flow to muscles and helps reduce the possibility of injury to joints and tendons. Consult a physical therapist or an exercise physiologist about the proper stretches to do.
Working out should be done in the aerobic zone. Too vigorous a program can put you into the anaerobic range. This causes lactic acid buildup and also makes you prone to injury. The rule of thumb for a good cardiovascular workout is to get your heart rate to its target zone (subtract your age from 220. The target range is the heart rate that is between 40 to 70 per cent of that number).
Make sure you drink plenty of water. Adequate hydration means drinking an 8 ounce glass of water before you work out and then a glass of water every 15 minutes during your workout. After your workout you should continue to drink. This will help with blood circulation, removal of toxins from the system, and also helps with cooling down.
Make sure you don’t start your exercise until at least two hours after a meal. Otherwise you could be in for an uncomfortable time with abdominal cramps, nausea, and diarrhea as consequences.
If you’re using machines such as stair climbers, elliptical trainers, rowers, and such, make sure you use proper form. Leaning on the railings or not paying attention to proper posture robs you of the benefit of your exercise and also may lead to injury.
If you are flaring from your arthritis, you might want to skip your workout that day. Note: Don’t confuse the muscle soreness and mild joint pain you get after a workout with a major flare. They are different.
If you are lifting weights, always make sure you get some instruction from someone who knows what they’re doing first. Start out slow with lower amounts of weight. It’s better to use lower amounts of weight and do more repetitions than it is to use larger amounts of weight that your body is not used to. Use a spotter if you’re unsure of yourself.
Keep an exercise log. It’s a good idea for motivation to see improvement as you continue to exercise and begin to improve your fitness.
Doctor...I've
Been Told I Have Spondyloarthopathy...Spinal Arthritis - What Is It?
By
Nathan Wei
Spondyloarthopathy is a long word referring to a group of autoimmune inflammatory forms of arthritis that may affect the spine. Examples of diseases that fall into this category include Ankylosing spondylitis, psoriatic arthritis, reactive arthritis (Reiter’s disease), juvenile spondyloarthropathy, and the arthritis associated with inflammatory bowel disease.
Factors these diseases have in common are:
• They affect the
sacroiliac joints and the spine
• Other joints including the fingers and toes may become inflamed
• Increased family history of the disease
• Lack of rheumatoid factor
The HLA-B27 gene is markedly associated with this set of conditions. This is detected through blood testing.
The back pain associated with spondyloarthropathy has a few distinguishing features that separates it from mechanical back pain due to degenerative arthritis.
Inflammatory back pain cause extended morning stiffness- at least an hour or longer. The pain from inflammatory causes tends to come on after midnight and in the early morning. Exercise improves inflammatory back symptoms but makes mechanical back pain worse. The peak age of onset is usually 12-40 years for inflammatory spine disease and 20-65 years for mechanical.
One major distinguishing characteristic is the presence of enthesitis. This is inflammation where the tendons meet the bone.
Other areas that this type of arthritis may affect include the eyes (iritis), lungs (restrictive lung disease), heart (aortic valve disease, heart block), gut (inflammatory bowel), and skin (psoriasis).
Peculiar sausage shaped swelling of the fingers and toes can also occur. This is called dactylitis.
The inflammatory spondyloarthropathies are a progressive debilitating form of arthritis. The diagnosis must be established as early as possible so that aggressive treatment can be instituted. This group od disorders can be controlled and often may be put into sustained remission.
Doctor, Help Me
- How Do I Find Arthritis Pain Relief?
By
Nathan Wei
The first and most important activity a doctor must do when the patient comes in is to make an accurate diagnosis. This is done with a careful history, physical exam, laboratory tests, and imaging procedures.
In the history, we ask questions such as:
• How long have you had the symptoms?
• What joints are involved?
• Is it symmetrical? One side like the other
• Is there a family history?
• Are there other symptoms?
On physical exam, we examine a patient from the top of the head to the bottoms of the feet! We look at the skin, eyes, ears, nose, throat, internal organs, and finally the joints
The goals of treatment are straightforward. They are:
• Relieve pain/inflammation
• Enhance quality of life
• Slow disease progression
• Control co-morbidity (associated diseases such as high blood pressure,
diabetes, etc.)
• Minimize risks of therapy
We first start with non-medicine treatment:
• Social support: make sure the patient’s family
and friends understand the problem
• Education: make sure the patient understands all the things they must do
themselves to get better
• Weight-loss: many patients with low back pain, knee pain, and hip pain are
overweight. All the medicines in the world aren’t going to help until weight is
corrected.
• Assistive devices: splints, braces, walkers, canes, etc. all may help.
• Thermal modalities: ice or moist heat depending on the situation
• Exercise: non impact as well as stretching and strengthening play a role.
• Modification of lifestyle: sometimes habits need to change and routines need
to be altered.
Medicines:
• Analgesics: These help reduce pain. They don’t block inflammation. Analgesics
may be habit-forming or addictive. They offer the potential for side effects as
well. Examples: Tylenol, Ultram, Darvocet, Percodan.
• Anti-inflammatory medicines: These block inflammation and help with pain.
There is the potential for side-effects including the liver, kidneys, and
cardiovascular systems. Examples: Naprosyn, Motrin, Celebrex.
• Disease-modifying drugs: these drugs slow down the progression of arthritis.
They are used in conjunction with analgesics and anti-inflammatory medicines.
Wxamples: hydroxychloroquine (Plaquenil), methotrexate, azathioprine (Imuran).
• Biologic therapies: these are lasers that target the immune abnormalities
found in many forms of arthritis. Examples: Enbrel, Humira, Remicade.
Specifically for arthritis related pain we also use medicines such as GABA stimulators such as gabapentin (neurontin) and pregabalin (Lyrica).
Lidoderm patches also help as do topical agents such as Myorx.
Sometimes injections of different types will be needed. These injections may be combinations of local anesthetics and glucocorticoid or they may consist of materials such as Botox. We have used the latter quite successfully in patients with neck and low back problems.
Doctor... I'm
Confused... Is There More Than One Type of Arthritis?
By
Nathan Wei
The term arthritis is derived from the Greek: “arthron” meaning “joint” and “itis” meaning inflammation.
It refers to more than 100 different types of arthritis conditions. These 100 different conditions pose special problems for both diagnosis and treatment.
Some of these conditions involve inflammation and others do not. Inflammation is the body’s natural response to injury or infection.
For an example of inflammation, take a simple scratch…your body automatically releases chemicals that cause fluids to accumulate and white blood cells to gather around the area of the scratch. As your body fights foreign substances and bacteria, inflammation…redness…heat…swelling…and pain occur at the sight of the injury.
In arthritis, unfortunately, this natural defense mechanism goes awry. Elements from the blood designed to fight infection and repair injury attack the body instead.
And, unless this inflammatory process is stopped, it will continue to attack the body and cause joint destruction.
So you can begin to see how treatments that just relieve the pain associated with the problem – but that do not completely halt inflammation – may not adequately treat this disease.
Getting proper treatment early on is important…because proper care can help sufferers lead more active and comfortable lives.
Let's examine some of these types of arthritis...
Osteoarthritis is the arthritis people think of as being associated with aging. osteoarthritis affects weight-bearing areas such as the spine, hips, knees, base of the thumbs, and feet. Genetics and mechanical factors also play a big role. Research is being done on medications that will slow down the progression of this disease.
Rheumatoid arthritis is the most common serious inflammatory form of arthritis. It affects roughly 1 per cent of the population and is the prototypical autoimmune form of arthritis. Because it may do most of its damage in the first year, early diagnosis and aggressive therapy is critical. Left untreated RA may shorten life expectancy by as much as 18 years!
Psoriatic arthritis is a potentially serious inflammatory form of arthritis that is often found in association with psoriasis. Because it may begin and progress insidiously, it can cause serious problems. Early diagnosis and aggressive intervention are recommended.
Polymyalgia rheumatica occurs in people after the age of 50 and presents with severe stiffness and aching in the neck, shoulders, and hips. Because it is very treatable, accurate diagnosis is needed. Because so many other conditions look like it, an accurate diagnosis is not always easy.
Ankylosing spondylitis affects the spine and the sacroiliac joints. Since it often presents with low back pain, it is often misdiagnosed. AS is very treatable; accurate diagnosis and aggressive therapy are advisable
Reactive arthritis is a form of arthritis that comes on after infections... the most common being types of infections being intestinal or genitourinary. Young adults are often affected. Appropriate medical treatment is very effective.
Gout is due to deposition of monosodium urate (MSU) crystals. In addition to joints, the kidneys are a big target of this disease. Dietary changes and medicines are very effective in treating this disorder.
Pseudogout is also due to crystals- deposits of calcium pyrophosphate or hydroxyapatite in most instances. Pseudogout may mimic other types of arthritis such as gout and rheumatoid arthritis. Further, it may coexist with other types of arthritis making it very difficult to diagnose.
Systemic lupus erythematosus is an autoimmune disease that affects many organ systems.
SLE most often affects women in the child-bearing years. Early diagnosis and management are necessary since this disorder is potentially life-threatening.
Polymyositis is an inflammatory form of muscle disease that is often associated with arthritis. Because it is a systemic condition that affects all muscles- including those that are responsible for the functioning of the heart, lungs, etc., careful examination and appropriate aggressive medical therapy are necessary.
Fibromyalgia is a soft tissue form of arthritis that is due to defective neurotransmitter function in the brain. Because these neurotransmitters are responsible for many sensory functions, patients with fibromyalgia present with bizarre symptoms. It is imperative that other forms of arthritis be ruled out first.
Lyme disease occurs as a result of infection with Borrelia burgdorferi. The organism is transmitted by a deer tick bite. Early recognition and antibiotic therapy is effective in most cases.
Doctor, Tell Me
The Truth About Fibromyalgia... Please!
By
Nathan Wei
Fibromyalgia is a common form of arthritis that is characterized by generalized aches and pains, chronic fatigue, non-restorative sleep, and often other symptoms that suggest multi-system disease. Important research findings have shown FM patients to have higher levels of Substance P- a neurotransmitter responsible for pain processing- and lower levels of somatomedin C and growth hormone, substances required for normal musculoskeletal health. Abnormalities involving the levels of serotonin, dopamine, nor-epinephrine, and muscle- related chemicals, adenosine and phosphocreatine have also been demonstrated.
Deficiencies in brain blood flow patterns as well as new genetic research indicating a mutation in the regulatory region of the serotonin transporter gene are unraveling some of the mysteries surrounding FM. Despite these exciting discoveries, a number of myths still surround this condition:
Myth# 1: “Only women get FM.” Actually more than 5% of patients are men and that number appears to be increasing.
Myth#2: “Only adults get FM.” Actually, FM probably begins in childhood. “Growing pains” may actually be a form of fibromyalgia. Approximately, two and one half per cent of children seen in a pediatric rheumatology clinic setting have FM.
Myth# 3: “FM is only a form of arthritis.” FM, while often presenting as a musculoskeletal syndrome, is a disorder that has its roots in central nervous system neurotransmitter dysfunction. This dysfunction leads to multi-system complaints. That is why FM patients often have breathlessness, palpitations, bowel and bladder symptoms along with aches and pains..
Myth #4: “FM is a wastebasket term for when a doctor doesn’t know what to call it.” This is the most damaging of myths. Patients with FM have a real disorder. While the science is lagging behind as far as providing specific commonly used tests that may assist in diagnosis, there are multiple stereotypical signs and symptoms that demonstrate true objective abnormalities and can help trained physicians identify patients who have FM easily.
Myth#5: “There is no treatment for FM.” Nothing could be farther from the truth. While there is no one individual treatment that works well for everyone, there are multiple treatments that are usually effective. Most people respond to a combination of therapies that include cognitive behavioral therapy, non-impact aerobic exercise, and medications. Other therapies that often help include; acupuncture, hypnosis, massage, chiropractic, tai chi, water exercise, nutritional supplements, and biofeedback.
Myth# 6: “Patients with FM should avoid exercise.” False! If done too quickly or vigorously, exercise can be painful. However, if a graduated program that allows the patient to ease into exercise and allows them to progress at an acceptable pace is instituted, exercise is actually a cornerstone of proper FM treatment. The key is proper technique and pace.
FM is a common problem. Patients should have hope because FM can be managed successfully. People who suspect they might have FM should be evaluated by a trained physician.
What the Heck
is Fibromyalgia?
By
Nathan Wei
The cause of fibromyalgia (FM) is unknown but theories pointing toward abnormal hypothalamic pituitary axis function or dysfunction of neurotransmitter pathways in the brain are currently popular.
Several studies have demonstrated different abnormalities in central nervous system functioning. Abnormal sleep studies showing alpha intrusion during delta (stage 4) sleep and a reduction of rapid eye movement (REM) sleep have been seen. In addition, abnormal SPECT scans have suggested lower blood flow to the thalamus and caudate nucleus in the brains of fibromyalgia patients.
Approximately 2 percent of the population has fibromyalgia. About 80 percent of patients with fibromyalgia are women. While fibromyalgia may occur as a primary condition, it is also a secondary condition, occurring in as many as 30 percent of patients with systemic lupus erythematosus and rheumatoid arthritis.
Patients with fibromyalgia complain of generalized pain affecting both sides of the body and both the upper as well as lower part of the body.
Pain tends to be aggravated by weather changes as well as by stress.
While patients will complain of subjective joint swelling, objective swelling is absent.
Sleep disturbance occurs in almost all patients. Complaints of chronic fatigue and non restorative sleep (feeling as if they haven’t slept) are common. Sleep apnea may aggravate the situation.
Tender trigger points are noted in all patients. A patient with 11 of 18 tender trigger points fulfills a major diagnostic criterion for the diagnosis of fibromyalgia. These trigger point tender areas are stereotypic meaning the same areas are tender in all patients with the diagnosis of FM..
Other symptoms include migraine headache, decrease in short term memory, cognitive dysfunction, blurred or double vision, hypersensitivity to sound and smells, shortness of breath, chest pains, palpitations, irritable bowel, irritable bladder, painful menses, painful urination, multiple drug allergies, multiple sensitivities to chemicals.
Laboratory testing will not be diagnostic. However, laboratory testing will help to exclude other conditions such as polymyalgia rheumatica, hypothyroidism, rheumatoid arthritis, systemic lupus erythematosus, etc., that might masquerade as fibromyalgia. FM is a diagnosis of exclusion so it is imperative that other possible causes of aches and pains are ruled out.
Imaging tests may also be helpful in establishing the presence or absence of FM.
Treatment must be individualized. Most patients will respond to a combination of non impact aerobic exercise (swimming, stationary bike, elliptical trainer), cognitive behavioral therapy, and medication.
Medications that have been found to be helpful include tricyclic antidepressants in low doses, muscle relaxants such as cyclobenzaprine, also in low doses, and selective serotonin reuptake inhibitors (SSRIs).
Other medicines such as gabapentin and tramadol may also be helpful.
How You Can
Beat Rheumatoid Arthritis Part 1: What is Rheumatoid Arthritis?
By
Nathan Wei
Rheumatoid arthritis (RA) is the most common inflammatory form of arthritis. It is characterized by inflammation of the synovial (joint) lining of multiple joints, usually presenting in a symmetric manner (meaning one side is like the other).
Early on, small joints such as the hands, wrists, ankles, and feet are involved. As the disease progresses, larger joints also are affected. Virtually, any joint can be involved.
Rheumatoid arthritis is an acquired autoimmune disease with a genetic predisposition. About 70% of patients have the genetic markers, HLA-DR4 or HLA-DR1.
