Articles on rheumatology

Rheumatology

Dr Aaina
A rheumatologist is an internist or pediatrician, who received further training in the diagnosis (detection) and treatment of musculoskeletal disease and systemic autoimmune conditions commonly referred to as rheumatic diseases. These diseases can affect the joints, muscles and bones causing pain, swelling, stiffness and deformity.Autoimmune conditions occur when the immune system sends inflammation to areas of the body when it is not needed causing damage/symptoms. These diseases can also affect the eyes, skin, nervous system and internal organs. Rheumatologists treat joint disease similar to orthopedists but do not perform surgeries. Common diseases treated by rheumatologists include osteoarthritis, gout, rheumatoid arthritis, chronic back pain, tendinitis, and lupus.Many rheumatologists also conduct research to find a cause of and better treatment of a rheumatic disease.How is a rheumatologist trained?A rheumatologist must complete four years of medical or osteopathic education followed by three years of residency training in either internal medicine or pediatrics. Some rheumatologists are trained in both. After residency, they must enroll in a rheumatology fellowship for two to three years to learn about chronic musculoskeletal and autoimmune conditions and their treatment.Rheumatologists then take a board examination to become board certified in rheumatology. This certification/exam has to be retaken every 10 years. Physicians are also required to participate in a certain amount of continuing medical education on a yearly basis.

FREQUENTLY ASKED QUESTIONS IN ARTHRITIS & RHEUMATISM

Dr. A N Roy, Rheumatologist
Q) What is Rheumatism?  A) Rheumatism is a popular term for Chronic Pain that applies to a variety of diseases that cause pain, stiffness and limitation of motion of joints, bones, tendons, ligaments and muscles. Q) Who is a Rheumatologist? A) A Rheumatologist is a specialist in treating the musculoskeletal disease (muscle, bone, joint specialist) .The role of the rheumatologist is to diagnose, treat and medically manage patients with Arthritis and other rheumatic diseases. Q) What is the difference between a Rheumatologist and an Orthopaedic Surgeon? A) A Rheumatologist is a specialist trained to diagnose, treat and manage various types of musculoskeletal problems. Surgeons who specialise in surgery of bones/joints are called orthopaedic surgeons.Q) What do Rheumatologist treat? A) Rheumatologists treat all forms of Arthritis, autoimmune disease, musculoskeletal pain disorders and osteoporosis. There are 100 types of those diseases, including Rheumatoid arthritis, Osteoarthritis, Gout, Lupus, Back Pain, Osteoporosis, Fibromyalgia and Tendonitis. Some of those are very serious diseases that can be difficult to diagnose and treat.Q) When should a patient consult a Rheumatologist?A) If the person is suffering from any of the below symptoms, he/she might behaving Rheumatic Diseases.Joint Pains and SwellingsSevere Point Pains and Stiffness in the morning.Severe back pain and Stiffness in the morning.Unexplained generalised body pains.Recurrent mouth ulcers/hair loss.Dryness of mouth/eyes, red rashes on cheeks.Recurrent heel pains.Prolonged unexplained fever after detailed work up by physicians.Wounds on skin not healing over a period of time, suspected to be due tovasculitis refereed by a surgeon/physician.Persistent problems regarding abortions referred after primary workup by aGynaecologist.Recurrent uveitis after primary work up by an Ophthalmologist.Unexplained pulmonary renal syndromes at primary care level. Q) Cause of Arthritis? A) Determining the cause of Arthritis can be difficult, because often several factors such as age, illness or infection, body weight, previous injury etc. contribute to an individual developing this problem. Q) Why me? Nobody in my family has it? A) There is a common misconception amongst people that arthritis runs in the family. This is always not true. It often arises sporadically without any family history. Q) Any Diet medication/restrictions? A) There is no scientific basis regarding food causing Arthritis, except gout, where patients are advised to have low purine diet and avoid alcohol, red meat , beans, mushroom etc. So No diet changes are required for most of these patients. Q) Does the climate influence Arthritis? A) Some patients find their Arthritis worsening in cold weather, while others during the rainy season. However, temperature/climate does not influence the course of Arthritis. Q) Can I walk, exercise, jog, or practice Yoga? A) Most Arthritis patients can walk, exercise or jog within reasonable limits. Yoga, in general, doesn’t ham Arthritis patients and can be carried along with other medicines. However, certain Yogic postures can be avoided as they may put excessive strain on the joints. It is best to consult a physiotherapist for this purpose. Q) Is Arthritis treatable? A) Yes, at present, there is treatment for the symptoms of Arthritis that help in managing pain and joint damage. These involve dietary changes, drugs, and in some cases exercise.

