Wednesday, December 18, 2013

What to ask your surgeon?

It is normal to be afraid of surgery. If given a choice, all of us would stay away from surgery. Our reasons for avoiding surgery are obvious. Surgeries come with a baggage of complications. Rarely a complication is severe enough to offset any potential benefit promised by the surgery. The complication itself becomes a bigger problem than the original illness. A complication can happen with the best surgeon having the purest intentions. Therefore it is wise to be scared of surgery. 

Yet we often find ourselves facing surgery. The truth is many problems cannot be solved effectively unless tackled by surgery. Surgery today is far more successful due to improved knowledge, experience and technology. Many patients have undergone surgery and have benefitted tremendously. So if a patient is offered surgery, how should he/she approach the situation?

The first question to be answered is 'Is my problem bad enough?' This is an obvious question and most patients address it correctly. Doing a major surgery for minor issues is a strict 'NO'. Often the alternative non surgical treatments are equally effective. Even though this is a simple decision to make, sometimes patients get carried away by social and economic pressures. I find patients asking for surgery just because they have seen a friend benefit from it or they have the money to buy it! Surgeries are of 2 types: the 'life saving' surgery and the 'quality of life' surgery. With life saving surgeries, the decision is easy. The problem is with 'quality of life' surgeries. For example: a decision to do angioplasty (heart) surgery is easy as it is life saving but a decision to do knee replacement is difficult as it is done to improve quality of life. 

The second question is 'what is the risk-benefit analysis?' Is the benefit promised by the surgery more than the risk of something going wrong or a complication happening. The best surgeries are the ones that offer good results with little risk. For e.g. Knee Replacement completely solves the patients problem (huge benefits) and has a low complication rate. At the other end of the spectrum are surgeries that are new, experimental and unproven. Beware of these as failure rates are high and complications are more.  In between are the surgeries that have proven good results but with a high complication rate. In this situation, I encourage patients to understand the risks completely by a detailed dialogue with the surgeon. 

The next question is 'How good is the surgeon?' This is a difficult question for the patient to answer. As a general rule a specialist will be better. Patients gauge a surgeons skill by his success. Though patients don't have a better way, this method of finding a good surgeon is flawed. Success or fame is multi factorial and a 'famous' surgeon may not necessarily be the most skilled. One effective way is to speak to patients already operated by the surgeon. They often give lots of insight and improve your confidence. 

The last question is 'Have I done my research?' We do a lot of research when we have to buy a new car or a new house. Similarly I encourage patients to do research when they are facing a surgery. Today is the age of information technology and all is available on the Internet. Details of the illness, the success rate of the surgery, the potential complications, the experience of other patients etc need to be researched by patients looking at a surgical option. The procedure should be discussed in detail with your surgeon. I see patients asking questions like 'Is there any guarantee for this surgery?' The answer is obvious and the surgeons who say 'YES' are lying. While this is not a sensible question to ask, there is a list of questions that every patient must ask his/her surgeon. 'What is the percentage of success of the surgery?', 'What are the complications?', 'What are the chances of something going wrong?', 'If a complication occurs, what is its treatment?', 'What is the recovery time?', 'How long will the surgical pain last?' are some of those questions.  

To conclude, everyone would like to avoid surgery but sometimes we cannot. If facing surgery, we should arm ourselves with knowledge beforehand so that we can take intelligent decisions and avoid facing nasty surprises later. 