Rheumatoid factors, which are antibodies to IgG, occur in 60-80% of adult RA patients. The level of rheumatoid factor in the blood seems to correlate with prognosis. it is now clear that rheumatoid factors exist in multiple forms and that the type of rheumatoid factor a patient presents with may indicate the type of course they will experience with their disease. The amount of rheumatoid factor also seems to correlate with disease severity.
The three abnormal factors that seem to be associated with the development of RA are an environmental trigger (the exact trigger is still unknown), genetic predisposition, and a hyper normal immune response.
RA affects about 1-2% of the population (2 million people) with a female to male ratio of about 3:1. Mortality in patients with RA is increased compared with the general population. Life expectancy is reduced about 7 years in men and 4 years in women.
The economic impact is staggering! Direct costs are $14 billion per year in the United States. After 5 years of disease, 27% of people are disabled. After 10 years of disease, 40 to 60% of people are disabled.
How You Can
Beat Rheumatoid Arthritis Part 2: How Does the Damage Occur in Rheumatoid
Arthritis?
By
Nathan Wei
The method by which rheumatoid arthritis causes damage is complicated and is still a somewhat controversial area. Here's what most experts agree on...
What happens is that various white blood cells including polymorphonuclear leukocytes, macrophages, plasma cells, dendritic cells, and specific lymphocytes called T cells and B cells become hyperactive and cause inflammation.
This inflammation leads to and is perpetuated by the production of chemical messengers, called cytokines. Cytokines are produced by macrophages, T cells, and B cells. These cytokines cause damage by attracting more inflammatory cells to the area, causing more cytokines to be produced. Cytokines promote the release of destructive enzymes that destroy cartilage and other tissues. The cytokines that seem to play the most important role are tumor necrosis factor (TNF) and Interleukin 1 (IL-1). Many other cytokines and cellular mechanisms are involved and this process is the subject of ongoing research.
As inflammation progresses, the synovium becomes swollen and takes on a life of its own.
At this stage it is called pannus and invades and destroys cartilage, bone, tendons, and ligaments resulting in joint deformity and loss of mobility. Some experts have compared the destructive potential of pannus to a slow-growing malignancy. Synovial inflammation causes joint pain, stiffness, swelling, warmth, and redness.
Rheumatoid arthritis effects are seen not only in the joints but in other organ systems as well including the eye, skin, heart, lungs, and peripheral nerves.
The presence of ongoing chronic inflammation has been the subject of recent investigations pointing to an increased risk of cardiovascular disease occurring in patients with rheumatoid arthritis.
How You Can
Beat Rheumatoid Arthritis Part 3: What Are the Symptoms?
By
Nathan Wei
Patients presenting to the rheumatologist are asked questions designed to elicit specific information. Since there are more than 100 different types of arthritis, it is important to get a good, accurate history of symptoms.
The most common symptoms are morning stiffness, joint pain and swelling, nodules under the skin in about 20% of patients, and fatigue.
The duration of morning stiffness generally exceeds one hour and often extends all day. Stiffness during the day may also occur if a patient sits for any length of time.
Joint swelling and pain affects both small as well as large joints in a symmetric fashion. Early on, small joints such as the hands, wrists, and feet are affected. As the disease progresses other joints become involved as well. Because patients vary in terms of pain tolerance, it may be necessary to ask relatives about a patient's pain symptoms. Questions regarding their ability to perform activities of daily living can provide valuable clues.
Fatigue is often profound and debilitating.
Since rheumatoid arthritis is a systemic illness it can lead to damage involving the brain and peripheral nervous system, skin, lungs, heart, and eyes.
Further, treatment with many of the medicines used in rheumatoid arthritis can lead to side-effects that affect the gastrointestinal system, the lungs, heart, and bones.
The course of RA is variable but progressive if untreated.
Causes of death include infection, malignancies, and vascular disease. There is some evidence that atherosclerosis (hardening of the arteries) is accelerated and that certain cancers such as multiple myeloma and lymphoma occur more often.
How You Can
Beat Rheumatoid Arthritis Part 4: "I Want to Know How It's Diagnosed..."
By
Nathan Wei
When patients present to the rheumatologist they often have not yet received a definitive diagnosis. Because there are so many different types of arthritis that present in a similar fashion, the diagnosis is not always easy to make.
Despite all the high tech tools available today, the most important part of evaluating the patient remains a careful history and physical examination (see Part 3). Helpful diagnostic laboratory tests include the rheumatoid factor, erythrocyte sedimentation test (ESR), C-reactive protein (CRP), and more recently a new test called the anti cyclic citrullinated antibody (anti-CCP). One note of caution: the presence of a positive rheumatoid factor doesn't necessarily indicate the diagnosis of rheumatoid arthritis. Multiple other conditions can cause a positive rheumatoid factor. By the same token, roughly 20 % of patients with rheumatoid arthritis are rheumatoid factor negative.
Imaging procedures such as magnetic resonance imaging and ultrasound are helpful. Diagnostic x-rays are of limited use because significant damage can occur long before it shows up on x-ray.
The goals of management include: aggressive and early treatment, reduction of signs and symptoms, prevention of deformities, maintenance of joint function, control of co-morbidities (other associated disease such as hypertension, diabetes, etc., a patient might have), and possibly... cure. While this last option is still not quite achievable just yet, it is becoming more of a possibility.
In addition to medications, treatment of RA includes diet, exercise, joint protection, and occasionally joint surgery.
The approach to RA treatment has changed dramatically in the last 5 years. Future articles will discuss the current management of rheumatoid arthritis.
How You Can
Beat Rheumatoid Arthritis Part 5: "Putting It Into Remission"
By
Nathan Wei
The options available for treatment have expanded greatly in the last 10 years.
Non steroidal anti inflammatory drugs: These help to reduce pain and improve function. They do not have an effect on the underlying disease. Examples include ibuprofen, naproxyn, sulindac, etodolac, nabumatone, celecoxib, and meloxicam.
These drugs are effective but they have potential side effects including peptic ulcer disease, kidney and liver damage, rashes, and fluid retention. Another problem associated with these drugs is the slight increase in cardiovascular events such as heart attack and stroke. These drugs require careful monitoring.
Corticosteroids: These drugs suppress inflammation but also have no effect on the underlying disease. Examples include prednisone, methylprednisolone, and prednisolone. Used long term they may have undesirable side effects including ulcers, cataracts, osteoporosis, adrenal gland suppression, thinning of the skin, and diabetes.
Disease-modifying anti-rheumatic drugs (DMARDS): These drugs slow down the progression of rheumatoid arthritis. Examples would be medicines such as methotrexate, sulfasalazine (Azulfidine), leflunomide (Arava), hydroxychloroquine (Plaquenil), and cyclosporine (Sandimmune).
Most DMARDS act slowly.
The workhorse of DMARDS is probably methotrexate. All DMARDS have the potential for significant side-effects and must be monitored slowly.
Biologics: Most recently, biologic therapies such as etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade), and anakinra (Kineret) have helped tremendously.
These drugs target the cells and cytokines that are the primary cause of rheumatoid arthritis. These drugs work quickly. Etanercept, adalimumab, and infliximab are anti-TNF drugs. They block tumor necrosis factor- the major culprit in RA – and by doing so keep it from doing damage. These drugs have a slightly different mechanism of action from each other but they essentially all do the same thing. And they do it well. These drugs have revolutionized our approach to RA.
Rheumatologists are using this group of drugs earlier in the course of disease to hopefully prevent damage from occurring. There is also some evidence that early aggressive treatment may prevent some of the long term complications of rheumatoid arthritis such as lymphoma and cardiovascular events.
Potential side-effects of anti-TNF therapy include an increased susceptibility to infection, the reactivation of latent tuberculosis, and the development of lupus-like or MS-like syndromes.
Kineret, unfortunately, does not have the same salutary effect and is not used very often.
The second wave of biologic therapies are available and offers hope for patients who fail anti-TNF treatment. The two newest drugs are abatacept (Orencia) and rituximab (Rituxan).
Abatacept is a co-stimulatory blocker. This means it prevents T cells from being activated to produce cytokines. Rituximab is a B-cell depleter. It removes B cells from a patient’s system. B-cells are felt to play a big role in the development of RA by some experts.
Both drugs are given by intravenous infusion. Side effects include infusion reactions and rashes. The long-term consequence of B-cell depletion is still uncertain.
More biologic therapies are on the horizon. These new drugs may prove to be more effective and safer than what is currently available.
In patients with more severe disease, a procedure where blood is passed through a special filter (Prosorba column) may be of use. As one might guess, it is not used very often.
New Year's Tips for Arthritis
Sufferers
By
Nathan Wei
1. Start a goal setting program. Too few arthritis sufferers set goals correctly. Resolutions are easier to keep if they are framed as goals. Goals should be SMART (specific, measurable, attainable, relevant, and time bound). A goal without a deadline is just a dream. You must write your goals down. Consider using affirmations (repeating the goals to yourself out loud). Goals should be written down in the present tense, e.g., “It is March 1, 2006 and I have lost 10 pounds and look great and can fit into that size 6 dress again...” Use vivid mental pictures to see yourself attaining your goals. Do this every day. As you attain your goals, refine and reset them.
2. The period between Thanksgiving and New Years tends to become one long blur of food. So a resolution to go on a sensible diet is a must, particularly if you have arthritis in the low back, hips, and knees. Don’t try to do too much at once. Also consider getting tested for food allergies if you have problems with unexplained fatigue, muscle aches, and arthritis pain that doesn’t seem to respond to the usual measures. A good assay is available through Immunolabs.
3. Exercise is the other side of the weight loss equation since diet alone will not get it off and keep it off. The reason health clubs are packed in January is because people have made a resolution to get the weight off. Unfortunately, by April, the health clubs are back to their baseline volume of people because the resolutions have been broken. Why? –Most of the time it’s because people try to do too much and get discouraged. Or, they give up because they don’t see the miraculous results they were hoping for. Start slow with realistic expectations. This will help you get to where you want to be and will also help you avoid injury. People with arthritis should try to incorporate non-impact aerobic (swimming, stationary bike, elliptical trainer), stretching, and strengthening types of exercise. Make sure you get expert advice and also make sure you get your heart checked out before starting an exercise program.
4. Give thanks. Find a few minutes every day to be thankful for what you have. Even when you have arthritis, there are so many activities you can participate in.
5. Work on your relationships. Think before you speak. Whom do you love and who loves you? Are you hard on others... hard on yourself? If you treated other people like you treat yourself would they tolerate it? What would you say about yourself if you wrote your own obituary? What would you want to be known for? You certainly don’t want to be remembered as “Tom, the arthritis sufferer...”
6. If you haven’t got a diagnosis yet and have nagging aches and pains, for goodness sake see a competent arthritis specialist! Consider going on a comprehensive nutritional supplement like Complete Wellness Vitamins, a pure glucosamine/chondroitin supplement like Joint Food, and a dietary Omega-3 fish oil supplement like Sea Gold. Talk about your treatment with your doctor. Wonderful arthritis medicines exist and can make the difference between being miserable and being in control of your life. For mild pain, a topical agent like MyoRx can offer tremendous relief.
7. Pay attention to your general health. Work on stress reduction by finding a good hobby. Use a planner of some type to manage your time better. This will free up your mind up for more important things. Try yoga or tai chi. If you haven’t done it yet, get the following looked at: blood pressure, cholesterol, heart, colon, and for women make sure your mammograms and pelvic exams are current.
Resolve to make a difference. These pieces of advice hopefully will help you jump start your new year and make it the best ever.
A Medication
Guide for Arthritis Patients: Do's and Don'ts
By
Nathan Wei
Arthritis patients require relief from their pain. They also require direction when it comes to medications.
Since these patients are often seen by multiple physicians and are receiving multiple medications, clear and direct information about how to manage their medications is important.
Here are some useful tips.
Safety In the Doctor’s Office...
• Keep a list of medicines you are taking (Rx, OTC, herbals)
• Bring a list of your medications to show the doctor
• Describe bad medication reactions you have had in the past
• Understand what your medications are for and their effects
• Understand how to talk them (e.g., how many, how often, what to do if a dose is missed)
• Write down how to take your medications. Know the doseage!
• Double-check to make sure you have enough medications to last to next visit
• Understand what bad reactions might occur from your medications and when to call the doctor
• Don’t be afraid to ask questions or express concerns
Safety in the Home
• Ask family members to help you remember to take your medications
• Don’t run out of your regular medications
• Read the Rx label each time you take your medication
• Don’t take medications in darkness
• Follow the doctor’s directions – if not, tell the doctor why you are taking them differently
• Store medications out of reach of children – do not refer to medications as “candy”
• Avoid using someone else’s prescription medication
• Call your doctor if you think you are having a bad reaction to your medication
Doctor, I Have
a Lump on a Finger Joint... Could It be Arthritis?
By
Nathan Wei
Finger joint lumps and bumps can be disfiguring and a cause of great concern for the patient. Here are some potential causes.
Osteoarthritis, the most common form of arthritis, often affects the hands. When it does, it often causes local inflammation of the distal interphalangeal joints (DIP or last row) and proximal interphalangeal joints (PIP or next to last row). This inflammation causes the joints to swell and hurt. The lumps that form are called Heberden’s nodes (DIP) and Bouchard’s nodes (PIP). Involvement of the base of the thumb may also cause a lumpiness or squared-off appearance.
Gout also causes lumps in the fingers. Gout may cause inflammation of the interphalangeal joints of the fingers. When this occurs, it may be indistinguishable from a flare of osteoarthritis. Middle-aged (post-menopausal) or elderly women on diuretic therapy are particularly prone to developing this. Gout may also cause soft tissue lumps. The diagnosis is made by aspiration of fluid from the affected joint or soft tissue mass with examination of the aspirated material using polarizing microscopy.
Rheumatoid arthritis causes joint swelling involving the wrists, metacarpophalangeal (MCP) joints (knuckles) as well as the PIP joints. Inflammation may lead to lumpiness. Rheumatoid arthritis also causes rheumatoid nodules to develop in the finger joints. These nodules occur in patients with long-standing and severe disease.
Swelling of the tendon sheaths in the palm of the hand may occur with different types of arthritis. This occurs because the tendon sheaths are lined with synovial tissue which may become inflamed. When this happens, the tendon sheath may swell and become lumpy. Sometimes the fingers begin to trigger or catch.
Ganglion cysts can affect the wrist. These are usually painless swellings that have a soft squishy feel to them. The old treatment used to be smashing them with the family Bible. Fortunately, this method of getting religion is rarely used anymore. The ganglion may be aspirated and injected with steroid if painful. Sometimes surgery is required if very symptomatic.
Soft tissue swelling as a result of blisters and calluses are usually not difficult to diagnose.
Plant thorn synovitis is a relatively common problem that may occur in people who grow rose bushes. Here a thorn from a rose bush may break off in the joint and cause a localized inflammation of the finger joint. This condition often requires surgery for both diagnosis as well as treatment.
Infections of the finger joints are a cause of finger lumps and must be treated aggressively. Activities such as fist fights or animal bites may be precipitating factors.
Dupuytren's contracture is a condition presenting as a "lump" or nodule in the palm near the flexion crease, most often at the base of the ring or small finger. This lump or nodule may also occur at the base of the thumb.
A rare disease called histiocytosis may also cause lumps to appear in the distal row of finger joints. Diagnosis is made by biopsy. Treatment is usually symptomatic although in its severe forms histiocytosis may be treated with chemotherapeutic agents.
Painful lumps on the pads of the fingers may develop as a result of bacterial endocarditis. This disease is an infection of the heart valves. The bumps are termed “Osler nodes.”