Unrefreshed Sleep+fatigue+body Ache+depression? It Could Be Fibromyalgia

Dr. Tanoy Bose, Internal Medicine
Haven't Heard of such a thing ever!I am sure that you have never heard of this term called FIBROMYALGIA. In fact a good lot of Doctors haven’t ever heard of the disorder and obviously majority of cases henceforth goes undiagnosed. Since, it is under the domain of Rheumatology, I find it comfortable to compose a few simple words regarding fibromyalgia in a FAQ format.So it goes like this1. What is this FIBROMYALGIA?In fact the question should have been set in the reverse format. Such as, “I am a person who was once quite active and energetic but since last few years I feel tired, fatigued, lethargic along with unbearable aches and pains all over my body especially over the mid and lower back, the arms and legs and lower abdominal pain. I feel quite down all the day and my sleep is not at all refreshing. I feel like sinking day by day and lack any form of initiative for doing day to day work. Even ample amount of rest do not provide any relief. Doctor, tell me what I am suffering from? Is it Vitamin D Deficiency, like other doctors have said or should I talk to a psychiatrist?”Well, the answer is, you are suffering from a condition where the pain threshold of your body is very low. That is even small non painful stimulus can elicit pain in your body. You are actually a pain sensitive person and there is no psychological issue with it, nor has Vitamin D got any business with it.This is called FIBROMYLAGIA, a condition where the entire human body system is perfect except the sensitivity towards pain. These people tend be too fragile to any form of stimulus which may in normal persons be non painful. Thus they tend to complain of aches and pain all over the body all throughout the day. Even episodes of anxiety and depression occurring in societal circumstances can evoke symptoms of disabling aches and pain. Since, the problem lies in the central pain processing mechanism of the nervous system, rests do not provide adequate relief. In fact one the classical feature of FIBROMYALGIA is unrefreshed sleep . Even after a good sleep at night , these people do not feel fresh after waking up in the morning and a sense of fatigue and lack of energy persists throughout the day.If the condition is unattended then it may gradually proceed to social withdrawal, mental depression, suicidal ideation and frank psychiatric disorders.2. Oh God! So the life seems to be doomed. Do we have any treatment or not? Am I supposed to be on lifelong medicines or it is a curable stuff??Mmmmm. Curable? I am sorry to say that your entire biology is built up to handle pain painfully. This sensitivity pattern is actually not completely acquired genetically. Scientists have proven that serious adverse life events, environmental factors and social factors together in varying proportions may cumulatively result in this disorder. Hence, cure is not there but indeed you can jump back to the peak of your life with proper management. So far as the medicines are concerned… well YES… I prescribe medicines so that people can ignore their aches and pains and sense of refreshment return back to their life along with added energy and vigour, but there are alternatives to medicines too.3. Wow… So How can you help me without any pills?Treatment without any medicines is called non-pharmacological therapy. Researchers after evaluating results of non-pharmacological manoeuvres over last 10 years have found that non-pharmacological therapy indeed outscores pharmacological [treatment by pills] therapy in many aspects. Non-pharmacological therapy has been categorised into three parts.i. Education ii. Psychological and iii. ExerciseWe will try to discuss in brief about these techniques in the following paragraph. Elaborate discussion is beyond the scope of this article.Educational TherapyEducational therapy is very simple modality of therapy. It consists of educating the patient regarding the disorder just the way I have detailed above. The sufferers need to know that the disorder lies in the pain sensitivity pattern and with appropriate treatment they can overcome the problems quite easily. In a word there should be plenty of positive thinking. Also, this is to be instilled in the mind of the sufferers that exercise do not aggravate the disorder if done in a scientific mannerPsychologicalThe major psychological therapy that has shown good results is the Cognitive Behavioural Therapy. Once again it has two parts. The Cognitive therapy consists of voluntary control of thoughts of a person so that the person starts thinking in a positive direction. An example of negative thought is “My pain is awful and there is nothing I can do about it” which by the help of cognitive therapy should be converted into” As bad as my pain might get, there are things I can do to make it at least a little better.” So this is an example of reinforcing the thought from a negative side to a more optimistic direction. This helps a lot in handling the pain problems and work excellent in tandem with medicines. Therefore, errors in thinking such as over generalizing, magnifying negatives, minimizing positives and catastrophizing are challenged and replaced with more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behaviour.The behavioural therapy includes involvement of two persons and it works in a format of forced change in behaviour of the person by the other which can be achieved in form of rewards or punishment. E.g. If you do not stop thinking negative, we are not going for the holiday this time--- an example of punishment. Or… If you stop thinking negative, we will be making this holiday abroad for sure--- an example of reward. In Fibromyalgia, a number of behavioural techniques are applicable including behavioural activation (getting patients moving again), graded exercise (initiating exercise, then slowly increasing activities), activity pacing (not over doing it on days patients feel good and remaining active on days they feel bad), reducing pain behaviours (not reinforcing behaviours associated with secondary gain), sleep hygiene (identifying then changing behaviours know to disrupt sleep), and learning relaxation techniques to lower stress (e.g., breathing, imagery, progressive muscle relaxation).ExerciseExercise has overall benefit on global well-being, physical function and pain and is currently recommended as the first step of a multimodal treatment strategy. Exercise may take a number of forms such as aerobic, strengthening, water, home based or group programs. Water exercise, or combined with education, is associated with improvements in both physical and emotional aspects of FM.Tai Chi is an exercise activity that combines both a physical and mental component and is ideally suited to persons with FM, with reports of improved function and quality of life When traditional yoga was compared to yoga combined with a yoga touch technique “Tui Na”, improvement was more sustained in the yoga group only Although FM patients often report poor exercise capacity, reduced cardiorespiratory fitness was similar to controls, suggesting that FM patients overscore their perception of exertion. In the absence