Thursday, October 24, 2013

Frozen Shoulder

Few disorders in Orthopedics affect a patient as dramatically as frozen shoulder does. Most often the pain starts suddenly without any warning. And what puzzles the patient is that the pain starts without any fall or trauma. The pain is severe and is aggravated by any sudden movement of the shoulder. At times the pain is unbearable. The pain worsens at night and patients are unable to fall asleep. They cannot lie down sideways because of pain. The pain is accompanied by increasing stiffness of the shoulder. The patient becomes very anxious because of this catastrophic onset of pain and inability to move the shoulder. 
Frozen shoulder comes with good news and bad news. The good news is that the disorder is self limiting. This means that it is notan ongoing problem like arthritis which ends up with complete destruction of the joint. On the contrary frozen shoulder undergoes a typical evolution from stage to stage and then completely resolves. Therefore almost all patients of frozen shoulder will eventually be completely cured of their illness. Sofrozen shoulder is not a bad disease to have. What then is the bad news? The bad news is that it takes awfully long for the shoulder to get better. Typically a patient suffers for one year to 18 months before the pain goes away. 18 months is a long time for someone to suffer severe pain and sleepless nights!
What is frozen shoulder? In order to understand frozen shoulder we need to understand some simple facts about the shoulder joint. The shoulder is a ball and socket type of joint. Like all other joints the shoulder is strengthened by ligaments and moved by muscles. Similarly the shoulder also has a covering or lining called the capsule. The capsule makes and keeps the lubricating fluid within the joint. In frozen shoulder the capsule gets inflamed and contracted. This inflammation causes severe pain with the slightest movement of the shoulder. The contracture of the capsule causes the shoulder to become stiff. Frozen shoulder in medical terms is also called 'adhesive capsulitis'. We are still not sure why frozen shoulder occurs. However we do know some definite risk factors. It is more common in diabetic patients. It also is more likely to occur in patients who have not moved their shoulder for a long time due to some other reason like an arm fracture or stroke. Frozen shoulder is generally seen in adults above 40 and is slightly more common in women. There are three stages through which the disease progresses before it finally resolves. First is the stage of inflammation. It lasts for approximately 6 to 12 weeks. It is characterised by severe often unbearable pain. In this stage, pain is more prominent than stiffness. The second stage is of stiffness. In this stage the shoulder is very stiff with almost no movement occurring in some patients. The pain reduces in intensity in this stage. This stage lasts for another 12 weeks. The last stage is of thawing. In this stage the disorder resolves. Movements of the shoulder begin to improve and eventually the patient is cured. This stage lasts for 6 to 12 months. 
Are frozen shoulder patients destined to suffer? Is there any treatment for this disease or can these patients help themselves? There is no medicine to cure frozen shoulder. However the disability from frozen shoulder can definitely be reduced. The aim of treatment is to bring back the movements of the shoulder with range of motion exercise. A physiotherapist helps guide the patient through the exercise routine. Once the patients learn the exercises, they continue doing them at home. Those who try to regain movements by exercise are able to reduce pain and shorten the duration of illness. However exercise is many a times extremely difficult because it worsens the pain. Many patients are just not able to do any exercise. We as doctors help patients reduce pain so as to enable patients to do exercise.Initial pain management is with medicines. Tablets are given only with the intention to decrease pain so that patient can do exercise. Exercise remains the mainstay of treatment. If tablets do not work, local injection of steroid medicine is given to reduce the inflammation and pain. One or two injections of steroids do not harm the joint. Repeated injections should be avoided. Sometimes the patients are able to exercise, but are not able to overcome the severe stiffness. For such cases we do a manipulation under anesthesia. As the name suggests, the patient is given anesthesia so that they do not experience any pain. Then the surgeon forcibly moves the shoulder in all directions to loosen the joint. After the manipulation, the patient needs to continue exercise to gain the movements and benefit from manipulation. In very resistant cases, arthroscopic surgery is done to cut the adhesions and allow shoulder movements. 
To conclude, frozen shoulder patients should not be worried about the pain as the problem is self limiting and will get better in time. All attempts must be made to exercise and gain movements with the help of your doctor. Patients who exercise are able to shorten the period of their disability and achieve a cure quickly! 