Doctor - What
can I do about Carpal Tunnel Syndrome?
By
Nathan Wei
Carpal tunnel syndrome occurs when the median nerve, one of the major nerves that provides innervation to the hand, is pinched in the carpal tunnel. The carpal tunnel is a narrow space on the palm side of the wrist. The “floor” of the tunnel is formed by the wrist bones; the roof is created by a tough piece of tissue called the flexor retinaculum. If the carpal tunnel opening becomes constricted for whatever reason, then pressure is exerted on the median nerve. The patient will develop symptoms such as burning, numbness, and tingling in the hand involving mostly the thumb, index, third, and part of the fourth fingers. If the pressure continues without adequate treatment, then the ability to use those fingers to grip will also worsen.
The carpal tunnel can be narrowed as a result of trauma, edema (fluid build-up as occurs during pregnancy), repetitive motion, thyroid disease, acromegaly (growth hormone excess), gout, and various forms of arthritis (rheumatoid arthritis is the most common).
The diagnosis is suspected by taking a careful history. Further corroboration is established through a careful physical examination by a skilled clinician. Nerve conduction tests are also helpful for confirmation.
The initial treatment may consist of splinting as well as anti-inflammatory medications. Rest- staying away from keyboard work if this is what brought it on in the first place – is mandatory.
If symptoms persist, then a corticosteroid injection into the carpal tunnel using ultrasound needle guidance is a good option. Data indicates that this procedure may be very helpful in alleviating the symptoms. Patients who do not respond to injection and splinting are probably candidates for surgery. While most patients may be suitable for endoscopic carpal tunnel release, others may require open release.
What Food Can I
Eat If I Have Arthritis?
By
Nathan Wei
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.
My Doctor Tells
Me I Have Gout-What Can I Do?
By
Nathan Wei
Gout is a type of inflammatory arthritis triggered by crystallization of uric acid within joints. Gout is an extremely painful condition. It is often associated with other medical condition such as diabetes, high blood pressure, kidney abnormalities, and elevated cholesterol.
The onset of gout appears to be related to both genetic as well as dietary factors. Uricase, an enzyme that is required for digestion of uric acid, does not function in humans because of a defective gene. The combination of this crippled gene along with dietary intake of foods high in purines leads to elevated levels of blood uric acid.
Certain foods such as red meat, shellfish, peas, beans, lentils, and spinach are high in purine content. Interestingly, it is the animal derived purines (meat and shellfish) which tend to increase the risk for gout while the plant-derived purines do not appear to.
Alcohol, in the form of beer and red wine, is a definite trigger for gout. It increases the production of uric acid and blocks the excretion of uric acid by the body.
Acute gout tends to affect joints such as the great toe, foot, ankle, and knee. Occasionally the wrist and elbow may also be affected. A typical attack of gout begins in the early morning with swelling, redness, heat, and pain. The pain is so intense that even the weight of a bed sheet cannot be tolerated on the affected joint. Acute attacks are treated with non-steroidal anti-inflammatory drugs, colchicines, and occasionally steroids. Weight and diet control measures along with abstinence from alcohol are secondary measures.
Chronic gout, which is gout that has gone on for several years, may affect virtually any joint. Chronic gout causes a particularly severe deforming type of arthritis. Patients have large deposits of uric acid, called tophi, in the joints and under the skin. Patients with chronic gout require uric acid lowering therapy. Drugs like probenecid are usually effective in patients with normal kidney function so long as they are not already excreting large amounts of uric acid in the urine. If they are, then probenecid should not be used.
Allopurinol is the drug that the majority of people who require uric-acid lowering therapy go on. Unfortunately, while it is effective, it is also extremely toxic and must be used cautiously by experienced physicians.
A new drug, febuxostat, is currently awaiting approval by the FDA and will offer an alternative to allopurinol.
Lifestyle modifications should include weight control, limits on red meat and shell fish consumption, and daily exercise.
Patients should also have co-morbid conditions such as hypertension, elevated cholesterol, and diabetes addressed.
What's the
Scoop on Flaxseed and Arthritis?
By
Nathan Wei
Flaxseed – also know as linseed- comes from the flax plant (Linum usitatissimum). The seed contain lignans which are fiber-type ingredients. The seeds also contain omega-3 and omega-6 fatty acids.
Flaxseed may be ground into flour or meal. It is also available as capsules (1000 mg) and also as the oil which is generally taken as one to three tablespoons daily.
Flaxseed contains alpha-linolenic acid (ALA). ALA is a type of omega-3 fatty acid that is converted to eicosopentanoic acid (EPA) and docosahexaenoic acid (DHA) which are the active ingredients in fish oil. Because of the high lignan content, flaxseed is a good source of fiber.
While there are few conclusive studies confirming the beneficial effects of flaxseed in rheumatoid arthritis, it is known that omega-3 fatty acids have anti-inflammatory properties. Several uncontrolled studies suggest that flaxseed is helpful in reducing the symptoms of joint stiffness and pain.
Flaxseed has anti-coagulant (blood thinning) properties so that patients taking blood thinners (Coumadin, heparin, Plavix, Lovenox) or non-steroidal-anti-inflammatory medicines.
Flaxseed should also be avoided if a patient has a history of uterine or breast cancer or prostate cancer.
Flaxseed may have cholesterol-lowering properties. Since this effect has not been well characterized, patients are advised to use caution if there is a history of hypercholesterolemia or there is concurrent use of cholesterol-lowering medicines.
There are also claims flaxseed may lower the risk for cardiovascular disease. This may make it more appealing for people who have inflammatory forms of arthritis such as rheumatoid arthritis where the incidence and risk of cardiovascular disease is increased.
The fiber in flaxseed also can block absorption of some medications.
Doctor...
What's the Best Treatment for Arthritis?
By
Nathan Wei
Regardless of the type of arthritis, the goals of arthritis treatment are similar.
These include the following:
• Relieve pain/inflammation
• Minimize risks of therapy
• Retard disease progression
• Provide patient education
• Prevent work disability
• Enhance quality of life and functional independence
While the goals are similar they are achieved using different approaches depending on the diagnosis. The effective management includes a combination of conventional medicines, effective alternative treatments, changes in diet and food, rest, exercise, lifestyle changes (e.g., weight loss if needed), and joint protection.
Factors involved in decision making include the diagnosis, the severity of disease, and the patient’s response to previous therapies.
The decision making doesn’t end there either. As a patient is followed over time, things change. What initially was felt to be an effective arthritis treatment may no longer be effective...and side-effects may occur.
Additions and deletions of medications need to be considered. Drug interactions with other therapies are a concern.
Co-morbid conditions (other medical illnesses) enter into the equation. Newer therapies, when they arrive, may change the picture.
Patient preference, when it can be accommodated, should also be considered. And this dovetails with a patient’s lifestyle... The right therapy for a working man of 35 may not be the right therapy for a retired woman of 80. The correct arthritis treatment for a hard-driving executive may not be ideal for a laid back person who wants to use as many natural remedies as possible.
Finally, the ever-changing landscape of insurance issues plays a role... in my opinion, way too big a role in decision making. In fact, I feel patients should not- not ever- make a decision to see a rheumatologist based on whether the physician “participates in their insurance plan” or not. The reason is that insurance plans do not pay a good physician what they are worth. If you value your health enough to get better, to feel less pain, to avoid crippling, then you owe it to yourself to see the best specialist, not the cheapest, and not just the one who “participates in your insurance plan.”
Doctor...Why
Does Arthritis Cause Fatigue?
By
Nathan Wei
Fatigue is extremely common in patients who have arthritis. While it is a common complaint in patients who have “bread and butter” types of arthritis like osteoarthritis, it is even more common in patients who have inflammatory disorders such as rheumatoid arthritis and systemic lupus erythematosus. Fatigue is often a sign of a flare of disease.
Another condition often accompanied by fatigue is fibromyalgia.
There are many factors that may be responsible for fatigue.
Sometimes it is the body’s method for dealing with a chronic painful condition. The body craves rest because it uses so much energy to combat the pain.
Another common reason is that arthritis often interrupts sleep. Not only is it more difficult to get to sleep but patients will wake up during the night, they will have difficulty falling back to sleep, and they will awaken early in the morning. This early morning awakening may also signal the presence of depression which is also a common problem in patients who have arthritis. Depression is also a cause of fatigue in patients with arthritis.
A corollary to this is stress. Stress not only aggravates the pain of arthritis; it can also aggravate fatigue.
Patients with more serious types of disease may have anemia which compounds the fatigue problem.
Medications can also contribute to fatigue. For instance some patients who are on methotrexate often report a “washed-out” feeling that occurs for one to two days after taking their methotrexate dose.
Fatigue has a major impact on the life of a person with arthritis. It causes daytime sleepiness, difficulty concentrating, and limits interpersonal relationships. Participating in all types of activities becomes more difficult. Also, some people fall into a nasty cycle of feeling tired, taking a nap during the day, which prevents them from getting to sleep that night.
So what can be done?
The most important thing is to get the arthritis under good control. That often improves fatigue by itself. Effective medications often make a big difference!
Correcting anemia is another action step. Sometimes the anemia will correct itself when the disease is controlled. Other times iron deficiency or other problems need to be addressed.
Improving the quality of sleep can help. Changing to a mattress made of memory foam is reported by some patients to be useful.
Getting into a regular sleep cycle is a good idea. Avoid large meals and caffeinated beverages before going to sleep. Sounds like common sense but too many people don’t follow common sense rules1
Medicines that adversely affect sleep like prednisone and hydroxychloroquine (Plaquenil) should be taken in the morning rather than in the evening.
A nice hot bath or shower before going to bed sometimes is helpful. Using warm moist heating pads is also a nice thing to try. Getting into a regular relaxing routine that consists of reading, listening to soft music, etc. can also ensure good quality sleep.
Regular exercise is another contributor to good quality sleep. Lack of exercise often causes fatigue. Regular exercise provides more energy, increases stamina, and improves sleep.
Stress reduction is an obvious benefit.
Eating a well-balanced diet can also contribute to less fatigue.
Patients should try to avoid prescription sleeping pills if possible. Herbal remedies may be useful though.
Doctor, What's
The Best Type Of Exercise For Arthritis?
By
Nathan Wei
Patients with arthritis benefit from exercise. Numerous studies have documented the improvement in strength and endurance that people with arthritis have who regularly engage in exercise versus those that don’t.
A good exercise program combines elements of aerobic, strengthening, and stretching. So what is the single best type of exercise? The answer is “all wet.”
Water exercise appears to be the single best form of exercise for people with arthritis. The buoyancy of the water relieves stress on joints. Because of buoyancy, people with arthritis can improve flexibility, perform movements, and even do strength training without the impact these exercises would have on the joints on land.
The water temperature should be warm. The warmth creates a soothing environment for painful joints. The warmth also relaxes muscles and improves blood flow.
It’s important to get medical clearance from your physician before embarking on any kind of exercise program. A physical therapist can help design a good water exercise program for you.
Spend at least 10-15 minutes warming up and stretching before starting your exercise program.
Doing water exercise at least 3-4 times per week is best. Each session should last about 30 minutes or so.
Make sure you move the joints gently without sudden jerking movements.
Go through a full range of motion.
Start slowly. This isn’t a race. You can build endurance over time. As your fitness improves, you can consider other forms of water exercise such as jogging with a buoyancy vest, using water resistance paddles, and lap swimming, etc.
Always make sure a lifeguard is present.
Water exercise can also supplement a land exercise program.
Doctor... I
Have Rheumatoid Arthritis - Can I Drink Alcohol?
By
Nathan Wei
Rheumatoid arthritis (RA) is the most common chronic disease and the most common cause of crippling. RA affects roughly 2 million Americans.
The treatment of RA involves the use of two major types of medications. The first type is the anti-inflammatory group. These help with symptoms. The second type is the disease modifying group. These help slow the disease process down.
Both groups of medicines are metabolized through the liver. What that means is that it is not a good idea to use alcohol either heavily or chronically while on these medicines. In fact, many rheumatologists advise their RA patients taking methotrexate- one very common disease modifying drug- to avoid alcohol altogether.
Another issue is the increased rate of peptic
ulcers that can develop in patients taking non-steroidal-anti-inflammatory drugs
(NSAIDS). Concomitant alcohol use increases the risk of ulcers.
Now… what is the evidence to the contrary?
A recent Swedish study found that a copious dose of alcohol reduced the risk that mice would develop rheumatoid arthritis.
Lead researcher Dr. Andrzej Tarkowski, professor of rheumatology at Goteborg University said, "I wouldn't dare to do it (the experiment) in humans."
The mice were given a daily regimen of tap water supplemented with 10 percent alcohol. "That would do liver damage in humans," Tarkowski noted.
Tarkowski, published the findings in the Proceedings of the National Academy of Sciences (December 19, 2006).
Tarkowski was interested in the mechanism by which alcohol might help prevent rheumatoid arthritis, an autoimmune condition in which the body attacks its own joint tissue.
"We have shown that it goes through the up-regulation [increase] of testosterone," he said. "That down-regulates inflammation, which is part of the arthritic process."
“Test tube studies also show that alcohol increases the migration of white blood cells, which take part in the inflammatory process,” Tarkowski added.
In the experiment, male mice were given injections of collagen to induce rheumatoid arthritis. The researchers noted a significantly lower onset of disease and fewer destructive symptoms in mice who drank water with 10 percent alcohol added in, than in those who drank plain tap water.
Does this now give permission for RA patients to party hardy?
The study has very little application to humans in that it was a study designed to study possible RA prevention in male mice through testosterone modulation.
Since most RA patients are women, the results of the study probably aren’t useful for most RA sufferers. It might be interesting someday to look at possible RA prevention in men using alcohol but it’s entirely too premature to look at it now.
Tarkowski also alluded to the possibility of using acetaldehyde, a breakdown product of alcohol, in preventing rheumatoid arthritis. Acetaldehyde though is toxic and it would have to be used cautiously, if ever, in a human trial.
My advice is that it’s OK to have an occasional drink. In particular, there is evidence that red wine might have beneficial effects as far as cardiovascular risk, which is a real worry in RA patients who appear to have accelerated atherosclerosis as part of their disease. But do it in moderation.
Doctor
- Does Fish Oil Help Arthritis?
By
Nathan Wei
Fish oil has been touted as a remedy for a number of conditions.
Data from at least a few randomized double-controlled studies have demonstrated a beneficial effect of dietary fish oil in rheumatoid arthritis In fact, more than nine studies overall have shown statistically significant reductions in the number of tender joints. In many of these studies, patients were able to lower the amount of non steroidal anti-inflammatory medications and corticosteroids. One study suggested that combining fish oil with olive oil may enhance the anti-inflammatory effects of fish oil. (Kremer J, et al Dietary fish oil and olive oil supplementation in patients with rheumatoid arthritis. Clinical and immunologic effects. Arthritis Rheum 1990; 33:810-820).
Fish oil works by reducing inflammation. Scant evidence indicates it may retard progression of rheumatoid arthritis… although the effect, if it exists, is relatively mild.
Fish oil is a great source of omega-3 fatty acids which can reduce inflammation. Fish oil also lowers triglycerides and reduces blood pressure therefore protecting against cardiovascular disease as well. This is noteworthy because of the known increase in cardiovascular risk, patients with rheumatoid arthritis have.
It is difficult to get therapeutic amounts of fish oil by eating fish alone. Supplements are advised.
The type of fish oil is important. The oil should be derived from cold-water fish such salmon, cod, mackerel, halibut, tuna, and herring.