of a single exercise program outperforming others, patients should be encouraged to choose an activity either land based or water, that is enjoyable, easy to follow, convenient and within budget in order to improve adherence.4. Wow… That means a complete change of lifestyle. I am very comfortable with Yoga and Pranayam. Please let me know about medicines. Do they actually help?That’s right. A complete change of lifestyle, positive thinking, generation of positive energy within and change of thought process and help you achieve more than half the goal. If medicines are supplemented , things may soon turn perfect for you. So lets discuss about the medicines and how they act and further, importantly, their adverse effects.The medicines are used to target the pain pathway. The basic treatment starts with PARACETAMOL and other pain killers commonly called NSAIDs. A few NSAIDs used in practice are Naproxen, Ibuprofen, Aceclofenac etc. PARACETAMOL can be taken at a maximum daily dose of 4Gms i.e. a tablet of 1000mg taken 4 times a day. The drug is practically side effect free drug but definitely it should be used with immense caution in patients who are chronic alcoholic, suffering from Liver disease and are taking medicines that can affect the liver. Otherwise, the medicine is so safe that one take it for an entire year. At low doses PARACETAMOL is used to treat fever and hence at doses of 500mg or 650mg, pain is unlikely to respond. Hence, for a pain killer effect, the dose should be at least 1000mg per day to 4000mg per day.Few patients may not benefit with PARACETAMOL alone in spite of a maximum dose. We often ask them to take NSAIDs for short duration, say 15 to 20 days. But NSAIDs are those pain killers who have their own battery of side effects e.g. gastritis, stomach ulcers, heart attack, kidney failure, cerebral stroke, rise in blood pressure etc. Once again they should be avoided in elderly patients who have got a chance to damage their kidney easily, cardiac patients as a heart attack may precipitate and kidney failure patients as it will worsen the kidney function.The next group of drugs are called the OPIODs. These medicines act at the central nervous system or in the brain and the pain processing centre at the high spinal cord area to suppress pain. They are safe but have a high risk of addiction. One classical example of OPIOD is Morphine and we are well aware that it comes under the category of NARCOTIC drug. Hence, its availability is a problem and its use is closely supervised. Another such OPIOD is TRAMADOL which is less addicting but shows effective pain relief. Often TRAMADOL is combined with PARACETAMOL in commercial preparations and they do well in quite a good number of patients suffering from Fibromyalgia. Although less, but TRAMADOL has a tendency to cause dependency. The important adverse effect of tramadol is nausea and vomiting and few patients tend to avoid this drug for this side effect.The next category of drugs is bit atypical. They are actually anti epileptics [Drugs used to treat Epilepsy] and Anti Depressants [Drugs that are used to treat low mood, lethargy, fatigue etc]. The most important of the anti-epileptic drugs is PREGABALIN. This medicine is approved for management of FIBROMYALGIA. The doses begin from 75mg once daily to a maximum of 300mg to 450mg in a day in divided doses. Pregabalin has shown excellent response in conjunction with exercise and behavioural therapy for management of FIBROMYAGIA. Although bit slow in onset of its action, Pregabalin can render good pain free life with alleviation of depression too, if the patient can tolerate. Now here lies the crux of the drug. This medicine is not free from side effects. Patients on PREGABALIN tend to suffer from dizziness, nausea, vomiting, unsteadiness of gait, increased sleep etc. I have seen patients developing these symptoms at doses as low as 75mg once daily but also I have witnessed patients who are comfortable at doses as high as 300mg in divided doses. Hence, there is a need of decision making and doctor patient trust while prescribing this medicine. I always make the patient aware regarding the possible side effects so that patients can identify the culprit drug. Another such anti-epileptic that have shown promising results is GABAPENTIN, which although has got the same bundle of adverse effects but patients seem to tolerate it much better.Among the anti-depressants the best results are obtained with drugs called AMITRYPTILINE, NORTRYPTILINE, ESCITALOPRAM, FLUOXETINE, MIANSERIN etc. Amtitryptilin is perhaps the most widely used drug and perhaps the most misused drug amongst the medical fraternity. Doctors tend to prescribe 10mg of Amtitryptiline at bed time to patients who often present with vague complains and this practice is actually unyielding in long term. Amitryptiline is given at a dose of 5mg to 100mg at bedtime depending on the patient’s tolerance and results. Once again, it is not free form side effects. Increased somnolence, dryness of mouth, rise in blood pressure, confusional state, hallucinations, retention of urine, cardiac rhythm problems etc are a few to mention. It is used at bedtime so that patients who do not have a good sleep can enjoy a satisfactory sleep and at the same time there will be quality results in management of depressive symptoms.Anti-depressants with lesser side effects are ESCITALOPRAM, FLUOXETINE , MIANSERIN which have used in variable doses in different patients with good results.5. Well, Although the discussion was worth a read but a few parts appeared Hebrew to me. Can you just summarise the whole story.Indeed. To summarise in a few points:A. Fibromyalgia is a disease of altered pain perception commonly found in middle aged females and is characterised by undue sensitivity to any physical or situational stimulus that manifests as Pain.B. Pain may be as a generalised body pain or may be localised at particular area such as low back, back of neck, legs, waist etc.C. It is characterised by sense of fatigue, lethargy, depression, aches and pains all over the body, lack of energy, poor sleep and sense of unrefreshed overnight sleep. There may be disturbing changes in mood and day to day performance in social life is greatly hampered.D. Patients with Fibromyalgia may sometime also have coexistent Migraine, Irritable Bowel Syndrome, Pain during Menstruation [Dysmenorrhoea] which are also a part of pain perception problem.E. It has often been noted that there is a history of serious psycho-social traumatic event that precedes the onset of the disease e.g. loss of near and dear ones, financial loss, mental stress, social issues etc.F. Behavioural Therapy and Positive thinking can help a lot in coping up with the problem of aches and painsG. Typically there is no definite cure for the disease but medicines can alleviate the symptoms and improve the quality of lifeH. PREGABALIN is an anti-epileptic medicine which is approved for treatment for Fibromyalgia. Anti-depressant drugs like Amitryptiline, Fluoxetine etc., work well in treating depressive symptoms of fibromyalgia. Fibromyalgia typically falls under the domain of rheumatology and the patients should consult rheumatologists for better management.