Thursday, September 26, 2013

Heel Spur

Heel pain is a common complaint in my OPD. Patients have lots of misconceptions and needless fear of heel pain. 
As we all know, the bones of the feet form an arch. Only the heel bone and the bones in the front of the foot (metatarsal heads) actually touch the ground while standing or walking. There is a strong fibrous tissue in the sole of the foot extending from the heel bone along the length of the foot. It is called the Plantar Fascia. Plantar Fascia is very tough and takes most of the weight of the body. It acts like a shock absorber. 
Sometimes the fascia gets inflamed especially at the point where it attaches to the heel bone. The condition is called Plantar Fasciitis (Heel Spur). The reason for the inflammation is not clear. It can happen to anybody at any age. It is uncommon in children. This results in heel pain. The pain typically is severe after a period of rest. The first few steps are very painful. As the person continues to walk, the pain decreases. A person with Plantar Fasciitis gets severe pain on taking the first step out of bed in the morning. Then the pain decreases with a few steps. At the end of the day, after walking and standing a lot, the heel becomes painful again. The severe pain (in some patients) and the difficulty in walking generate a lot of anxiety. The inflammation leads to growth of new bone at the area of attachment of the Plantar Fascia. This new bone can be seen on x-ray. It looks like a spur, hence the name - 'Heel Spur'. The name is a misnomer. It is the inflammation of the fascia which is the reason for pain and not the new bone formation. The growth of the bone is a reaction to the inflammation. Therefore surgical removal of the excess bone rarely leads to a decrease in pain!
Thankfully, Plantar Fasciitis is a benign disorder. By that I mean it does not lead to progressive damage of bone or tissue. More often than not the disorder is self limiting. After a period of time which is variable from patient to patient, the Fasciitis resolves by itself. 
There is no cure for this condition. However, as the condition will better itself over time, treatment is directed at reducing pain.  So, how should patients deal with this pain? My first recommendation is to wear soft footwear. One should wear soft slippers at home especially in houses that have a tiled or marble flooring. For outdoors, one should wear comfortable shoes like running shoes. In addition one can use a silicon heel insert in the shoe for added softness and comfort. This simple remedy will decrease pain considerably. Soaking the feet in hot water at the end of the day will also help decrease pain. I also recommend stretching exercises. One effective way to stretch the fascia is to stand on ones toes for 10 to 20 counts. 
In some patients these simple measures do not work. A short course of anti inflammatory medication prescribed by your doctor may help. But taking these medicines for long periods of time has its own problems and is not recommended. For those in severe pain who have no relief with the usual treatment methods, I recommend a local steroid shot (injection). As the steroid is used locally, systemic side effects of steroid medication do not occur. As such, a single steroid injection in the heel is safe. This injection permanently solves the problem for most patients. In a few, the pain recurs after a few months and rarely the injection does not give any relief at all. 
To conclude, Plantar Fasciitis is a disorder that a patient should not worry about. It is not a serious illness. In all probability it will cure itself, given enough time. Simple treatment methods and a few lifestyle modifications will work for most patients. Those in severe pain should opt for the injection as it is safe. Surgery is rarely required and there are no guarantees that it will work. 

Wednesday, August 14, 2013

Bone Mineral Density

 A common myth among patients is that all bone related or orthopaedic problems are related to a lack of calcium. Daily, I see patients who are taking calcium supplements on their own accord. People especially women feel that they need to take calcium beyond a certain age, or taking calcium will prevent orthopaedic problems in the future. Usually it is a friend or family member that has scared a person into taking calcium supplements. 

It is wrong to attribute all bone problems to calcium. Often the source of musculoskeletal pain is a joint! There are many joints in the body. Everyone is familiar with the large joints like the hip or knee and small joints like the ones found in the hand and foot. There are also lesser known joints like the facet joints found in the spine (neck and back). Inflammation of the joint is known as arthritis. Arthritis has little to do with the lack of calcium. Therefore taking calcium will not reduce joint pain! 