Fish oil comes in a variety of preparations. The most common is gel caps. Each gel cap should contain at least thirty per cent EPA/DHA, which are the active compounds. For rheumatoid arthritis about 2.6 grams of fish oil containing 1.6 grams of EPA should be taken twice a day.
A few words of caution. Patients on anticoagulant therapy with warfarin may notice their clotting times will bounce around. Pregnant woman may want to avoid eating cold water fish because of the danger of mercury toxicity. On a lighter note, burps often have a fishy taste and odor.
Doctor... What
About Exercise For Fibromyalgia?
By
Nathan Wei
The treatment of fibromyalgia (FM) involves a triple-pronged approach involving medication, cognitive behavioral therapy and exercise. Medications and cognitive behavioral therapy have been discussed in other articles. In this article we will discuss specific exercise regimens that may be helpful.
Because the pain of FM may increase with physical activity, many patients with FM become sedentary. This sedentary lifestyle is the start of a downward spiral that leads to deconditioning. Deconditioning then makes symptoms worse at rest and even minimal exertion becomes painful. It is critical to avoid deconditioning because once it occurs, the treatment of FM becomes much more difficult.
Exercise- the proper amount and type- may prevent this deconditioning. Types of exercise that have been evaluated in patients with FM include aerobic exercise, stretching and strengthening, and combined stretching, strengthening, and flexibility exercises.
Aerobic exercise consists of walking, biking, and pool-based forms of exercise. While walking is the most convenient form of exercise, the impact of walking may be too much for some people with FM. Low to no impact types of exercise such as a stationary bicycle, elliptical trainer, and swimming appear to be the best tolerated forms of aerobic exercise.
High intensity exercise where the heart rate is more than 150 beats per minute is poorly tolerated. This discourages the patient with FM and they usually stop exercising. This situation obviously should be avoided.
More moderate forms of aerobic activity where the heart rate is kept to about 55% to 70% of age-adjusted maximal heart rate is better tolerated. Exercise should start well below the capacity of the patient and gradually increase in duration to a goal of 30 minutes of moderate aerobic activity per day.
In our clinic we recommend that patients start with 2-3 minutes a day and increase as tolerated from that point.
Studies have also evaluated strengthening and stretching for FM. While there may be some benefit with these modalities, aerobic conditioning appears to be the type of exercise that has the most value.
As with all programs, treatment needs to be individualized. Some patients may benefit from stretching and strengthening along with their aerobic exercise.
Exercise, in conjunction with cognitive behavioral therapy and medications, works for the majority of motivated patients.
I Have
Fibromyalgia - Why Am I Sad In Winter?
By
Nathan Wei
Some people, and this number may actually be larger than once supposed, do not do well in the winter. They develop a severe mood disorder that has been referred to as seasonal affective disorder. SAD may be more common in patients already suffering from fibromyalgia.
Modell and colleagues studied 226 patients with SAD and found that it actually was a syndrome consisting of multiple symptoms (Modell, JG, et al. Biol Psychiatry. 2005; 58: 658-667.) These consisted of depression, fatigue, social withdrawal, anxiety, feelings of guilt, carbohydrate craving, insomnia, increased appetite, weight gain, and gastrointestinal symptoms. The onset of these symptoms may simulate a fibromyalgia flare. And in fact, there is very little difference from a clinical viewpoint. Symptoms begin in the late fall and continue through the end of March with January and February being the worst month for symptoms.
SAD is felt to be due to abnormal functioning of the pineal gland at the base of the brain. The normal circadian rhythm is regulated by the pineal. The pineal gland secretes melatonin in the evening and shuts off melatonin during daylight hours. Dysregulation of melatonin secretion, both in the amount as well as the timing appears to be the major glitch. Srinivasan proposed that the morning fatigue- non-restorative sleep- occurring with SAD could be due to prolonged melatonin secretion in the morning (Srinivasan V, et al. J Biol Psychiatry. 2006; 7: 138-151.)
Treatments for SAD should be familiar to fibromyalgia patients. The first involves use of a light box for 30 minutes in the morning. Theoretically, this should shut off pineal secretion of melatonin because of the light exposure on the eyes. A light box has to be high intensity emitting at least 10,000 lux. A variety of these “sun boxes” are available. They cost approximately $400-600. The light box should be used after consulting with your medical specialist. Careful adherence to instructions will help prevent eyestrain and headaches.
Alternatively, selective serotonin reuptake inhibiting medicines (SSRIS) may also be used. The drug that has been studied the most is Prozac. While usually well tolerated, it does have potential side-effects including palpitations, sleep disturbance, and loss of libido.
Melatonin taken in a small dose (0.1 mg) in the late afternoon may also be effective for SAD. This dose is small enough not to cause drowsiness but is enough to make the pineal gland reset the body’s biological clock. Since the usual over-the-counter dose is 3 mgs, a patient may need the help of a compounding pharmacy to be able to get the tiny 0.1 mg dose.
Combining the low-dose melatonin with a light box also seems to be effective.
Exercise is another treatment that is useful. Non impact aerobic exercise helps stimulate blood flow, increases energy, and stimulates endorphin production in the brain. All of these help with the fatigue and mood problems that occur with both SAD and FM.
Finally cognitive behavioral therapy should not be neglected. It is a cornerstone of FM care and also is beneficial for SAD.
Doctor...
I Have a Pain in the Neck - What Can I Do?
By
Nathan Wei
Neck pain is a common and costly medical ailment. Few studies of really effective medical treatments exist compared with those, say, for low back pain.
Many drugs used in clinical practice have been tried. Among those are nonsteroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressants, neuroleptic agents, and opioid analgesics.
While uncontrolled studies show benefit, controlled studies are lacking. So what has been shown to work so far? According to a recent study, there are only two medicines that have been proven to be effective. The first is intravenous methylprednisolone for acute whiplash used within eight hours for whiplash and the second is intramuscular lidocaine for chronic mechanical neck disorders. (Peloso PM, Gross AR, Haines TA, et al. Medicinal and injection therapies for mechanical neck disorders: a Cochrane systemic Review. J Rheum 2006; 33:957-967).
What is disheartening is that the usual treatments such as anti-inflammatory drugs and acetaminophen have been largely ineffective- at least according to this one large study.
Even epidural injections were classified as showing "limited evidence of benefit."
A number of interventions in this large study were ineffective. These include:
• Oral psychotropic agents
• Oral anti-inflammatory agents and oral analgesics
• Intramuscular injections of multivitamins.
• Nerve-block injections
In addition, several interventions were judged to have shown "moderate evidence of no benefit." These included intramuscular injections of botulinum toxin (Botox A), intracutaneous injections of sterile water, subcutaneous injection of carbon dioxide and melatonin.
So what can you do if you’re a patient?
First of all, remember that these studies that are published in the literature have flaws. They do not report the data from private practices. Also, many of the studies that are reported as being “negative” are done in large medical centers where there is already a built in bias that these treatments don’t work. It’s sad but true. A lot of academic doctors really don’t believe in treatment. They’d rather write negative papers.
Second, make sure you see a skilled rheumatologist... one who is skilled in the management of osteoarthritis and neck problems.
The things that might afford some relief in addition to the two described above are also- at least in my 25 years of experience are:
• Physical therapy for chronic problems
• Chiropractic for acute problems
• A neck support pillow
• Ice/ moist heat
• Gentle traction
• Exercises done under the supervision of a skilled therapist
• A soft cervical collar worn temporarily
• Epidural, nerve block, and soft tissue injections (despite what they say, I
think they work)
Doctor...Tell
Me about Boswellia and Arthritis
By
Nathan Wei
Boswellia is also know as Indian frankincense, salai guggal, and boswellin. The proper botanic label for boswellia is Boswellia serrata. It is derived from the resin of the bark of the Boswellia tree. While it grows in other parts of Southeast Asia, it is found abundantly found in the Indian subcontinent.
Boswellia is available in either pill or capsule form. The dose for most people is generally 300 mg to 400 mg taken three times a day.
For a product to be effective, it should contain at least 60 per cent boswellic acid. It is the boswellic acid that contains the active ingredient. A number of nutritional supplements now contain boswellia. Look for a reputable manufacturer.
The condition for which boswellia has had the most supporting evidence for a beneficial effect is arthritis.
The most convincing study was published in 2003 (Phytomedicine. 2003 Jan;10(1):3-7) when a research study examined thirty patients with osteoarthritis of the knee. Half of the patients received daily supplementation with 333 mgs of Boswellia. The other half received placebo. After the first intervention, washout was given and then the groups were crossed over to receive the opposite intervention for eight weeks. All patients receiving boswellia reported decrease in knee pain, increased knee flexion and increased walking distance. The frequency of swelling in the knee joint was decreased. Radiologically there was no change. The observed differences between drug treated and placebo being statistically significant, are clinically relevant. Boswellia serrata extract was well tolerated by the subjects except for minor gastrointestinal symptoms.
The conclusions were: “Boswellia serrata extract is recommended in the patients of osteoarthritis of the knee with possible therapeutic use in other arthritis.”
Other studies have demonstrated anti-inflammatory and analgesic properties. Diseases that have been studied where good results have been reported include rheumatoid arthritis, osteoarthritis, inflammatory bowel disease, and bursitis.
Is Aromatherapy
Effective for Arthritis?
By
Nathan Wei
Ever since Marcel Proust wrote about the ability to transport one’s emotions via smells in Remembrances of Things Past, the use of olfaction (smelling) stimulators has fascinated many people, including physicians.
One type of alternative medical treatment is aromatherapy. Aromatherapy is the use of essential plant oils either massaged into the skin, added to bath water, inhaled directly or diffused into the surrounding environment.
More conventional physicians are also beginning to look into the medical properties of aromatherapy in the treatment of diseases. There are more than 200 oils, which are often used in combination to treat different problems, including headaches and insomnia.
The essential plant oils are obtained from the flowers, leaves, stems, buds, branches, or roots. The oils are extracted through a variety of methods such as steam distillation or cold-pressing.
When an essential oil is inhaled, the molecules enter the nose and stimulate the limbic system of the brain. The limbic system influences emotions and memories and is complexly linked to other areas such as the adrenal glands, pituitary gland, and hypothalamus. Through these connections, it is possible to regulate heart rate, blood pressure, stress, memory, hormone balance, and breathing. The essential oils used in aroma therapy are then theoretically able to have physiologic effects that may alter emotions or pain perception.
Essential oils can be toxic when taken internally so they should only be administered under the guidance of a qualified professional.
Aromatherapy blends for the treatment of arthritis are usually made from pure essential oils, but also from hydrosols and -- more recently -- phytols. For application to the skin during massage they need to be mixed with vegetable oil, a cream base or a carrier lotion. Essential oils must always be used diluted when applied to the skin. A dilution of 3% essential oils in 97% base is generally regarded as very effective and safe.
Examples of some oils which have been used to
treat arthritis include:
Benzoin, Chamomile, Camphor, Cypress, Eucalyptus, Ginger, Juniper, Lavender,
Hyssop, and Rosemary.
Few well-controlled studies have been done to formally test aromatherapy in arthritis. One recent uncontrolled observation was made by an orthopedic surgeon in Japan.
Dr. Nobumasa Shiba, director of orthopedic surgery at the Tokyo Metropolitan Police Hospital, became interested in aromatherapy as an alternative treatment for osteoarthritis in knee joints, which occurs when the cartilage in the joint wears away. About 1 million people in Japan have the degenerative condition.
To test the effectiveness and safety of aromatherapy for patients, Shiba carried out an experiment on a group of patients with osteoarthritis of the knee. Thirty-six patients, aged 40 or older who had had physical symptoms for more than three months, were entered into the uncontrolled trial.
The thirty-six patients massaged lavender oil, effective for pain, and rosemary camphor oil, to improve circulation, into their knees in the morning and evening for two weeks.
More than 75 per cent of the patients said their symptoms, including pain, had lessened.
The uncontrolled nature of this study obviously makes interpretation suspect.
A form of aromatherapy used by thousands of people in the United States on a daily basis are menthol-based topical arthritis rubs.
Aromatherapy needs to be studied more intensely before it can be formally recommended as a standard treatment for arthritis. It does seem to help with symptoms in some people. There is no evidence it has any effect on slowing the progression of arthritis.
Doctor ... How
do I get Arthritis Pain Relief?
By
Nathan Wei
Arthritis is the most chronic joint disease and affects almost 70 million Americans. Arthritis symptoms include pain, stiffness, joint swelling, and sometimes fatigue. These symptoms can be so severe that they affect a person’s ability to perform such routine activities of daily living such as dressing and undressing, combing their hair, or opening jars.
So how does a person with arthritis get pain relief?
Here are a few important tips…
Exercise. Proper exercise is important. Low impact aerobic exercise increases blood flow to the joints. Strengthening exercises help to stabilize the joints. Range-of-motion exercises increase flexibility.
Rest. Just as important as exercise is rest. Properly cushioned, well-fitting shoe, canes, walkers, and braces are all methods to help rest joints. These devices should be used after consulting with a physical therapist to ensure that damage is not being done to the joint by excessive reliance on the assistive device.
Over-the-counter medicines are an option. Low doses of analgesics (such as acetaminophen) and anti-inflammatory medicines can help relieve the discomfort of mild arthritis. Topical agents such as capsaicin are also helpful. Proper and timely application of cold or heat can also be a tremendous aid for patients. Neither should be applied for longer than 20 minutes at a time and extremely hot or extremely cold applications should be avoided.
Weight control is essential. Even small weight losses can improve physical function and reduce pain.
So what do you do if you still hurt?
Arthritis treatment and pain relief often depends on the diagnosis. Different types of arthritis (and there are more than 100 different kinds) are treated differently. For most types of arthritis, though, there are some general principles that apply.
Prescription anti-inflammatory medicines or, as they are called, non-steroidal-anti-inflammatory drugs (NSAIDS) are often used to treat arthritis pain. Examples include Motrin, Naprosyn, Celebrex, and Mobic. While effective, they do have potential side-effects including allergic reactions, stomach ulcers, and cardiovascular risks. Nonetheless, they may help relieve pain tremendously.
Patients who have localized joint pain often benefit from steroid injections directly into the affected joint. A well-trained rheumatologist using ultrasound or fluoroscopy for needle guidance should be consulted. Patients with osteoarthritis (“wear and tear arthritis”) in the knees can get relief from hyaluronic acid injections. These are synthetic lubricants that are effective in relieving pain. Other joints also respond to this method of treatment.
Nutritional supplements such as glucosamine and chondroitin as well as a host of other supplements may also be useful. They are worth a try.
In patients whose arthritis has progressed beyond what medicines can do to help, surgical procedures such as arthroscopy (inserting a small telescope into the joint and removing damaged and diseased tissue) or arthroplasty (joint replacement) may be necessary.
I
Have Arthritis - How Do I Lose Weight?
By
Nathan Wei
Patients with arthritis, particularly osteoarthritis (OA), need to maintain weight at an ideal level. Ideal body weight is dependent on what your body mass index (BMI) is.
To calculate ideal body weight, here is how to calculate body mass index or BMI.
The formula is:
BMI = weight (in pounds) x 704 divided by [height (in inches) X height (in inches)]
Weight categories: BMI
Underweight <18.5
Normal 18.5-24.9
Overweight 25-29.9
Obese >30
Why is weight so important for arthritis? Studies have shown that overweight or obese women who lose about 11 pounds (2 BMI units) decrease the risk of having OA of the knees by 50 per cent. Gaining 11 pounds increases the risk of knee OA by 28 per cent.
While the correlation with symptoms is still uncertain, it seems clear that there is added stress on the body with excess weight.