Build Strong Bones and Eliminate Knee Inflammation

Dr. Vishwas Virmani, Physiotherapist
There’s no doubt that remaining active is crucial for building and strengthening your bones. But if any part of your body is in pain – especially weight-bearing joints such as your knees – it’s pretty hard to keep moving.That’s why today we’re going to discuss the importance of avoiding knee problems, and easy ways to prevent and relieve knee pain, including a simple exercise you can do at home.Not All Exercise is the SameIf you’re a “Saver,” you know that not just any exercise will do when it comes to increasing bone density and strength. As I explained in the Save Our Bones Program, to really build bone, you need to engage in weight-bearing exercise that utilizes the effects of gravity on bones and muscles.When your knees hurt, though, doing such exercises is certainly difficult, if not impossible. Even getting in and out of a car or climbing a short flight of stairs becomes a painfully challenging task.The Importance of Healthy Knees for Your Bone HealthAll of your joints and bones are important, of course. But knees have a particular role in bone health because they are so central to weight-bearing exercise.Your thigh muscles are pivotal in maintaining the integrity of your knee joints. Walking, for example, is an excellent overall bone-strengthening activity, but it doesn’t target the specific muscle groups that stabilize the knee.A study from the University of Iowa showed a 50% decrease in knee pain in women who had the strongest thigh muscles in the study. Other muscle groups play a role in maintaining the knee joints as well.General Care of the KneesKnee pain does not have to be an inevitable part of ageing. I want to talk about some general tips for keeping your knees healthy, and then we’ll move on to a special knee-strengthening exercise that you can do right in your home.Keeping your hip and bottom muscles (the “glutes”) strong helps keep the pelvis at the proper angle. Strong bottom muscles align the hips and thigh bones (femurs), which in turn keeps the knee joints in proper alignment.Stretching is also important, because it keeps muscles limber and flexible. Muscles that are rigid can pull joints out of alignment, but supple muscles hold your skeleton in proper form and help absorb shocks.In our modern world, excessive sitting has become quite a health hazard. With regard to the knees, sitting weakens the outer hip and leg muscles while tightening up the inner thighs and groin muscles, creating imbalance. The knee, of course, is one of the main joints that suffer when this happens. Stretching the inner thighs and groin muscles helps even out the imbalance, especially when combined with strengthening the outer hip and leg muscles.Strengthening your core muscles also improves your knees’ integrity. It may seem odd that abdominal muscles would affect your knees, but they do. You see, when your abs are weak, your pelvis tends to tilt forward, creating a “sway back.” Strong abs “tuck” your tummy in and pull the bottom of your pelvis forward. Once again, it’s all about alignment; you can’t have healthy knee joints if the rest of your body knocks them off-balance.And now, I want to share with you an easy exercise to prevent knee aches and pains:The Knee CurlStand and hold onto the back of a chair.Lift your right leg straight out behind you, without pointing your toes.Bring your heel toward your buttocks as far as you can by bending your knee. Don’t move your hips, and keep the leg you’re standing onSlightly bent. Hold for one second, then lower to the floor.Repeat the movement 10 to 15 times.Switch legs and do 10 to 15 curls with the left leg. Then perform another 10 to 15 curls with your right leg. Finish by doing 10 to 15 curls with your left leg.
I chose this exercise not only because it is geared toward the knees, but also because it is typical of the moves you’ll find in the Densercise™ eBook System. You see, Densercise™ is designed with knee pain prevention in mind. You’ll find exercises that strengthen the thighs, core muscles, and knees without hard impact, such as:Step UpSide LungeChair DipsWall SquatsHeel LiftChair Knee LiftMountain Pose to Chair Pose and many more!You can do all these exercises right in your home – no special equipment necessary!

Top 5 Myths About Gout

Dr. Sharath Kumar, Rheumatologist
Myth no 1:- Eating vegetables such as tomatoes, lettuce as well as consumption of dal can cause you to develop gout. Actually though purines in these vegetables and dals can be converted into uric acid, research has shown that this generally does not happen inside the human body. In fact the american college of rheumatology, and arthritis foundation (USA) handouts regarding diet in gout clearly state that patients can have all vegetables as well dals as the only purines which are to blame for gout are animal purines. So enjoy those veggies without guilt. Myth no 2:- Gout can cause pain all over the body Gout is a very painful arthritic condition. It can cause pain in several joints and sometimes causes pain in areas outside the joint called bursae as well. However gout generally causes severe pain and swelling and redness in a single joint which lasts for one to two weeks . Since uric can be elevated in many people without gout (see Myth number 3) many patients who have pain due to other reasons when tested for uric acid are found to have high uric acid. Their pain is totally unrelated to the "normal elevated uric acid" (see Myth number 3) but unfortunately the uric acid gets blamed for their pain. Myth no 3:- A high uric acid causes pain High uric acid IN THE BLOOD is found in many people. However it is only when this uric acid exceeds a certain level (generally 6.5mg/dl) does the uric acid sort of spill out from the blood into the joints. Now uric acid when it first spills into the joints does not cause any problems. In fact scientist estimate that the uric acid has to be elevated and continue to spill into the joints and keep accumulating in the joints FOR ATLEAST 10 to 20 years to ultimately cause pain and swelling  in the joints. Uric acid goes up AFTER puberty in MEN and AFTER MENOPAUSE in women. Thus most men develop gout in their late 30s (puberty = 16 years + 20 years)  and in their late 70s in women ( menopause = 45 + 20 years ). During these 20 years when uric acid is accumulating silently without causing problems if you test the blood you may get a high uric acid in many people who do not have any problem. This is called asymptomatic hyperuicemia or "normal elevated uric acid". During this time you can have other problems causing pain which can be falsely blamed on uric acid.Myth no 4:- Once my uric acid has come down I can stop the treatment for gout. High uric acid in the BLOOD spills over and accumulates in the joint and causes gout as explained in myth number 3. Thus to treat gout and make sure you are cured of gout (see myth number 5) we need to treat the uric acid which has accumulated in the JOINT and not the uric acid in the blood. Thus a low uric acid in the blood does not tell us the level of the uric acid in the joints and may be a false reassurance. Hence patients should continue to take medications for their gout even when their blood uric acid is normal. They should trust their rheumatologist who will be scientifically estimate the uric acid in their joint better and them to guide them regarding how long and at what dose they need to take their medications. Myth no 5:- Gout is not curable This is the worst myth of all. I have had many patients who are scared to start medications since they feel that they will be on the medications life long once they start. However gout if treated properly it is a potentially curable disease. However since patients do not start medications and continue taking medications for a few years they have to live with decades of intermittent painful gout. In addition what is not known is gout can also increase your risk of developing heart disease and kidney failure. Thus even if you are superman and can bear the pain that gout brings, you will not be able to bear heart attack or kidney failure. So you should take treatment and cure gout. You owe that much to your body. 