So if lack of calcium does not cause joint pain, then what does a lack of calcium do? A decrease in the calcium content of bones is typically called osteoporosis (different from osteo-arthritis) There are other disorders of calcium like osteomalacia and rickets but these are rare. Osteoporosis affects women after menopause. It is the lack of female hormones (estrogen and progesterone) that leads to osteoporosis. Osteoporosis also affects men but at a later age and less commonly. Osteoporosis is a silent disease. That means that it causes very few or no symptoms. Many patients of osteoporosis will not know that they are suffering from it! This is similar to medical illnesses like diabetes and hypertension (high BP). Time and again the first symptom of osteoporosis is a fracture of the hip or a vertebra (spine fracture). Rarely osteoporosis may cause bone or muscle pain or tenderness (pain on pressing the bone). 

If osteoporosis is a silent disease, how do doctors and patients diagnose it? Like diabetes early diagnosis of osteoporosis is critical as treatment can reduce fracture risk. Earlier it was difficult to diagnose osteoporosis. Doctors would get some idea of bone strength by looking at x-rays of the patient. However x-rays are a crude test as they show osteoporosis only in the advanced stages. By then it is too late! Measuring the blood calcium levels gives no indication of the strength of bones or the level of calcium in the bones. Nowadays technology has improved. A DEXA scan is currently the gold standard for measuring bone mineral density (BMD). DEXA scan checks the density in the lower back and hip which are the critical areas. DEXA scan is a computerised X-ray based test. Ultrasound of the wrist or heel can also be done. Ultrasound is popular as it is portable (used frequently in patient camps) and cheaper. But ultrasound is less accurate and the wrist and heel density may differ from the density in the back and hip. I do not recommend treatment decisions to be made on ultrasound based bone density results. Does everybody need to do a DEXA scan? The answer is NO! The World Health Organisation (WHO) recommends BMD testing in all postmenopausal women above 65 years of age. In post menopausal women less than 65 and premenopausal women, density testing is required only if they have certain medical risk factors (ask your doctor). There is no need for healthy premenopausal women to do a DEXA scan or other BMD testing. BMD testing is also not recommended for healthy men with no risk factors. 
To conclude, I advice my readers to be smart about calcium supplements. Taking unnecessary supplements in the hope of reducing pain is a waste of money. At the same time one should be alert about osteoporosis. Timely BMD testing by DEXA scan is the key. If osteoporosis is diagnosed by a DEXA scan, then treatment with supplements is imperative.
BMD measurements have today become essential for fracture prevention and osteoporosis treatment, but due care is needed in utilising this asset.