For instance the force exerted on the hip and knee during walking is about three times one’s body weight. Overweight and obese people could conceivably be increasing damage to cartilage. Alteration of gait- the way one walks- would also have detrimental effects on the weight-bearing joints. Obese people do tend to alter their gait.
Some evidence suggests that obese people also have circulating hormones and growth factors that also could aggravate the development of OA.
Weight loss is simple… but not easy. Essentially you have to take in fewer calories than you use up. That means a combination of diet and exercise is what is required.
It may be as simple as avoiding high fat snacks and limiting portion size. Men over the age of 50 should reduce caloric intake to 1,800 calories a day while women over the age of 50 should limit their caloric intake to less than 1,400 calories a day. If this is combined with a moderate exercise program, weight should come off at a rate of 1 to 2 pounds a week.
Exercise is key. Exercise not only helps with weight control but it can also strengthen the muscles that protect joints. You should start slow but aim for 30 to 40 minutes 6 days a week as an eventual goal.
Aerobic exercise such as walking, riding a stationary bike, using an elliptical trainer or cross country ski machine may all be helpful. Swimming is another great form of exercise as is a rowing machine. (Avoid using a rower if you have low back problems.)
Weight training is helpful. And stretching should also be considered as an important component of any exercise program. Tai chi is a useful form of exercise for some people.
Doctor
- Does Acupuncture Work for Arthritis?
By
Nathan Wei
Traditional Chinese medicine has used acupuncture to relieve pain as well as to cure disease. During an acupuncture session, a practitioner will insert thin needles into the skin at any one of more than 2,000 carefully defined meridian points. The ancient theory of why acupuncture is effective is that needle insertion restores qi (life force) flow throughout the channels of the body. When qi is at optimal levels, there is harmony with the universal forces of yin and yang. This leads to improved health and relief of pain.
While the traditional acupuncture approach has been to use the needles by themselves, modern acupuncturists may rotate the needles or apply low levels of electric current to improve the effectiveness of the procedure. Sometimes acupressure is also given during the same session. Moxibustion which is the use of herbs that are burned during the procedure is also used. Some practitioners also use “cupping” which is a method where suction cups are applied to meridian points.
Theories as to how acupuncture relieves pain have included the “gate theory” which suggests that pain signals travel along neural pathways through “gates.” If a competing stimulus such as acupuncture needles, then pain signals are blocked.
Another theory has to do with endorphin release by the brain due to acupuncture stimulus. Another theory is that acupuncture helps produce analgesic neurotransmitters in the spinal cord.
One large study of acupuncture in osteoarthritis of the knee was performed at the University of Maryland. Researchers compared traditional Chinese acupuncture with sham acupuncture (using either retractable needles or real needles inserted into false pressure points). The study group consisted of 570 patients who reported limited benefits from anti-inflammatory medication and exercise.
The study demonstrated a statistically significant improvement in both pain measures as well as mobility measures in patients receiving real acupuncture versus sham acupuncture.
The authors concluded that “True traditional Chinese acupuncture is safe and effective for reducing pain and improving function in patients with symptomatic knee osteoarthritis who have moderate or greater pain despite background therapy.”
Some notes of caution. The effect of acupuncture in relieving pain is not huge. The effects are modest and do take time. The second issue is that the placebo effect undoubtedly enters into the equation.
An interesting study from Dr. George Lewith in Southampton, England used positron emission technology to demonstrate that brain blood flow was altered in a different manner with real acupuncture compared with sham acupuncture therefore validating the concept of a real pain modulating effect of acupuncture on the brain.
Unfortunately, acupuncture does take a long time to work. Dr. Hochberg from the University of Maryland states, “You really have to give acupuncture … six months in order to get maximum benefits from it.”
Another downside is the cost. Generally, the charge is anywhere from 60 to 100 dollars a session. Expect that it will cost about $2,000.00. Fortunately, some insurance carriers will cover the cost.
Acupuncture will not be a substitute for conventional treatment. You should use it in conjunction with your regular arthritis therapy. Make sure you see a licensed practitioner.
My
Doctor Says I Have Rheumatoid Arthritis And Fibromyalgia... Can I Have Both?
By
Nathan Wei
Fibromyalgia is a frequent cause for musculoskeletal pain. It is characterized by aching, stiffness, tender trigger points, and fatigue. Patients often complain of waking up feeling exhausted. They also state that they feel like they’ve “been beaten up.” Patients with fibromyalgia often have other symptoms such as decreased short term memory and hypersensitivity to environmental stimuli such as sounds, smells, and lights. Weather changes seem to aggravate the symptoms.
Fibromyalgia (FM) may either be primary, meaning it occurs by itself with no other underlying disease process being present. Or it may be secondary to or associated with other types of arthritis. For example FM is frequently associated with rheumatoid arthritis, systemic lupus erythematosus, and Lyme disease.
It is difficult to estimate what percentage of RA patients also have FM, since there are features common to both conditions. It is safe to say that during the course of RA, a patient will also have flares of FM. The distinction between a flare of FM versus a flare of RA may be difficult to make.
Rheumatoid arthritis is also characterized by aches and pains as well as fatigue. Weather changes also tend to cause flares or magnify flares.
Features that sometimes help are the presence of obvious synovial inflammation and elevation in laboratory measures such as the erythrocyte sedimentation rate or C-reactive protein. Magnetic resonance imaging and ultrasound may also be helpful in making the distinction between RA flare versus FM flare. Occasionally both conditions flare concurrently making the diagnostic confusion even greater.
Making the distinction between a flare of RA versus a flare of FM is critical. The treatments are very different.
Doctor, What's
this I Read About Trace Metals for Rheumatoid Arthritis... Will They Help Me?
By
Nathan Wei
A number of trace metals have shown anti-rheumatic effects. This article discusses some of these.
Zinc has been shown to inhibit the inflammatory response (Simkin PA. Treatment of rheumatoid arthritis with oral zinc sulfate. Agents Actions 1981;8:587-595).
As a result, it has been investigated as a possible treatment for RA. In one double-blind study, 24 patients with moderately severe RA, refractory to conventional therapy, were randomly assigned to receive zinc (50 mg elemental zinc three times daily in the form of zinc sulfate) or placebo for 12 weeks. Compared with the placebo group, the zinc treated group had significantly reduced joint swelling, morning stiffness, and improved patient subjective assessment of disease activity (Simkin PA. Oral zinc sulfate in rheumatoid arthritis. Lancet 1976;2:539-542).
However, in two other controlled studies, zinc was not significantly more effective than a placebo (Rasker JJ, Kardaun SH. Lack of beneficial effect of zinc sulphate in rheumatoid arthritis. Scand J Rheumatol 1982;11:168-170. Mattingly PC, Mowat AG. Zinc sulphate in rheumatoid arthritis. Ann Rheum Dis 1982;41:456-457).
Studies drawing different results and conclusions are not uncommon in rheumatoid arthritis. In one of the negative studies, the disease was more severe than in the study that produced positive results. It is highly likely that a trace metal like zinc is helpful only for mild or moderately severe RA. In addition, administration of large doses of zinc can result in a deficiency of copper, a mineral that may be even more important for arthritis than zinc (Abdulla M. Copper levels after oral zinc. Lancet 1979;1:616).
While the evidence does not indicate supplementation of zinc alone will produce great benefit, it is possible that combining zinc with copper and perhaps other nutritional treatments might be more effective.
Copper also has mild anti-inflammatory effects. Rats fed a copper-deficient diet had an exaggerated inflammatory response in two models of acute inflammation (Milanino R, Conforti A, Fracasso ME, et al. Concerning the role of endogenous copper in the acute inflammatory process. Agents Actions 1979;9:581-588).
The role of copper complexes as anti-arthritic
agents has been reviewed (Sorenson JRJ. Copper chelates as possible active forms
of the antiarthritic agents. J Medicinal Chem 1976;19:135-148).
Some studies have surmised that copper complexes of NSAIDs have greater
anti-inflammatory effect and are less toxic than the parent compounds. For
example, in animal models of inflammation, the copper chelate of aspirin was
active at one-eighth the effective dose of aspirin. Another interesting
phenomenon is that while NSAIDs lead to peptic ulcer, copper chelates of these
same drugs have anti-ulcer activity in animal studies. It has been postulated
that NSAIDs become active in vivo by forming copper complexes. If true, then the
ulcer causing effect of NSAIDs may be due to their tendency to extract copper
from certain tissues.
NSAID copper complexes have not been approved by the U.S. Food and Drug Administration. The long-term safety of administering copper complexes to humans has not been studied. An interesting theory is that perhaps supplementation with "nutritional" doses of copper (e.g., 2-4 mg per day) could increase the efficacy and reduce the toxicity of NSAIDs.
Copper bracelets have been claimed by some to be beneficial for arthritis. Most conventional doctors do not agree.
With that as background, a pilot study using copper bracelets was performed. A total of 160 individuals with arthritis, half of whom had previously worn a copper bracelet, were randomly assigned to one of two groups. Group 1 wore a copper bracelet for one month, and then a placebo bracelet (anodized aluminum resembling copper) for a second month. Group 2 wore the same bracelets in reverse order. Of those patients who noticed a difference between the two bracelets, significantly more preferred copper (p < 0.01) than placebo (Walker WR, Keats DM. An investigation of the therapeutic value of the "copper bracelet:" dermal assimilation of copper in arthritic/rheumatoid conditions. Agents Actions 1976;6:454-459).
Previous users of copper bracelets had their symptoms worsen during the time they were wearing the placebo bracelet. Interestingly, the weight of the copper bracelets fell by an average of 13 mg during the month they were being worn, suggesting that some copper from the bracelet may have been absorbed through the skin. One disturbing cosmetic side effect of some copper bracelets is greenish discoloration of the skin underneath the bracelet.
Obviously, further research is needed.
Some naturopathic practitioners prescribe 30-90 mg zinc and 2-4 mg copper daily as part of an overall nutritional program for RA. These supplements can cause nausea, particularly if taken on an empty stomach. Since taking large amounts of zinc alone may lead to copper deficiency, these minerals probably should be used in combination. There is no evidence that taking zinc and copper at separate times of the day improves their efficacy. Although studies on zinc as a treatment for RA typically used 150 mg of elemental zinc per day (as zinc sulfate), some doctors recommend lower doses of better-absorbed forms of zinc such as zinc picolinate or zinc citrate.
Selenium is also known to have anti-inflammatory effects (Roberts ME. Antiinflammation studies. II. Anti-inflammatory properties of selenium. Toxicol Appl Pharmacol 1963;5:500-506).
Serum selenium levels were significantly lower in a group of 87 patients with RA than in healthy individuals. The reduction in serum selenium was greatest among patients with the most severe disease (Tarp U, Overvad K, Hansen JC, Thorling EB. Low selenium level in severe rheumatoid arthritis. Scand J Rheumatol 1985;14:97-101).
In one double-blind trial, 15 women with RA received either 200 mcg selenium daily (from selenium-rich yeast) or a placebo for three months. Pain and joint inflammation were reduced in six of eight women treated with selenium, but there was no significant change in the placebo group (Peretz A, Neve J, Duchateau J, Famaey JP. Adjuvant treatment of recent onset rheumatoid arthritis by selenium supplementation: preliminary observations. Br J Rheumatol 1992;31:281-286).
On the other hand, selenium did not improve RA symptoms in another study (Tarp U, Overvad K, Thorling EB, et al. Selenium treatment in rheumatoid arthritis. Scand J Rheumatol 1985;14:364-368). The reasons for this dichotomy of findings are not entirely clear.
So. What's the bottom line? Trace metals have shown some interesting properties when used to treat patients with RA. Like all alternative therapies, they should be used with caution.
Holiday
Exercise Tips for People with Arthritis
By
Nathan Wei
Exercise is one of the cornerstones of comprehensive arthritis treatment. Components of a good exercise program include non-impact aerobic, stretching, and strengthening. During most of the year it’s setting a regular program is doable. During the holidays it’s more difficult. Whether you exercise outdoors or indoors, there are some important principles to adhere to.
Here are some useful tips for you to follow…
1. Consult your physician at least once a year to make sure your physical condition is stable enough for exercise.
2. Set realistic benchmarks for the holidays. You may be used to exercising daily or 5 days a week. During the holidays your schedule will be disrupted. That’s OK. Do what you can and don’t get frustrated.
3. Remember, it all counts. If you find yourself doing more shopping and walking around the mall, that’s OK. While it’s not the same workout as running or working out on the elliptical trainer or stationary bike, it’s still exercise.
4. This is a good time to assess the best use of your time. Most people find it more convenient to have the exercise equipment at home. This helps you avoid those trips to the gym. Why fight the traffic?
5. You may have to alter your usual routine. If you’re used to working out in the late afternoon, you may want to get up early and exercise if you know the family has plans for later in the day.
6. Sometimes you may have to break up your exercise into blocks. Instead of doing 45 minutes all at one time, you might want to do 25 minutes in the morning and 20 minutes later in the day.
7. If you need to drop the kids off at an activity, use the time that you’re waiting for them to go for a run or a walk.
8. Pencil it in. If you use a planner (and everyone should), pencil in your exercise time just like you would any important appointment.
9. Reward yourself. If you are able to do an extra good workout, let yourself have that extra piece of pie. You deserve it. But just one extra piece.
10. Vary your routine. Just like the rest of the year, alternate your workouts. Ironically, it may be easier during the holidays because you may have to substitute mall walking for the treadmill.
11. Take time out to rest. Pacing yourself is important. If you’re sticking to your exercise program, don’t forget to take some down time in the form of meditation or even a good old-fashioned nap!
12. Target your heart rate. Your target heart rate is 60 to 90 per cent of your maximum heart rate. Here’s how to calculate it. Subtract your age from 220. Multiply that number by 0.6 and 0.9. Exercise while keeping your heart rate (beats per minute) between those two numbers.
13. If you like exercising outdoors, be sure to stretch and warm-up before you go out; use layers (inner layer for perspiration absorption and wicking away of moisture- use synthetics like polypropylene or silk [UnderArmour or Coolmax make good choices]; middle layer for warmth [fleece]; outer layer to break the wind and keep out the cold); cover your head and make sure your hands and feet are well insulated; avoid hypothermia.
When you have arthritis it’s important to be kind to yourself during the holidays. Take good care of your body and it will take care of you.
What Are
Surgery Options For Osteoarthritis Of The Knee
By
Nathan Wei
Conservative approaches to osteoarthritis of the knee include non-steroidal anti-inflammatory drugs, good quality forms of glucosamine and chondroitin, physical therapy, corticosteroid injections, viscosupplementation (injections of lubricant into the knee), and bracing.
For people who do not respond to these measures, there are more aggressive approaches available. The first is arthroscopy. This is a procedure where small telescope is inserted into the knee. Using specialized cutting instruments, damaged and diseased tissue is removed and flushed out of the knee. For many patients this affords relief.
If the arthritis damage is limited to one side of the knee, an osteotomy (removal of a wedge of bone to help the bones of the knee line up better) can be a very good option. This procedure is best done in patients under the age of 60 who are active and who do not have severe inflammatory changes. The only disadvantage is that because bone is removed, it may make subsequent knee replacement surgery more difficult because there is less bone to anchor the replacement in.
Resurfacing is a procedure where a thin layer of the femur (upper leg bone) and a thin layer of the tibia (lower leg bone) are removed. A layer of metal is applied to the femur and a layer of plastic is applied to the tibia. Sometimes the back of the patella (kneecap) is also resurfaced. This type of procedure is good for people who only have a moderate amount of damage and who have relatively good bone stock.