Uric Acid and Joint Problems - Facts and Myths

Dr. Anuj Shukla, Rheumatologist
There is a lack of awareness and many myths related to uric acid and joint problems. This article is to increase the awareness regarding this topic in general public and among doctors.What joint problems can uric acid cause?The only joint problem related to high blood uric acid level is “Gout”Symptoms of Gout are episodes of severe pain, redness and swelling at the base of the great toe (Image). It can involve different joints in the foot and occasionally ankles and knees. The episode starts with severe pain in great toe base that increases rapidly within first 12-hours to maximum intensity. Pain and swelling that subsides gradually over a week or two, leaving behind the almost normal joint.In addition to joint problems, high uric acid is related to kidney stones and high blood pressure.You are more likely to get Gout ifYou have high blood uric acid levels (>7mg/dl)Are maleAre an older adultAre obeseYou are taking certain medicines to increase urine outputEat certain foods, like red meat and organ meat (liver)Drink alcohol and sugary drinks, like soda sugar-sweetened juiceHave certain health conditions, like kidney failure, high blood pressure, and diabetesHave had a kidney transplantWhat joint problems are not due to high uric acid?Uric acid related joint problems are not seen in young women and does not cause mild joint pain. Uric acid cannot lead to continuous joint pain and swelling for months (>45 days). Mild pain at the base with a gradual outward deviation of great toe over months to years is not due to high uric acid. Uric acid does not cause whole body pain. Uric acid also does not lead to lower back pain.How is gout diagnosed?Your doctor will diagnose gout based on your symptoms mentioned above and examination of joints. He may require X-rays, ultrasound, and sometimes joint fluid aspiration to confirm the diagnosis. Blood uric acid level is not necessary to diagnose Gout.How is gout treated?Treatment has two parts.  It starts with rest, ice pack application and use of painkillers to control the pain and swelling of the joint involved. Later in some patients medicines to decrease blood uric acid level below <6mg/dl are required. This medicines to lower uric acid levels once started needs to be taken regularly and will prevent further episodes of joint pain. Lifestyle changes like weight reduction, avoiding alcohol, taking water enough to avoid dehydrations also help to control gout.Do you need treatment for all high uric acid levels (>7 mg/dl)?No, there is no need to treat high uric acid levels that are not causing above joint problem or kidney stones.Treatment of high uric acid is required only in patients withRepeated attacks of Gout (described above)Patients with long duration kidney diseasesThose who have repeated kidney stones with high blood uric acidWhat diet precautions I should take if I have Gout?There is a wrong concept among doctors and public, that Gout patients should not take vegetarian protein diet for example pulses and whole grains. Uric acid and arthritis have nothing to do with high protein diet. Uric acid is the end product of purine metabolism and not protein.Diet to be avoided by patients with high uric acid and gout areNon-vegetarian diet for example red meat, liver, and kidney, artificially sweetened soda drinks and excessive alcohol intake. Most of the western literature recommends taking more of vegetarian sources of proteins, as they are low in purine. Increasing milk and milk products in the diet decreases blood uric acid.What if I don’t take any treatment for Gout?In the absence of appropriate treatment and care, over months to years, uric acid crystals get deposited in joints and can damage them forever. They can also get deposited below skin leading to multiple swellings in the body, medically termed as Tophaceous Gout.References for further readingRichette P et al. 2016 updated EULAR evidence-based recommendations for the management of gout. Ann Rheum Dis 2016;0:1–14.Neogi T. In the Clinics-Gout. Ann Intern Med. 2016;165(1):ITC1-ITC16.Jordan MK et al. British Society for Rheumatology and British Health Professionals in Rheumatology Guideline for the Management of Gout. Rheumatology (2007) 46 (8): 1372-1374.Khanna D et al. 2012 American College of Rheumatology Guidelines for Management of Gout Part I: Systematic Nonpharmacologic and Pharmacologic Therapeutic Approaches to Hyperuricemia. Arthritis Care Res (Hoboken). 2012 Oct; 64(10): 1431–1446.Khanna D et al. 2012 American College of Rheumatology Guidelines for Management of Gout. Part 2: Therapy and Antiinflammatory Prophylaxis of Acute Gouty Arthritis. 2012 Oct; 64(10): 1447–1461.