Hip Replacement

Arthritis affects the hip joint just as it affects the knee. Hip arthritis is less common in Indians and Asians. One disease that we commonly see is avascular necrosis (AVN). In AVN the blood supply to the head of the femur (thigh bone) is cut off due to some pathology. The most common reasons for AVN are alcohol intake and steroid medication. The dead femoral head loses its round shape and becomes flat and deformed. This leads to destruction of the hip joint and arthritis. Patients have severe pain in the hip. Movements become restricted and very painful.   In advance stages patients have difficulty in walking. They walk slowly with a limp usually with support of a stick or walker.
There are many non surgical and surgical treatments of AVN in the early stages. However in the late stages the only solution is total hip replacement (THR). Similarly end stage arthritis of the hip due to any cause can be successfully treated by hip replacement alone. Hip replacement has been around for more than 60 years. In this time hip replacement has seen a tremendous evolution. Hip replacement can be partial or total. In partial hip replacement, only the ball (head of femur) is replaced. The original cup of the patient is retained. This surgery is typically done for older patients who fracture the neck of femur (hip fracture).
In total hip replacement, both the ball and socket is replaced. This surgery is done for hip arthritis where both ball and socket are damaged. Originally in total hip replacement both components (stem and cup) were fixed to bone with bone cement (cemented hip). The cemented stem (which holds the ball) works very well and has a long life. However the cemented cup lasts only 10 to 12 years. The need to improve life of the prosthesis led to the evolution of uncemented hips. In uncemented design, the cup and the stem are fitted into the bone without using cement. The surface of the stem and cup is made very rough or porous. This allows the bone to grow into the surface. As a result of this bone growth, the life of the prosthesis improves tremendously.  
Originally in total hip replacement, the ball was made ofmetal and the cup was made of high density plastic (metal onplastic). The problem with plastic is that it wears out over time. There has been a big improvement in these materials over the years. The original plastic has undergone a series of changes (highly cross linked) which has improved the durability of the plastic. The biggest change has been the introduction of ceramic. Early ceramic was brittle and had issues of breakage. With later generations of ceramic, the breakage problem was solved. By using ceramic heads instead of metal ones, the wear of the plastic cups is reduced (ceramic on plastic). Then came the ceramic cups. By using a ceramic cup and ceramic ball (ceramic on ceramic), there is very little wear of the cup and the life of the prosthesis is improved drastically. Ceramic on ceramic THR is ideal for the younger patient as it is very durable and lasts a long time. However it is a technically sensitive surgery and has to be done perfectly. It is also very expensive.
Total hip replacement is a life altering surgery. After the initial couple of months which are required to recover from the surgery, the patient starts experiencing dramatic relief of pain. Pain literally and magically disappears. In most arthritic conditions of the hip, the leg becomes short and thisshortening is corrected immediately after surgery. Movements become free and painless. Patient is able to walk normally without a limp or pain. Some patients even manage to run after surgery. In short patients become normal after hip replacement surgery and are cured of their arthritis. With modern surgical techniques and newer prosthetic materials and designs, these patients are able to enjoy their hip replacements for a long, long time.

Friday, July 19, 2013

Exercise Update: Too Much Too Fast

Time and again we are inspired to exercise. It may be due to motivation from a family member or a friend. It may be after seeing someone successfully lose a lot of weight. It may be the result of a warning given by a doctor. It may be due to a sudden surge of self motivation or enthusiasm. And when we finally start exercising, we land up having pain and discomfort. Sometimes the pain is bad enough to force us to stop exercise. The conclusions reached by people who face this situation are always interesting! 'Exercise does not suit me!', 'Exercise will damage my joints!', 'The doctor is bad!', 'Exercise is not a treatment, I need a proper treatment!' etc. Are these conclusions justified? Can exercise be harmful? 

Yes, there are conditions in which certain exercises can prove to be harmful. A classic example is of a patient with a bad heart who is advised not to exert or walk. Another scenario is a post operative setting after surgery where the doctor will caution against certain exercises. But these situations are rare. And for these patients, the treating physician will be very firm and specific in his advice not to do certain activities or exercise. But for the majority of us who are in average, if not good health, exercise can do little harm. 

I have seen many people cleverly use this situation to their advantage! These are the ones who do not want to exercise and understandably so … exercise requires a lot of effort and can be very boring. Besides the results achieved from exercise are never instant! So by saying 'exercise does not suit me' they manage a quick and easy escape from doing exercise .... and concerned relatives stop bothering them! 

So why do some of us experience pain and discomfort after exercise? To understand this we need to understand the nature of our muscles. Our muscles are high maintenance tissues. I say this because of the following reason. When we work our muscles, they will become larger and stronger. The more we work our muscles, the stronger they become. The strength and endurance of our muscles is directly proportional to how much we exercise them. This is easy to understand. The trouble happens when we stop exercising. The strength of muscles falls drastically when exercise is discontinued. And this fall is always quick. It doesn't matter if a person has exercised for one month or one year or ten years. If he/she stops exercising, everything is lost in a matter of a few months. Now lets consider an example. A person has toiled in the gym for ten years. He has a well toned and muscular body. He has a set routine that he is following religiously. He then takes a break for 6 months. He does not do any exercise. After 6 months he returns to the gym. In his mind he is still a fit person as he remembers the efforts he has put in for ten years.  So he starts following the same routine he was accustomed to. But his muscles are now much weaker than he realises. As a result he does more than his muscles can handle. The result is pain, discomfort and potential injury. He has made the mistake which most people make of doing too much too fast! Similarly, consider a person who doesn't exercise. He has decided to start exercising. He is excited and motivated about exercising. He ends up making the same mistake. The enthusiasm drives him to do too much too fast. The result is again pain, discomfort and potential injury. 