A relatively new procedure is paste grafting. Here, a hole is drilled in an area of arthritis to expose bleeding tissue. A paste consisting of crushed up bone and cartilage cells is then placed in the hole and the patient is not allowed to bear any weight on the repaired knee for several months. The paste is supposed to promote regeneration of cartilage. Preliminary data is encouraging.
Cartilage plug grafting is a procedure used when there is a single localized defect in the cartilage of the femur. A plug of cartilage is removed from the intercondylar notch of the knee (a non weight-bearing area). The plug is then placed into the cartilage defect in the femur. While this is good for localized defects, it is not useful for large defects due to osteoarthritis.
Autologous cartilage implantation is a procedure where a plug of cartilage is removed from the intercondylar notch of the knee (a non weight-bearing area). The plug is then used to provide cartilage cells which are grown in a laboratory. The patient then undergoes a second surgery where the cartilage defect in the weight-bearing part of the knee is carefully debrided (cleaned), then a patch is placed over this defect and cartilage cells grown from the first harvesting procedure are injected underneath the patch. Cartilage cells then grow over a period of several months. This procedure is good only for isolated cartilage defects and not for generalized osteoarthritis of the knee. Patients must not bear any weight on the leg for at least six months.
Synthetic cartilage plugs can also be inserted. The plug is made of synthetic biodegradable material that permits the patient’s own cartilage cells to grow within the defect. This procedure is best used for younger patients (50 or younger) who have a localized defect. It takes several months for the plug to take hold.
Patients who have a damaged meniscus (cartilage cushion) due to arthritis can have a replacement meniscus donated from a cadaver source. These grafts can last about 4-5 years. The one danger is that the body may reject them.
Total knee replacement is a procedure where the end of the femur and the end of the tibia are removed and replaced with appliances consisting of metal capped with ceramic or plastic. Knee replacements last 12-15 years. A revision of this replacement may be required if the knee replacement is older than 15 years. Recent data indicates that a an exercise program instituted before surgery greatly enhances the chance of success.
If You Have
Rheumatoid Arthritis You May Want To Start Going To Indian Restaurants!
By
Nathan Wei
Folk and herbal remedies for arthritis are often found, after scientific scrutiny, to have beneficial effects. A recent study seems to support the role of turmeric as a spice that could help alleviate the pain and inflammation of rheumatoid arthritis.
Turmeric is the spice that flavors and gives yellow color to curries and other foods. It has been used for centuries by practitioners of Ayurvedic medicine to treat inflammatory diseases. Turmeric extract containing the ingredient curcumin is marketed widely as a dietary supplement for the treatment and prevention of a variety of disorders, including arthritis.
Janet L. Funk, MD and Barbara N. Timmermann, PhD, researchers at the University of Arizona, Center for Phytomedicine Research, set up a series of experiments to determine whether (and how) turmeric works as an anti-arthritic. They began by preparing their own extracts from the root of the plant and compared them with commercially available products.
Dr. Funk and her colleagues then tested in animal models a whole extract of turmeric root, only the essential oils, and an oil-depleted extract containing the three major curcuminoids found in the plant root.
Of the three extracts, the one containing the major curcuminoids was most similar in chemical composition to commercially available turmeric dietary supplements. It also was the most effective, completely inhibiting the onset of rheumatoid arthritis.
Dr. Funk states that, “This was the first study that has examined turmeric with the researchers' own prepared, well-defined extracts… the study represents the first documentation of the chemical composition of a curcumin-containing extract tested in a living organism… for anti-arthritic efficacy. It also provides the first evidence of anti-arthritic efficacy of a complex turmeric extract that is analogous in composition to turmeric dietary supplements.”
The significance, she explains, is that “translating the results of trials such as these to clinical use depends on accurate information about the chemical content and biological activity of the botanical supplements available for use. This work paves the way for the preclinical and clinical trials needed before turmeric supplements can be recommended for medicinal use in preventing or suppressing rheumatoid arthritis.”
Dr. Funk and her colleagues add, “This study also provides the first in vivo documentation of a mechanism of action -- how curcumin-containing extracts protect against arthritis.”
“We found that the curcuminoid extract inhibits a transcription factor called NF-KB from being activated in the joint. A transcription factor is a protein that controls when genes are switched on or off. Once the transcription factor NF-KB is activated, or turned on, it binds to genes and enhances production of inflammatory proteins, destructive to the joint.
The finding that curcuminoid extract inhibits activation of NF-KB suggests that turmeric dietary supplements share the same mechanism of action as anti-arthritic pharmaceuticals under development that target NF-KB. It also suggests that turmeric may have a use in other inflammatory disorders, such as asthma, multiple sclerosis and inflammatory bowel disease.”
In addition to preventing joint inflammation, Dr. Funk's study shows that the curcuminoid extract blocked the pathway that affects bone resorption. Bone loss associated with osteoporosis in women typically begins before the onset of menopause. Bone loss is also a feature of rheumatoid arthritis.
(Funk JL, Frye JB, Oyarzo JN, Kuscuoglu N, Wilson J, McCaffrey G, Stafford G, Chen G, Lantz RC, Jolad SD, Solyom AM, Kiela PR, Timmerman BN. Efficacy and mechanism of action of turmeric supplements in the treatment of experimental arthritis. Arthritis Rheum. 2006: 54 (11): 3452-3464).
Note: This story has been adapted from a news release issued by University of Arizona Health Sciences Center.
Author’s note: This study is interesting from at least three points of view. First, it confirms the effectiveness of an herbal supplement for adjunctive treatment of rheumatoid arthritis and provides information on a possible mode of action. Second, it gives credence to the use of turmeric in standard dietary supplement form for arthritis. Third, the bone loss inhibiting effect of turmeric is an important one given the magnitude of osteoporosis as a public health issue.
I, for one, am making reservations to my favorite Indian restaurant as soon as I can.
Am I At
Increased Risk to Develop Rheumatoid Arthritis Because I'm Car Mechanic?
By
Nathan Wei
A recent Swedish study seems to indicate that people who have occupational exposure to mineral oils, in particular hydraulic or motor oil, have an increased risk of developing rheumatoid arthritis by about 30%.
Berit Sverdrup and fellow researchers from the Karolinska Institute in Stockholm, Sweden, selected a group of patients diagnosed with rheumatoid arthritis (RA) between May 1996 and December 2003. They matched these patients with people of the same age, gender and residential area, who acted as controls. Shortly after they had been diagnosed with RA, the patients were asked to complete a questionnaire regarding occupational exposure to different types of mineral oils, such as cutting oil, motor oil, form oil, hydraulic oil and asphalt. The same questionnaire was sent to controls.
In total, the study included 1419 cases and 1674
controls. Only males reported high occupational exposure to oil, mostly motor
and hydraulic oil. A group of 135 men diagnosed with RA and reporting high
exposure, as well as 132 matching controls, was retained for further study.
The research results showed that men highly exposed to motor or hydraulic oil
have a 30% higher risk of developing RA than unexposed men.
Exposure only increased the risk of developing 'rheumatoid factor positive' (RF+) rheumatoid arthritis, a generally more severe form of RA. It didn't increase the risk of developing rheumatoid factor negative (RF-) rheumatoid arthritis. Exposure to oil is also linked to a 60% increased risk of developing ' anti-cyclic citrullinated peptide antibody positive' (anti-CCP+) rheumatoid arthritis. Anti-CCP is a more specific marker for RA than RF is. It may also represent a disease with greater severity.
This study confirms results found in animals - exposure to mineral oil had been shown to induce arthritis in rats -- and raises questions regarding exposure to other environmental or occupational agents. Exposure to environmental toxins may be linked to the development of certain kinds of arthritis. (Sverdrup B, Kallberg H, Bengtsson C, Lundberg I, Padyukov L, Alfredsson L, Klareskog L. Association between occupational exposure to mineral oil and rheumatoid arthritis. Results from the Swedish EIRA case-control study. Arthritis Research & Therapy 2005, 7:R1296-R1303)
Authors note: We still don't know what causes RA. However, studies like this are very intriguing.
How
Does Cold Laser Work For Arthritis?
By
Nathan Wei
Arthritis affects almost 70 million Americans. The most common forms of arthritis are osteoarthritis, a degenerative disease in which the cartilage wears away, and rheumatoid arthritis, which is an autoimmune inflammatory condition. Also, there are other conditions that fall under the "umbrella" of arthritis including bursitis, tendonitis, low back and neck pain, carpal tunnel syndrome, and so on.
The common symptom of most forms of arthritis is pain. Pain develops as a result of multiple factors including inflammation with stimulation of neural peripheral pain sensors due to either biochemical factors such as cytokines or to mechanical factors- joint deformity. Arthritis pain may be accompanied by other problems including loss of range of motion and disability.
While medicines, injections, and surgery all have their place and are valuable, there is still a need for potentially useful adjunctive modalities that might speed up recovery and reduce pain faster.
Low level therapeutic laser, better known as phototherapy, is a relatively new form of treatment. Its premise is that certain wavelengths of light have effects on living tissue. This effect is termed “photobiomodulation.”
Phototherapy has been shown in experimental settings to stimulate cell growth, increase cell metabolism, improve cell regeneration, induce an anti-inflammatory response, reduce edema, reduce fibrous tissue formation, reduce levels of substance P, stimulate production of nitric oxide, decrease the formation of bradykinin, histamine, and acetylcholine, and stimulate the production of endorphins. These effects are felt to be what reduce pain.
Most cold lasers in use today use a combination of light emitting diodes and infrared emitting diodes.
The beneficial effects of cold laser were first noted in wound healing in rats (Mester E, Spy T, Sander N, Tito J. Effect of laser ray on wound healing. Am J Surg 1971; 122: 523-535).
Subsequently, laser was found to be beneficial in a number of animal models and is till being studied as a possible tool for cartilage regeneration and healing (Lin Y, Chai CY, Yang RC. Effects of helium-neon laser on levels of stress protein and arthritic histopathology in experimental osteoarthritis. Am J Phys Med Rehab. 2004; 83: 758-765).
Data regarding the usefulness of cold laser on
different conditions seen in a rheumatology office include:
Rheumatoid arthritis and osteoarthritis (Brosseau L, Welch V, Wells G, Tugwell
P, de Bie R, Harman K, Shea B, Morin M. Low level laser therapy for
osteoarthritis and rheumatoid arthritis: a meta-analysis. J Rheum. 2000; 27:
1961-9);
Elbow tendonitis (Simunovic Z, Trobonjaca T, Trobonjaca Z. Treatment of medial and lateral epicondylitis- tennis and golfer’s elbow- with low level laser therapy: a multicenter double-blind, placebo-controlled clinical study on 324 patients. J Clin Laser Medicine Surg. 1998; 16: 145-51);
Fibromyalgia trigger points (Simunovic Z. Low level laser therapy with trigger points technique: a clinical study on 243 patients. J Clin Laser Medicine Surg. 1996; 14: 163-167);
Neck arthritis (Ozdemir F, Birtane M, Kokino S. The clinical efficacy of low-power laser therapy on pain and function in cervical osteoarthritis. Clin Rheumatology. 2001; 20: 181-184);
Carpal tunnel syndrome (Naeser MA, Hahn KA, Lieberman BE, Branco KF. Carpal tunnel syndrome pain treated with low-level laser and micro amperes transcutaneous electric nerve stimulation: a controlled study. Archives Phys Med Rehab. 2002; 83: 978-988);
Shoulder tendonitis (England S, Ferrell AJ, Coppock JS, Struthers G, Bacon PA. Low power laser therapy of shoulder tendonitis. Scand J Rheum. 1989; 18: 427-431);
Low back pain disorders (Tasaki E, et al. Application of low power laser therapy for relief of low back pain. Ninth Congress of the International Society of Laser Surgery and Medicine. Anaheim, CA. USA. November 2-6, 1991; Tuner J, Hode L. The Laser Therapy handbook. Prima Books. 2004. Sweden, p. 81).
Adequate clinical assessment is vital to determining whether a patient is a good candidate for laser therapy. Also, laser is a complementary therapy; it should be used in conjunction with other therapies as well. Concurrent medications, etc. should not be forgotten.
Phototherapy is FDA approved for a number of applications and has been deemed safe. It also requires relatively little time to perform. Established protocols and tissue dosages have been established that make clinical application relatively easy.
The number of sessions required varies according to disorder, length of time the disorder has been present, and the severity of the disorder.
Contraindications include pregnancy (use of the laser over the pregnant uterus), thyroid exposure, over a pediatric epiphysis, transplant patients, directly on an active cancer, on an are where there has been a recent (within 24 hours) steroid injection, or on the chest of a patient with a pacemaker.
While cold laser is considered by some to be unproven, it appears so far to be a safe, effective mode of therapy for many rheumatologic disorders and is worth trying before subjecting a patient to more invasive and dangerous procedures.
My Doctor Says
the Bump on My Elbow is a Rheumatoid Nodule... What's That?
By
Nathan Wei
Rheumatoid nodules are soft tissue lumps that occur in 20-30% of rheumatoid arthritis (RA) patients. They may be found almost anywhere on the body, but are most often seen in areas where there are bony prominences. These include pressure points such as the elbow, back of the forearm, and knuckles of the hand. Sometimes they may occur on the back of the head or Achilles tendons.
Nodules usually occur in chronic active cases of rheumatoid arthritis, and are commonly associated with more severe joint deformity and serious disease. People with rheumatoid nodules often have very high levels of rheumatoid factor in the blood.
At a microscopic level, these nodules often contain the same types of cellular infiltrates as seen in the joints.
Patients with very serious RA may have problems in other organ systems. These are referred to as extra-articular (outside the joint) manifestations. These extra-articular areas include the lungs, eyes, skin, heart, brain, and blood vessels. Nodules may vary in size during the course of the disease process. With increasing severity of disease, the nodules may increase in size and in number.
Complications of rheumatoid nodules include a number of problems such as:
• increased pain due to pressure phenomena
• limited joint mobility due to size and location of the nodules
• nerve damage due to location of nodules
• ulceration of the nodule leading to infection
• fistulas (draining channels) that connect the inside of the nodule to the skin surface. Fistulas can easily become infected.
• infection
Surgical removal is an option. Patients with
rheumatoid nodules tend to heal more slowly than people without the disease. As
a result, removal of nodules needs to be done carefully and the surgical wound
monitored carefully for dehiscence (reopening). In particular, patients who are
taking corticosteroids may be the ones who need to be monitored most carefully.
Nodules may also reoccur, particularly if they are located in areas where there
is repetitive pressure or trauma.
Steroid injections into the nodule may reduce the size of the nodule.
My Hand
Tingles - Could I Have a Pinched Nerve? And if So, What Can I Do About It?
By
Nathan Wei
Having a hand fall asleep and stay asleep with numbness and tingling is often caused by a pinched nerve.
The term “pinched nerve” describes a type of damage or injury to a nerve or set of nerves. The two most common problems that cause pain and numbness in the arm and hand are carpal tunnel syndrome and a pinched nerve in the neck.
Carpal tunnel syndrome is often associated with repetitive movements with the hand such as typing or factory line work. The most common symptoms are numbness in the first two fingers, pain at the wrist and loss of grip strength. The symptoms can also involve the whole hand and radiate up the arm, and they are usually worse with movement. Symptoms often wake a person up at night due to the position of the hand during sleep.
An unusual condition, entrapment of the ulnar nerve at the wrist, is usually the result of a space-occupying lesion such as a ganglion cyst, a lipoma, or ulnar artery aneurism. Repetitive trauma, such as operating a jackhammer, sometimes causes this condition. Nerve compression is more common in people with arthritis, alcoholism, diabetes, and/or thyroid problems.