Living Well With Rheumatoid Arthritis

Dr. Dheeraj Kondagari, Rheumatologist
If you were recently diagnosed with arthritis or one of the other rheumatic diseases, you are not alone. An estimated one crore people in India of all ages and genders have arthritis or other rheumatic conditions. Many rheumatic diseases are chronic conditions. They are unlikely to go away. There may not be a cure for your condition, but effective management is available for most. Many people with rheumatic disease lead happy, satisfying lives year after year. You may be feeling anxious, even a little overwhelmed. This is a natural response to an unexpected turn in the road.How do you handle your very real concerns? By knowing the facts. First, the reality. With proper treatment, you can manage this condition and still have a good and productive life. There are numerous medications that have been proven effective and Rheumatology experts who will help. However, you also have to take control of the situation. That means making sure you get adequate exercise, ample rest and good nutrition. It also means learning about this disease and taking steps to address your own needs. The knowledge you acquire and the positive approach you take to your new lifestyle will make the difference between just coping with rheumatic disease and living well, despite your diagnosis. What is rheumatic disease?Arthritis and other rheumatic diseases are a family of illnesses that can cause inflammation (redness, swelling and pain), changes in the joints and pain in the surrounding structures.They also may make it difficult to do daily activities. In fact, there are more than 100 different rheumatic conditions including, but not limited to, osteoporosis, rheumatoid arthritis, gout, fibromyalgia, osteoarthritis, systemic lupus erythematosus, and scleroderma. While the symptoms may vary, as a rule, these conditions target the musculoskeletal system, including the bones, joints, muscles, and tendons that contribute to function. Some people also can have internal organ involvement or even more than one of these conditions at the same time. Therefore, it may take time for your primary care physician, rheumatologist, or other healthcare professional to determine your particular diagnosis and the best treatment approach for you. Your participation in this effort―and your patience―will make a substantial contribution to a successful diagnosis and your comfort levels.What can you do? Make your medical visit count!Plan ahead for your visits with your health care provider and, above all, communicate. Arrive with a list of your specific concerns. Consider bringing someone with you who can listen to the health care provider and take notes as appropriate. Respond to the medical professional's queries honestly and directly. Talk about your emotions, stress or discomfort if they are interfering with your lifestyle. Ask for a clearer explanation if you don't you understand any recommended treatment, including benefits, instructions and duration. Identify the team of medical professionals who will be of the most benefit to you. Initially,your rheumatologist, who has special training in the diagnosis and treatment of rheumatic diseases, will probably work closely with your primary care provider. Once you are diagnosed,a number of other medical care providers are available to help you manage your condition,Orthopedic surgeons, Nurse practitioners/physician assistants, Physical therapists, Occupational therapists, Pharmacists, Health educators, Psychologists. Make it a point to learn more about your medications. Rheumatologists only prescribe or recommend treatments to help patients manage their arthritis. The real key to living well with the disease lies with the patients themselves. Research shows that people with arthritis who take part in their own care fare much better. An important fact not shared openly by many doctors is that they go a mile extra to help patients who are interested in themselves and work more and more on patients who want to get better and resume their normal activities. So don’t resign yourself to fate. Only you, with the help of medicines, good understanding about arthritis and good scientific strategies can fight the disease effectively. It is very important that you take these medicines regularly and only as prescribed. You have to follow these important instructions while taking treatment for effective remedy 1)Start the medications –Early start of treatment is very important in preventing joint damage. Due to ignorance and apprehending side effects of drugs prescribed, patients do not start medications. The rheumatologist aptly takes care of patients and administers drugs as per the requirements only. If the patients do not comply and do not take the medicines prescribed by the rheumatologist, joints may get damaged permanently and one is compelled to go for surgeries to repair them, which is very costly.2) Do not give in to illogical fears about medications –Side effects are like accidents. They occur rarely and individual patient specific. If the patient follows up regularly and gets some basic tests done at regular intervals, as advised, most side effect can be identified at the earliest and corrected. Fortunately all these side effects are rare and can be managed very easily provided they are reported at the earliest possible time. Follow contraception as advised by your rheumatologist if you need to be on methotrexate, cyclophosphamide, leflunamide and mycophenolate mofetil. However after a certain washout period of these drugs, you can try to conceive again.Discuss all your concerns with your doctor.3) Don't stop the medications when you feel better. Medicines for reducing damage and inflammation need to stay in your bloodstream at therapeutic levels. Skipping a dose when you feel better could cause the pain and inflammation to return. It may be more difficult to relieve. Its better to keep it under control than allow it to flare and try to get it under control again. Your doctor will himself reduce and stop medications one by one if your disease is inactive for more than 3­-6 months.4) Keep up your appointments and do not use medicines on your own. You may not feel the need to see your rheumatologist when your arthritis is less active. Still keeping your appointments is important. Also do not continue the medicines on your own. Self treatment may be dangerous. During your regular planned visits your doctor will monitor the course of disease and determine response to treatment, adjust your treatment if necessary and Look for side effects based on clinical examination and lab tests as well.5) Do regular physical activity –Regular exercise is one of the best things for overall health. When the disease flares up, as stretching to keep joints flexible. Inactivity can make pain, fatigue and stiffness worse. As your disease becomes less active, increase your exercise. Talk to your physiotherapist about the best and safest exercises for you. Warm water aerobic exercises maybe another choice to consider as­ it relieves stiffness and pain steps down a little. 6) Quitting smoking and maintaining oral hygiene may reduce the chances of developing severe forms of arthritis according to recent evidence. They also reduce risk of cardiovascular events which is increased in Rheumatoid arthritis.7) Dietary restrictions ­- There is no clear evidence for any dietary restrictions in Rheumatoid Arthritis. However, for reducing cardiovascular risk, the American Heart Association recommends eating fish twice a week. Fish high in omega­3s are powerful anti-inflammatory foods that offer a multitude of health benefits. Don't eat fish? Other foods rich in omega­3 fatty acids include walnuts, canola oil, and soybeans.8) Fight Depression ­Living with Arthritis is not easy. It can be painful and unpredictable developments do occur. It may be hard to do normal things you enjoy. It is understandable to become sad at times, but you do not have to accept depression as a part of your disease. Discuss these feelings with your doctor. Family support is also required. Developing motivated and proper frame of mind to fight the disease is of utmost importance. According to recent evidence Individual Patient‘s interest in self care is the most important factor in the treatment of rheumatological diseases9) Don't log on without a diagnosis: Don't log on to various internet sites describing symptoms and pains to diagnose yourself. Many rheumatic diseases will be associated with elevation in sedimentation rate (so called, ESR test) pain and stiffness of the joints . So better have a documented diagnosis first. Also you should check only valid patient education sites on the web to get trustable information. 10) Whenever you are in severe illnesses due to infections, you need the opinion of a Rheumatologist available, regarding usage of the prescribed drugs.11) Pneumococal and annual Influenza vaccines are advised to prevent infections. Discuss with your doctor if you have other comorbidities like COPD,Diabetes and you are aged above 55 years.12) Get your eyes checked up by an opthalmologist every 6 months to look for steroid induced effects or hydroxychloroquine effects13) Doctors give you a prescription only after weighing potential benefits against risk. You can have increased hair loss, nausea, burning in the chest, oral ulcers, allergic reactions & skin rashes, increased friability and striae of skin, cataracts, weight gain, increase or decrease in certain cell counts, osteoporosis, avascular necrosis of bones, increase in infections, increase in blood sugars, facial hair, acne, slight increase in blood pressure, etc. while using these drugs. However, in majority of the patients these are easily manageable (Ex: increasing the dose of anti diabetic oral drugs or insulin in case of diabetic patients). It is generally advised to concentrate on the benefits of the drugs, keeping an eye on the side effects. Stopping medications out of illogical or unrealistic fears may lead irreparable damage to bones, joint deformities and serious organ damage in various diseases. Good news is that apart from the traditional anti rheumatic drugs which do work quite well,there are newer drugs in research and some, already into the market. It is possible now to prevent joint damage with these medications.