So what is the solution? Once we understand the nature of our muscles, the solution is obvious! When exercising we need to start slowly. Time spent on a treadmill, speed of walking, everything should be very less. Similarly number of exercises done and number of repetitions should be minimum. A person should feel like he has done nothing in the initial sessions of exercise. If he experiences pain or discomfort, he should realise he is doing too much, too fast. He should aim to find a level of exercise so low that he feels no pain. Once that level of exercise is understood, then that level must be maintained for a sufficient number of days. All increments in exercise must be small and many days apart. The second crucial step is to do an adequate warm up before starting the actual exercise. In a warm up the muscle groups are stretched repeatedly so the muscle gets toned up. A stretched and warmed up muscle is far less likely to get pulled or otherwise injured during an exercise session. In this way one can exercise without pain or injury and can enjoy the experience of exercising and gain the benefits as well. 
So the next time you experience pain after a session of exercise, do not be discouraged. Don't reach absurd conclusions like 'exercise is harmful for me?' Do not stop exercising. Understand that you are probably doing too much too fast. With this new understanding, you can get back to exercising without pain! 

Sunday, March 03, 2013

Let's Look Around Us!

Let’s look around us. People are becoming ill! It's the curse of the modern times. Technology has improved and mankind has made progress. But this progress has had an adverse impact on health.
Let’s take food for example. To become successful, the business of food has to run on the sole basis of taste. That which tastes good sells. So, all technology is used to make tasty food, even if this is at the risk of making it unhealthy. Let’s look around us. Walk into a mini market and see what is up for display. Biscuits? - Extremely unhealthy snack made of sugar! Cakes? - Unhealthy! Jams? - Unhealthy! Papads and pickles? - Unhealthy! Instant noodles? - Unhealthy! Colas and ice creams? - Unhealthy! Chips? - Unhealthy! Chocolates and candies? - Unhealthy! What is common in all these food products? They taste good. So what do we do? We buy these and feed it to our children! Unbelievable but true... We take the unhealthiest of foods and give it to the people that matter most to us! Then what is the surprise when these children go on to become very ill as adults?
Let’s look around us? When attending a marriage, what is talked about the most? It's the food! The success of a marriage function is based solely on how tasty the food is? The richer the food (in oil and unhealthy ingredients) the more appreciated is the function. The motto is "more the merrier". So maximum points go to the meal that had the most starters. Fried foods get a thumbs up. Then what is the surprise when a young man gets a heart attack?
Let’s look around us? What is the most happening thing now in the restaurant business? Buffets and Buffets with unlimited starters. Some buffets have 5 varieties of starters and some have 7 or even more! And after the starters are done with you have to eat the main course which you have to walk 5 - 10 metres just to look at. And if that is not enough, there is separate counter for a variety of deserts! We feel proud of ourselves that we managed to eat so much more at a low price. Little do we realise that we have actually paid to get ourselves harmed and damaged.
Let’s look around us? Fast foods - aren't they awesome? May it be Chinese or pizzas or burgers? Think about it. Bread made of Maida, butter, fried patties, lots of cheese, mayonnaise, MSG etc. Doesn't sound too awesome to me!
Aren't we consuming too much? If not too much in quantity, too bad in quality?