Pain is not usually a symptom of ulnar nerve
entrapment at the wrist. Most patients report weakness and increasing numbness,
symptoms that may be the result of direct pressure on the outside edge of the
hand.
Depending on the location of the problem, ulnar nerve entrapment at the wrist
produces sensory and/or motor changes to the hand. The most common of these is a
tingling sensation over the ring and little fingers, as well as the loss of
sensation at the tip of the little finger. There may be signs of muscle atrophy,
or weakness of the muscles uses to spread the fingers apart.
A pinched nerve in the neck is caused by the nerve being compressed as it exits the spine. The problem is usually a herniated disc or a bone spur. The pain often shoots down the arm when the neck moves; it can also cause numbness and weakness.
Peripheral neuropathy is a general term for disorders of the peripheral nervous system. The peripheral nervous system is the network of nerves outside the central nervous system (the brain and spinal cord) connected to the spinal cord. Peripheral neuropathy is a common condition that can cause numbness and tingling. It can be caused by diseases of the nerves or by other illnesses. Diabetes is one of the most common causes of peripheral neuropathy. Other causes may include:
• Excessive alcohol consumption
• Nutritional deficiencies
• Infection or inflammation
• Overexposure to toxic chemicals, such as mercury or lead
• Tumors
• Rheumatoid arthritis
Nerve compression problems behind the elbow are called cubital tunnel syndrome. The ulnar nerve passes through the cubital tunnel which is a bony passageway. When you "hit your funny bone" and have tingling in the small and ring fingers, you are hitting the ulnar nerve at the cubital tunnel.
Treatment for a pinched nerve usually involves resting the affected area. Pain medication may be prescribed. Occasionally corticosteroid injections are used along with splinting and physical therapy. Sometimes changes in occupational routine will be recommended. In some cases, surgery is recommended. Carpal tunnel syndrome may be managed with either closed endoscopic nerve release or open release. Cubital tunnel is managed with open release. Physical therapy and splints or collars may also be used.
Treatment for peripheral neuropathy often focuses on treating the condition that caused it—for example, controlling diabetes or repairing a ruptured disk. Physical therapy may also be recommended.
Doctor - What
Kind of Exercise Can I do if I Have Knee Arthritis?
By
Nathan Wei
Interestingly, running has not been shown convincingly to be a risk factor for knee arthritis. Some studies have suggested an association but an equal number of studies have not. One of the best studies to date has shown that if you keep your mileage under 30 miles a week, the risk of osteoarthritis of the knee is pretty low.
That being said, once arthritis does develop in the knees, then other types of exercise should be considered. Now the purpose of this article is to discuss only the aerobic component of an exercise program. Patients with arthritis need to include aerobic, strengthening, as well as stretching in a comprehensive program.
One option is an elliptical trainer. While these are most often found in fitness clubs, they are available for home purchase and use. An elliptical trainer provides a movement that is midway between a bike and a stair-climber. The feet stay on the pedals and the movement is a smooth elliptical (oval) motion so there is no impact. Some models have attachments for a back and forth arm movement so that there is a total body workout. The angle of pedals as well as the resistance to pedaling can be adjusted. This provides an excellent cardiovascular, low-impact workout. The elliptical trainer is my personal favorite.
Another option is swimming. Swimming provides the best cardiovascular workout and is completely non-impact. The primary concern with swimming is that patients with shoulder problems may have more pain and aggravation of their shoulder symptoms with certain strokes. In addition, patients with low back arthritis may also notice their symptoms worsening with certain maneuvers. If your problems are only knee related, swimming is a great choice.
A stationary bike is another good form of aerobic conditioning. It is a no-impact workout. People with knee problems should use a very low tension and start out slowly. Otherwise worsening of knee symptoms can occur. Quad strengthening and hamstring stretching should also be performed if a stationary bike is used.
Cross-country ski machines are not quite as popular as they once were. And that’s too bad because this is a wonderful piece of equipment. This device provides a workout for both the upper as well as the lower body. The feet move in a back and forth gliding motion (make sure you get a good quality machine that moves smoothly rather than in a jerky fashion). No pounding or other impact accompanies this type of exercise. The attachments for the arms provide a brisk workout for the upper body also. Resistance can be changed for both the legs as wells as the arms.
One note of caution… people with low back problems should exercise caution since back symptoms can get worse.
Treadmills are also an alternative. For people with knee problems though, these may not be a good choice. There is impact. Very high end treadmills have a softer more forgiving deck. If you notice that the treadmill makes your knee pain worse, you’re probably better off using something else.
Stair-climbers are probably not a great idea. The reason is that the motion of bending and straightening the knee with loading from the rest of the body often times will hurt. This is particularly true for people who have significant arthritis between the patella (kneecap) and the femur (upper leg bone).
With all exercise equipment, it is critical to get clearance from your physician before embarking on a vigorous program. Also it is a good idea to use a heart monitor to make sure your heart rate stays within the range appropriate fro your age group. Obviously, a lot depends on the condition you’re in before you start.
Doctor... What
Can You Tell Me About the Arthritis Remedy, Limbrel?
By
Nathan Wei
Flavocoxid (Limbrel) is a new arthritis medicine that is considered both a drug as well as a food. It contains a blend of natural ingredients featuring flavonoids -- anti-inflammatory compounds that are more commonly found in foods such as green, leafy, vegetables, brightl colored fruits, soy, peanuts, cocoa and green tea. In clinical trials and in the real world so far, Limbrel has improved patients' arthritis symptoms including discomfort, stiffness and loss of mobility. It has been tested in osteoarthritis only and its benefits in other types of arthritis are unknown.
Patients may want to consider taking Limbrel to replace or reduce the amount of nonsteroidal anti-inflammatory drugs (NSAIDs) they take. This class of drugs includes pain relievers such as ibuprofen and naproxen, which ease arthritis symptoms but are associated with possible side effects such as stomach ulcers, gastrointestinal bleeding, liver toxicity, possible cardiovascular risks, and kidney damage.
Degenerative diseases are accelerated by abnormally low levels of chemical compounds such as flavonoids and antioxidants. The result is chronic inflammation which is a contributing factor to arthritis progression through the elevated production of inflammatory metabolites in the body.
Limbrel is designed to correct nutritional deficiencies, delivering arthritis-fighting antioxidants in a more concentrated and compact form than is usually possible with diet alone. Limbrel is comprised of the anti-inflammatory flavonoids baicalin and catechin, derived from the natural botanical sources Scutellaria baicalensis, Baikal scullcap and Acacia catechu. These have potent antioxidant action that may prevent the oxidation of free radicals that leads to some forms of inflammation. Taking Limbrel may help restore and maintain the balance of fatty acids in osteoarthritis, which in turn has the potential for reducing inflammation in two different pathways (cyclooxygenase and lipoxygenase) associated with arthritis. In contrast to the dual pathway effect of Limbrel, NSAIDs target only the cyclooxygenase pathway.
According to Primus Pharmaceuticals, the makers of Limbrel, the ingredients in Limbrel are "GRAS" or "Generally Recognized as Safe," meaning that they meet FDA standards for safe use in humans. Other GRAS ingredients include well-known nutrients such as folic acid, vitamin C and calcium, which likewise have therapeutic benefits. In clinical studies, Limbrel's side effects were no worse than placebo.
Long-term risks of Limbrel are unknown at this point.
Limbrel should not be taken with other NSAIDS. Limbrel can be taken with or without food, although some research suggests that taking it one hour before or after meals may increase absorption. If you are allergic to flavonoid-containing foods such as fruits, vegetables, nuts, cocoa, red wine or tea, tell your doctor before taking Limbrel.
Limbrel appears to be a safe alternative for patients who would ordinarily not be a candidate for an NSAID.
Doctor... Does
Gender Play a Role in the Prognosis of Rheumatoid Arthritis?
By
Nathan Wei
Women with rheumatoid arthritis (RA) have significantly less chance of remission than men, finds research published in the Annals of the Rheumatic Diseases. This appears in an online report published in December 2006.
The authors based their findings on approximately 700 adults who had been recently diagnosed with rheumatoid arthritis.
Their average age was 58, and they had had their disease for an average of six months. Two thirds of study participants were women, and they tended to be younger than the men.
After two years, the disease had gone into remission in just under four out of 10 study participants. After five years, the proportion in remission was similar, at 38.5%. But only around one in five were in remission at both time points.
Gender was a significant factor in the progress of the disease. At two years, just under a third of the women (32%) were in remission compared with almost half of the men (48%).
By five years, the gap had widened, with just under 31% of women in remission compared with 52% of the men.
Men were more than twice as likely to be in remission as women at both time points.
Women did not have more severe disease than the men initially, but it quickly became more severe and progressed more rapidly than it did among the men.
Differences in how long a person had had the disease, their age, or their drug treatment could not explain the discrepancy in remission rate, say the authors.
This gender difference for chance of remission is disturbing enough.
However, another potentially major issue is the marked increased incidence of cardiovascular events described in women with RA. Women with rheumatoid arthritis have high rates of non fatal heart attacks. This occurs even without traditional risk factors being present. (Solomon, et al. Circulation 2003; 107: 1303-1307). This complication adds to the concern regarding the long term prognosis of RA occurring in women.
There is some good news though. This study reports data from a large population of patients who experienced disease for a significant amount of time before the advent and use of the newer biologic therapies. It is quite possible that these drugs will change these statistics for the better. The ability to induce remission in both genders has improved dramatically.
Arthritis
Pain: Super Easy Natural Methods for Reducing Arthritis Pain Most Doctors Don't
Know About
By
Nathan Wei
While conventional arthritis treatments are extremely effective in controlling pain, they do present the possibility of devastating side-effects. Here are some natural treatments you might want to consider.
“This will only hurt a bit...” Urtica dioica is the stinging nettle plant. Descriptions of the use of the stinging nettle plant for arthritis dates back approximately 2,000 years to biblical times. Taken orally, products made from nettles may interfere with the body’s production of inflammation-causing chemicals specifically tumor necrosis factor-alpha (TNF-a). They may also enhance responses of the immune system. Chemicals in nettles are also thought to reduce the feeling of pain or interfere with the way that nerves send pain signals. All of these effects may reduce the pain and stiffness of arthritis and similar conditions. Another similar "treatment" is bee stings. Until recently, bee sting therapy was "pooh-poohed" by the medical establishment. It turns out they were wrong. Bee venom appears to have potent anti-inflammatory properties. In animal studies conducted last year, doctors in South Korea found that melittin, the principal peptide in bee venom, blocks the expression of inflammatory genes that can cause painful tissue swelling in rheumatoid arthritis patients.
“Drink your tea...” Recent research has shown that green tea contains polyphenols –chemical compounds that reduce the expression of a gene involved in the inflammatory response in arthritis. Black tea also may be beneficial.
“Be sure to take your vitamins, dear...” Vitamin C has been demonstrated to slow the loss of cartilage due to osteoarthritis, while a diet that is low in vitamin D has been shown to accelerate the progression of osteoarthritis. In a recent study, patients who had a diet high in vitamin D (or who took vitamin D supplements) reduced their risk for progression of their arthritis by 75%. Another study looking at more than 25,000 people concluded that a low intake of vitamin C can increase the risk of developing arthritis.
“Take two aspirin and call me in the morning...” A couple of ultra natural remedies are actually quite old. Willow bark contains salicylic acid, the key ingredient in aspirin. Boswellia has been used for centuries to reduce inflammation and pain and improve arthritis symptoms. A study showed that taking these 2 herbs is just as effective as taking drugs like ibuprofen.
“Tutti frutti...” Dark colored berries such as cherries and blueberries contain anthocyanins. These are potent antioxidants. An antioxidant, is any substance that, when present at low concentrations, significantly delays or prevents the oxidation of substrates. In other words... prevents the degenerative process. The best example of a degenerative process is osteoarthritis. Fresh berries are delicious as well. Another fruit source that helps with arthritis is grapes. Grape skin contains resveratrol, a natural compound that acts as a COX-2 inhibitor. Resveratrol both suppresses the COX-2 gene and deactivates the COX-2 enzyme, which produces inflammation. A study appearing in the Journal of Biological Chemistry confirmed that resveratrol acts as both an antioxidant as well as a COX-2 inhibitor. Options for getting your grapes include eating them, or drinking grape juice or wine.
Arthritis Tips
- How To Sit Comfortably If You Have Arthritis
By
Nathan Wei
Arthritis patients have a difficult time walking. However, they also can have a difficult time sitting as well. When you sit, the chair should be easy to get in and out of. The chair should allow your feet to rest flat on the floor when you are sitting all the way back in the chair. Allow the full length of your thighs to rest comfortably on the seat of your chair.
When sitting in achier, your feet should be supported at all times.
The chair back should give firm support so that your body maintains an erect sitting position. Armrests will help you stand up from the chair.
Avoid sitting in one position for too long since this will aggravate stiffness and pain. Change your position frequently.
At work your desk should be high enough to allow you to sit erect with relaxed shoulders. You should be able to reach your work surface with your forearms without having to lean forward or twist your body.
A computer keyboard should be at the right height that allows you to hold your elbows at right angles. These tips should not take the place of getting up and walking around every hour or so.
If your neck and shoulders get stiff, try a slanted table top that will raise your work surface to eye level.
Even your recliner should have a high back
extending to the top of your head to provide neck support. Consider placing a
small pillow behind your neck. The pillow should fit comfortably into the curve
of your neck and not push your head forward.. Armrests should be at a
comfortable height so that you don’t hunch your shoulders or slump to reach the
arm rests. The chair should make it easy for you to move and change your
position frequently so you don’t sit in one position for a prolonged period of
time.
Some people may feel more comfortable with a pillow or other support behind the
low back.
Getting out of a chair properly is also important. You should slide forward and place your feet a few inches apart and behind your knees. Place the palms of your hands on the arm rests or one the seat next to your thighs. Push down with your hands and legs, bending your head and upper body forward over your knees. Straighten your knees and back until you are erect. If you have a back problem, you should depend on your knees and not bend as far forward. Do not push with your knuckles. Use your palms and legs. Raising the seat height with cushions may be helpful.
Chair height can be changed using commercially available chair leg extenders.
How Do You
Measure Inflammation In The Blood If You Have Arthritis?
By
Nathan Wei
The body responds to inflammation by changing the production of protein in the liver and other protein producing organs in the body. Proteins whose blood levels are altered by inflammation are called acute phase reactants.
The two most common methods for measuring acute phase reactants are the erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP).
The ESR, or as it is sometimes called, the “sed rate”, measures the speed at which red blood cells settle or “sediment” in a narrow tube over a one hour period of time. The speed that the cells settle is directly proportional to the amount of acute phase reactant proteins that are present in the blood. Because inflammation increases the amount of proteins in the blood, the sed rate increases. This is because when proteins coat red blood cells, they sediment faster leading to an increased rate of red blood cell sedimentation.
Unfortunately, the sed rate is not specific and can be altered by other circumstances such as anemia or inappropriate specimen handling.
CRP changes occur more rapidly and return to normal more quickly than changes in ESR. CRP is also not affected by anemia nor is it quite as susceptible to specimen handling errors.
Measurement of acute phase reactants is important in arthritis disorders since elevations indicate the presence of inflammation while normal values indicate that inflammation is not present. Serial measurement of acute phase reactants is important for monitoring therapy in diseases such as rheumatoid arthritis, polymyalgia rheumatica, and giant cell arteritis.
The upper levels for both ESR and CRP are influenced by both gender and age.
Your rheumatologist will best be able to interpret these values.