Occupational Therapy a Solution for Osteoarthritis

Dr. Chaitanya Ulhas Mantri, Occupational Therapist
First, let us understand what is Osteoarthritis ...    OA is a degenerative disease of joints that affects all of the weight-bearing components of the joint:Articular CartilageMenisciBoneAbout OSTEOARTHRITIS [OA]:Most common joint disease Most common form of arthritis Most OA patients > age 45  Women> menMost often appears at the ends of the fingers, thumbs, neck, lower back, knees, and hips.Joints affected by Osteoarthritis[OA]OA-RiskFactors:Age:Strongest risk factorOA can start in young adulthood but risk increases with ageGender:Affects more in women than menMore common in men before age 45, women after age 45OA of the hand particularly common in womenJoint injury/Overuse from physical labor or sports:Trauma to any joint increases risk of OA Ligament or meniscus tearsRepeated movements in certain jobs increase risk Obesity:Joint overload is among strongest risks for knee OAObesity a risk to Knee OAOA–Symptoms:Gradual onset PainStiffnessSwelling or tenderness in one or more joints Crunching feeling or sound of bone rubbing on bone (called crepitus) when the joint is usedRadiographic Diagnosis:Asymmetrical joint space narrowing from loss of articular cartilageHow to Manage OA ???Goals in Managing OA :Decreasing painIncrease range of motionIncrease Muscle strengthOccupational therapy for Osteoarthritis: It would involvePain management through use of Physical Agent Modalities, Exercises to improve and maintain Range of Motion of the jointExercises to Strengthen Muscles of the jointUse of Energy Conservative and Work Simplification Techniques to help in doing the activity with easeUse of Joint Protection Technique while using the jointErgonomic Modification in Work & Home environment

Fibromyalgia- an Incurable Problem!!!

Dr. Uday Bapusaheb Pote, Orthopedist
I am sorry to mention incurable, but it’s the sad truth.It is a syndrome affecting the muscles, soft tissues wherein the person suffers from widespread chronic pain (greater than 3 months duration), insomnia (restless sleep, disturbed sleep), fatigue, irritability, depression/anxiety and disturbed memory.There are specific trigger points on the body where pain is typically felt.The above image shows where are the tender points.How do I know I am suffering from fibromyalgia?Symptoms mentioned below occur in combinations or all together, never only one symptomChronic Pain (greater than 3 months duration) widespread over the body especially over upper back around trapezius and scapular region, lower back region, multiple joint pains.Disturbed/ unfulfilled sleep and some suffer from insomnia.Easy fatiguability, evening fatigue even after not doing much of work.Depression or anxiety.Cognitive dysfunction ( difficulty thinking or remembering things)Previous history of trauma- mental and or physical can trigger this syndrome.Most common in young and middle aged females. But any sex at any age can suffer.Can it be something other than fibromyalgia?Absolutely!Fibromyalgia is a diagnosis by exclusion, that is, the doctor will exclude all other causes before labeling you as a fibromyalgia patient.It was termed as a Rheumatoid variant (rheumatoid arthritis- multiple joint pains with swelling and inflammation leading to deformities of joints). But recent papers suggest that this is an independent syndrome.LAB tests-ESR/CRP/ASO titre/RA factor- to rule out rheumatoid arthritis or any seronegative arthritis.Vitamin B12 and Vitamin D3- low levels do cause tingling/numbness/disturbed cognitive functions and fatiguability/muscle pains respectively.Thyroid function tests.Iron and magnesium levels.If all the above is normal then physical examinations by your doctor will reveal the tender points, which along with other symptoms can guide him to make a diagnosis of fibromyalgia.There are guidelines provided by American College of Rheumatology (ACR) which according to various physical examination provides score to help diagnosis of fibromyalgia. (The guidelines are smudgy and does not accurately diagnose the condition- many false positive results. So not routinely used.)What exactly goes wrong?There are two main biological variants which are responsibleThreshold for pain is reducedPain response is maladaptive.Add to the above emotional disturbance or negative mental influence and the combination results in FIBROMYALGIA. Patients who have negative self image, not happy with their work/ careers, problems in family, not appreciated by spouse/ friends/family/at work place are more prone to suffer.Days of work are lost due to pain and fatigue. Patients mental and physical well being is disturbed due to chronic pain.So is it for REAL or is my mind playing games?Believe me- you and me both want it to be mind games. But its NOT.There are various chemical substances which are released in our bodies like serotonin, endorphins which are inhibitory neurotransmitters which are reduced and substance P, glutamate, which are excitatory sensory inputs are in excess in patients suffering from fibromyalgia.There is dysregulation of many other chemicals like dopamine, growth hormones, etc.So the medical fraternity has recently recognized the existence of this syndrome named FIBROMYALGIA.INCURABLE?YES!There are no treatments that can cure fibromyalgia but there are multiple ways by which you can keep in check the pain and other symptoms.Lifestyle modifications- Exercises which will keep you active. I would prefer my patients doing exercises which are fun. Be it good gym/ yoga/ swimming/ games/walk. Interactive and joyful environment is more beneficial.Eat healthy- fruits, vegetables, a nice balanced diet. Avoid greasy food and carbogenic drinks. Keep a food journal.Medicines- doctor’s will prescribe you medicines to help you sleep properly (as disturbed sleep is universal in fibromyalgia) and pain medicines. Both of which will be temporary. Also multivitamin and calcium supplements will be prescribed. anti anxiety and anti depression meds can also be prescribed. Physiotherapy- to some extent (IFT, SWD and Ultrasound therapy) helps in reducing pain and exercises will tone your core muscles.MOST IMPORTANT IS POSITIVE OUTLOOK IN LIFE. Without this all the above mentioned therapies will fail.Have a good social support group and talk to your doctor about any symptoms or feelings you find disturbing. Do not try to fight fibromyalgia alone- family and friends help to reduce the burden of this disease.