Doc... I've
Got Severe Pain Between My Shoulder Blades - What's Causing It?
By
Nathan Wei
There are many causes of pain in the shoulder blades. Pain between the shoulder blades can occur as a result of mundane problems such as working at the computer too long without a break. Some causes though are serious and must be addressed immediately.
Here are some them:
Gall Bladder Pain
Sporadic pains in the middle of the upper abdomen, or just below the ribs on the right side are felt. The pain may spread to the right shoulder or between the shoulder blades. The pain can be accompanied by nausea and vomiting and sometimes excessive gas. The attack can last from a few minutes to two to three hours before getting better. The frequency and severity of attacks is very variable. Attacks can be triggered by eating fatty foods such as chocolate, cheese or pastry. It can be difficult to distinguish the pain from other diseases, such as: gastric ulcer, back problems, heart pains, pneumonia and kidney stones.
Neck source from arthritis or disc disease
This is a general pain located in the neck area
and may be associated with stiffness in the neck muscles. The pain may radiate
down to the shoulder or between the shoulder blades. It may also radiate out
into the arm, the hand, or up into the head, causing a one-sided or double-sided
headache. The muscles in the neck are tense, sore and feel hard to the touch.
Acute pain can give rise to abnormal neck posture in which the head is forced to
turn to one side; this condition is known as torticollis.
The pain at the base of the skull may be accompanied by a feeling of weakness in
the shoulders and arms. There may be a prickly or tingling sensation in the arms
and fingers.
Angina Pectoris
Angina pectoris derives from Latin and translates as 'tight chest'. It feels like a heavy, crushing pain or a constricting feeling in the center of the chest behind the breast bone (sternum) or on the left side of the front of the chest. The pain can radiate out to either one or both arms, more often the left. It can be experienced in the throat, jaw, the stomach and, more rarely, between the shoulder blades.
Angina is often brought on by:
• physical exercise
• psychological stress
• extreme cold
• a heavy meal.
Once these trigger factors stop, the pain generally ends quickly, usually within 2 to 10 minutes.
Liver Cancer
Liver cancer, an abnormal cell growth in the liver presents in two ways:
• Primary cancer means that the cancer started in
the liver
• Secondary cancer of the liver occurs when a cancer starts someplace else and
spreads to the liver.
The early warning signs of liver cancer:
A hard lump in the abdomen, below the rib cage on
the right side.
Discomfort in the upper abdomen on the right side.
Pain around the right shoulder blade, or pain between the shoulder blades.
Yellowish skin color (jaundice)
Abdominal swelling causing a feeling of fullness
Esophageal Cancer
Esophageal cancer appears as a tumor, or an abnormal growth of cells in the esophagus. The esophagus is the food passageway that connects the throat to the stomach.
Esophageal cancer usually does not cause any symptoms until the cancer has advanced to a stage that is too late for effective treatment. The main symptom is difficulty in swallowing food. There is a frequent sensation of food getting stuck in the throat or chest.
Signs of advanced esophageal cancer include:
Pain when swallowing.
Pain in the throat or back, behind the breastbone or pain between the shoulder
blades.
Decreased appetite and weight loss.
Hiccups with the feeling of food getting stuck in the throat or chest.
Vomiting and coughing up blood.
Aortic dissection
When the aorta, the major artery leading from the heart, tears, there can be sudden sharp pain in the spine between the shoulder blades. This is an obvious surgical emergency.
What's The
Best Way To Treat Osteoarthritis Of The Hand? Do The Europeans Know Something We
Don't?
By
Nathan Wei
Symptomatic osteoarthritis (OA) of the hand affects 20% of those people older than 55 years and has the potential for significantly affecting activities of daily living. Interference with grip and fine precision pinch and dissatisfaction with cosmetic appearance are major concerns.
Current evidence for the management of hand OA is currently based on either expert opinion or what appears to be effective for OA affecting other joints. However, the small size and accessibility of hand joints allow a different range of interventions than in large joint OA.
The European League Against Rheumatism (EULAR) is the American equivalent of the American College of Rheumatology. They formulated guidelines for OA of the hand at their annual meeting in June 2006.
The 11 recommendations were as follows:
• Optimal management of hand OA requires a combination of nonpharmacologic and pharmacologic (non drug and drug) treatment modalities individualized for each patient.
• Therapy of hand OA should be individualized based on the localization of OA; risk factors (age, sex, adverse mechanical factors); type of OA (nodal, erosive, traumatic); presence of inflammation; severity of structural change; level of pain, disability and restriction of quality of life; comorbidity (other concurrent diseases) and comedication (other concurrent medicines) (including OA at other sites); and patient wishes and expectations.
• All patients with hand OA should receive education concerning joint protection (how to avoid adverse mechanical factors) together with an exercise regimen (involving both range of motion and strengthening exercises).
• Local application of heat (with paraffin wax or hot pack), especially before exercise, and ultrasound are helpful.
• Splints are recommended for thumb base OA, as well as orthoses to prevent or correct lateral angulation and flexion deformity.
• Local treatments are preferred over systemic treatments, especially for mild to moderate pain and when only a few joints are involved. Topical non-steroidal anti-inflammatory drugs (NSAIDs) and capsaicin are safe and effective.
• Because of its efficacy and safety, paracetamol (up to 4 g/day) is the oral analgesic of first choice. It is the preferred long-term oral analgesic for patients who respond. (Paracetamol is an analgesic similar to acetaminophen).
• In patients who respond inadequately to paracetamol, oral NSAIDs should be used at the lowest effective dose and for the shortest duration, and the patient's requirements and response to therapy should be reevaluated periodically. Patients with increased gastrointestinal risk should use nonselective NSAIDs (eg., regular anti-inflammatory drugs like ibuprofen or naproxen) plus a gastroprotective (medicine to protect the stomach lining) agent or a selective Cox-2 inhibitor (eg., drugs like Celelbrex). In patients with increased cardiovascular risk, Cox-2 specific inhibitors are contraindicated, and nonselective NSAIDs should be used with caution.
• Symptomatic Slow-Acting Drugs for Osteoarthritis (eg, glucoasamine, chondroitin sulphate, avocado soybean unsaponifiables, diacerhein, intra-articular hyaluronan) may offer symptomatic relief with low toxicity, but effect sizes are small, suitable patients are not defined, and clinically relevant structure modification and pharmacoeconomic benefits have not been established.
• Intra-articular injection of long-acting corticosteroid (cortisone shots) is effective for painful flares of OA, especially at the trapeziometacarpal joint.
• Surgery, such as interposition arthroplasty, osteotomy, or arthrodesis, is effective for severe thumb base OA and should be considered in patients with marked pain and/or disability after failure of conservative treatments.
While these guidelines are useful, they are by no means comprehensive nor are they hard and fast rules.
In our clinic we have found many other types of therapy to be helpful. For instance, compressive driving gloves worn inside out so the seams are on the outside at night are helpful for reducing morning stiffness.
We advocate the regular use of therapeutic paraffin baths.
Steroid injections are very useful but should be done using ultrasound guidance to ensure accuracy.
Symptomatic OA at the base of the thumb that does not respond to injection with glucocorticoids can be treated arthroscopically with debridement followed by an injection of a viscosupplement. (Wei N, Delauter SK, Beard SJ. Arthroscopic debridement and viscosupplementation: a minimally invasive treatment for symptomatic osteoarthritis involving the base of the thumb. J Clin Rheum. 2002 Jun;8(3):125-9.
Finally, the role of the hand therapist is key in maintaining functionality in patients.
My Doctor
Wants Me to Participate in an Arthritis Clinical Trial - I'm Worried About
Placebo
By
Nathan Wei
Arthritis is the most common cause of crippling
and disability in the United States. It affects approximately 70 million
Americans- almost 25 percent of the population.
Clinical trials involving medicines for arthritis are valuable in that they may
eventually lead to a cure for this condition.
It has been demonstrated that the placebo response in arthritis clinical trials can reach up to 30-40 percent. That means that roughly one-third of patients receiving placebo will pronounce they are feeling better... or patients receiving placebo will feel that they are 30-40 percent better than they were before taking medication.
In any event, the placebo response has been derided by academic physicians as proving that a given therapy doesn’t work... and lauded by other physicians who feel that the placebo response should be harnessed. The latest study from Manchester is firmly in the camp of the latter group.
Research by the Human Pain Research Group at The University of Manchester suggests that people's responses to placebo vary according to their way of thinking.
Forty normal volunteers took part in an experiment funded by the Arthritis Research Campaign (the British equivalent of the American Arthritis Foundation) using an artificial pain stimulus, and were led to expect reduced pain after the application of a cream which was actually a placebo.
Lead researcher Alison Watson said: "Any medical treatment involves a placebo element; the psychological suggestion that it is going to work. So we theorized that a proportion of any treatment's effectiveness would relate to how much we wanted it to work, believed in it or trusted the person administering it.
"Doctors and nurses can transmit a lot of information about a treatment and its effectiveness through their words and gestures. We know that when people visit their preferred physician, the treatment or advice they receive will be more effective than that given by a physician they prefer not to see. Similarly, red pills have been shown to be more effective than green ones; so we wanted to test whether all this was due to expectations of successful treatment and trust in the person giving it."
Twenty-four of the volunteers initially received a moderately painful heat stimulus to both arms. The placebo cream was then applied to the skin, but they were led to believe that the cream on one of their arms may be a local anesthetic.
After the application of the cream, the intensity of the heat stimulus was turned down on one arm without informing the volunteer. Subsequently, the intensity was returned to its previous level, but - in contrast to the 16 people in the control group – 67 percent of the treatment group continued to perceive the heat as less painful.
Watson says, "The expectation of pain relief leads to a release of endorphins, the brain's natural pain killers, which is likely to contribute to a sensation of reward and well-being.
"Interestingly, there was an exact split in the range of responses to the placebo; a third of people reporting a reduction in the pain intensity in the "treated" arm only, another third in both arms and the remainder's intensity-ratings not being influenced by the application of the cream. The different responses can be related to the different levels of pain relief the volunteers expected, which may have allowed their individual suggestibility to influence their assessment of the pain experience.
"Our findings suggest that different individuals may have different styles of placebo response, which is likely to affect how they respond to real treatments too. Understanding these differences could better inform the way doctors and nurses provide treatments in the future.
"It could also facilitate more effective clinical trial design, which could substantially reduce the costs of developing new pain killers for patients with conditions like... arthritis.
"A further, exciting possibility is that we could develop talking and drug-based therapies to enhance people's response to placebos. The experimental methods we're using will allow us to test out such possibilities as a method of treating pain."
The response to treatment from a trusted
physician should not be underestimated. It suggests that the rapport a person
has with their physician is an important determinant of whether they will
improve or not.
It also suggests that patients who wish to participate in an arthritis clinical
trial should probably do so since they will often do better than they would if
they didn’t. The thirty-forty percent placebo response is significant.
Arthritis clinical trials also offer the benefit of free study related care so patients will benefit from cost savings as well. The testing during the course of arthritis clinical trials is valuable since it often uncovers health issue the patient was unaware of and may actually save their life. Finally, many clinical arthritis trials reimburse patients for time and travel which is another added bonus. Finally, clinical arthritis trials are often done by experienced and respected physicians... so your care will often be of much higher quality than it will be with a run-of-the-mill arthritis physician.
Going On A
Trip Soon - Here Are 17 Tips For Flying More Comfortably If You Suffer From
Arthritis
By
Nathan Wei
Travel can be exciting particularly if it is to a vacation destination.
Here are some useful tips for airline travelers with arthritis.
Prepare ahead of time. Make sure your agenda is set and that the proper travel arrangements have been made. Double check the airport flight times and triple check them the day before you go. Often, flight times can change at the last minute. If you can, print your boarding passes ahead of time. Most domestic airlines allow you to do this 24 hours before a flight. These measures will help reduce the stress of getting to the airport and finding out that your travel arrangements have been completely changed. Sites like Travelocity or other similar sites can get you the best fares and will also notify you of flight changes. While you’re at it, make sure your passport is up to date if you’re traveling abroad.
Find out through your travel arranger or through a guidebook a way to find an English speaking doctor should you need one. Carry your insurance information with you.
If you have an executor, let them know who your attorney is prior to your trip. It’s not the most pleasant thing to think about but you should make sure, in the event of a tragedy, personal and financial decisions are in writing.
If you are traveling to foreign countries, use a neck pouch to carry your important papers and money. You may be considered an easy mark for thieves if you carry your valuables in a regular purse. Since ATMs are available almost everywhere except for very remote areas, it makes sense to limit the amount of cash you carry around at any one time.
Make a packing list. Make a list of the clothes items, then a list of other things like your wallet, cash, planner, sunglasses, camera, etc. Remember that federal regulations will limit what you can take on board. This is particularly a problem when you take a number of medications.
Make sure your medicines are in properly labeled prescription containers so the TSA people don’t take them away from you. Do not put your medicines in your checked luggage! Ever!
If you think you need assistance, call the airlines and make sure they are aware you need a wheelchair. Most airlines are very accommodating. If you plan on doing a lot of walking and your arthritis affects your hips, knees, or feet, use a cane or walking stick. It will help a lot. While you’re at it, make sure to invest in well-cushioned, supportive footwear. Don’t economize here!
Make sure to get a note from your doctor if you have to travel with medicines like Enbrel or Humira that require a small cooler. This will speed your trip through security. If possible, check your baggage at the curb. It’ll save a lot of time. Also, if you have metallic joint replacements, get a note from your doctor; otherwise, your journey through security could be a very interesting one.
Use wheelie luggage carriers instead of a shoulder bag. A travel vest that has lots of pockets also is very useful for carrying around stuff that ordinarily you might have to use a bag for.
Travel on board an airplane can be a painful experience if you’re not prepared. Bring along a neck support pillow. The airline should also supply you with a small pillow you can use to support your low back. Get an aisle seat so you can get up and walk. Stretch. Do this as much as you can.
While sleeping on a flight is sometimes difficult, some rest is better than none at all.
The buttons to provide air conditioning or lighting are sometimes hard to reach and grasp. Again, don’t be shy about asking for assistance.
While we’re on the topic of buttons, Velcro fasteners are convenient, lightweight, and are a good idea for use with travel clothes.
Sometimes it makes sense to keep your carryon with you. When placed on the floor, it makes a nice footrest. You will have to stow it under the seat in front of you on take off and landing.
Drink plenty of water. This will help you with fatigue which is a problem for anyone, let alone somebody with arthritis. While current regulations don’t allow you to take bottled water from home on board, you can use a water bottle and fill it at a water fountain before getting on board.
If you need to store stuff in the overhead bins, ask for help. Don’t be shy. People are more than glad to help. The same goes for taking it out of the overhead bin.
Make sure that when you schedule your trip, you also schedule time for “rentry.” In other words, make sure that when you arrive home, you have created enough space so you don’t have to dive right back into work or other responsibilities.
How Can
"Electricity" Help Arthritis
By
Nathan Wei
What is considered an emerging area for arthritis therapy is the use of pulsed electromagnetic field (PEMF) therapy and electrotherapeutics. Termed, “electroceuticals”, PEMF are highly-refined electromagnetic fields that are now being used to non-invasively "kickstart" the body's natural anti-inflammatory response to treat pain and inflammation and help soft tissue wounds heal faster.
Numerous in vitro and clinical studies have demonstrated that electric and magnetic energy has a positive effect on connective tissue healing. This has prompted an extensive amount of research in orthopedics and rheumatology. While modern pulsed electromagnetic fields (PEMF) have been available for more than 20 years, they are only now becoming a standard of care for delayed union fracture treatment.
Electr