Know More About Various Knee Problems and Injuries

VAISHU
Most people have had a minor knee problem at one time or another. Most of the time our body movements do not cause problems, but it's not surprising that symptoms develop from everyday wear and tear, overuse, or injury. Knee problems and injuries most often occur during sports or recreational activities, work-related tasks, or home projects.Injuries:Anterior Cruciate Ligament (ACL) InjuriesThe anterior cruciate ligament is often injured during sports activities. Athletes who participate in high demand sports like soccer, football, and basketball are more likely to injure their anterior cruciate ligaments. Changing direction rapidly or landing from a jump incorrectly can tear the ACL. About half of all injuries to the anterior cruciate ligament occur along with damage to other structures in the knee, such as articular cartilage, meniscus, or other ligaments.Posterior Cruciate Ligament InjuriesThe posterior cruciate ligament is often injured from a blow to the front of the knee while the knee is bent. This often occurs in motor vehicle crashes and sports-related contact. Posterior cruciate ligament tears tend to be partial tears with the potential to heal on their own.Collateral Ligament InjuriesInjuries to the collateral ligaments are usually caused by a force that pushes the knee sideways. These are often contact injuries. Injuries to the MCL are usually caused by a direct blow to the outside of the knee, and are often sports-related. Blows to the inside of the knee that push the knee outwards may injure the lateral collateral ligament. Lateral collateral ligament tears occur less frequently than other knee injuries.Meniscal TearsSudden meniscal tears often happen during sports. Tears in the meniscus can occur when twisting, cutting, pivoting, or being tackled. Meniscal tears may also occur as a result of arthritis or ageing. Just an awkward twist when getting up from a chair may be enough to cause a tear, if the menisci have weakened with age.Tendon Tears(Tendonitis)The quadriceps and patella tendons can be stretched and torn. Although anyone can injure these tendons, tears are more common among middle-aged people who play running or jumping sports. Falls, direct force to the front of the knee, and landing awkwardly from a jump are common causes of knee tendon injuries.FracturesThe most common bone broken around the knee is the patella. The ends of the femur and tibia where they meet to form the knee joint can also be fractured. Many fractures around the knee are caused by high energy trauma, such as falls from significant heights and motor vehicle collisions.DislocationA dislocation occurs when the bones of the knee are out of place, either completely or partially. For example, the femur and tibia can be forced out of alignment, and the patella can also slip out of place. Dislocations can be caused by an abnormality in the structure of a person's knee. In people who have normal knee structure, dislocations are most often caused by high energy trauma, such as falls, motor vehicle crashes, and sports-related contact.Overuse Injuries includes:Inflammation of the small sacs of fluid that cushion and lubricate the knee (bursitis).Thickening or folding of the knee ligaments (plica syndrome).Pain in the front of the knee from overuse, injury, excess weight, or problems in the kneecap (patellofemoral pain syndrome).Irritation and inflammation of the band of fibrous tissue that runs down the outside of the thigh (iliotibial band syndrome).Osteoarthritis (degenerative joint disease) may cause knee pain that is worse in the morning and improves during the day. It often develops at the site of a previous injury.Osgood-Schlatter disease causes pain, swelling, and tenderness in the front of the knee below the kneecap. It is especially common in boys ages 11 to 15.A popliteal (or Baker's) cyst causes swelling in the back of the knee.       Infection in the skin (cellulitis), joint (infectious arthritis), bone (osteomyelitis), or bursa (septic bursitis) can cause pain and decreased knee movement.A problem elsewhere in the body, such as a pinched nerve or a problem in the hip, can sometimes cause knee pain.Osteochondritis dissecans causes pain and decreased movement when a piece of bone or cartilage or both inside the knee joint loses blood supply and dies.Treatments:-When you are first injured, the RICE method (rest, ice, gentle compression and elevation) can help speed your recovery. Treatment depends on the location, type, and severity of the injury as well as your age, health condition, and activity level.Nonsurgical TreatmentMany knee injuries can be treated with simple measures, such as:Immobilization. Your doctor may recommend a brace to prevent your knee from moving. If you have fractured a bone, a cast or brace may hold the bones in place while they heal. To further protect your knee, you may be given crutches to keep you from putting weight on your leg.Physical therapy. Specific exercises will restore function to your knee and strengthen the leg muscles that support it. (Cryotherapy, Ultrasound, IFT and knee exercises) * Taping if requiredNon-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling.Surgical TreatmentMany fractures and injuries around the knee require surgery to fully restore function to your leg. In some cases - such as many ACL tears surgery can be done arthroscopically using miniature instruments and small incisions. Many injuries require open surgery with a larger incision that provides your surgeon with a more direct view and easier access to the injured structures.