So let’s see where we spend this excessively accumulated energy? Let’s look around us. It’s the beauty of modern technology. We live in apartments that have lifts. We travel in cars or bikes or public transport. We sit or stand and work. All work is done from one place.  So business is conducted on the cell phone. Bills are paid sitting at home. All banking is done without actually going to a bank. Groceries, vegetables, food stuffs and medicine are delivered home.  Exercise? Gym? Morning walk? Yoga? We don't have time for these luxuries! We are too busy earning money! We are so busy that we haven't stopped to find out how much money is enough! When we finish earning, then we will concentrate on fitness! Little do we realise that by the time we finishing earning, it's too late. By then we are spending our earnings more on doctors and less on enjoyment.

We have seen the impact of technology on food and exercise. Now let’s see its impact on other aspects of health. Let’s look around us. People are stressed. The stress of a job! Deadlines, pushy bosses, financial commitments and competition. The stress of family! Duties towards parents, harmony with one’s spouse and time for children. The stress of achievement and success! Becoming rich, becoming famous or becoming both. Stress, stress and some more stress. No wonder diseases like blood pressure, diabetes and coronary heart disease are on the rise.

What about orthopaedic problems? Let’s look around us. Once again we have technology to thank! Sitting on a chair and working on a computer for hours together to earn a living! Or standing for hours together in a factory! Or travelling for 50-60kms every day on a bike or driving a car! Add to that a poor diet, lack of exercise and stress and I assure you that you will get plenty of orthopaedic problems.

So friends, let’s stop and look around us. What are we eating? How much are we eating? Do we need to eat as much as we are eating? Can we eat healthier? Are we spending the calories we are consuming? Are we exercising enough? Is it worth taking out the time for fitness? Why are we stressed? Do we really need to earn more and where do we need to draw the line? Is family important? If yes are we giving enough time to our families? Are we really living or just going through the motions like robots?

Let’s prevent technology from ruining our lives!

Wednesday, February 06, 2013

Rheumatoid Arthritis

Joints are complex moving parts of the body made up of bones and ligaments and moved by muscles. Inside the joint, the bones are lined by a smooth cartilage that allows friction free movement between the bones. The joint is covered by a capsule that has an inner lining (synovium) which secretes lubricating fluid. Arthritis means inflammation of a joint (from Greek: arthro - joint + itis - inflammation). In arthritis there is damage to cartilage. Arthritis causes the joint to become painful, swollen and stiff.  There are different types of arthritis. The commonest type is called osteoarthritis. Osteoarthritis (OA) is caused by wear and tear that occurs with age (mechanical disorder). It usually affects large weight bearing joints like the hip and knee. It is a slow process that worsens over many years and it affects the older individual. The second type of arthritis is inflammatory arthritis. In this type there is severe inflammation of the lining of the joint (synovium). There are many types of inflammatory arthritis. Rheumatoid arthritis is the most common type of inflammatory arthritis. In addition to osteoarthritis and rheumatoid arthritis, arthritis can also be caused by infection (septic arthritis) and trauma.
Rheumatoid arthritis (RA) is a type of inflammatory arthritis. It typically affects the younger individual and is more common in women. Why rheumatoid arthritis occurs, is still not clear. It is hereditary, which means that if a mother has it, her daughter is more likely to get it. It is also an auto-immune disorder. Normally the immune system of the body has mechanisms to detect foreign bodies (invading bacteria in infection) and attack them. In auto-immune disorders, these mechanisms are disturbed and the immune system starts attacking the body’s own structures (self). RA affects multiple joints. The commonest joints to be affected are the small joints of both hands and feet. In addition to the hands and feet, it can affect almost all other joints like ankle, knee, hip, wrist, elbow and shoulder. In the spine it affects the cervical spine (neck). In addition to pain, RA causes swelling of the joints and stiffness. The swelling is severe and obviously visible. The stiffness also is severe and typically occurs in the morning. It usually takes more than an hour for the stiffness to settle. RA factor is a blood test that is positive in RA. But RA is a clinical diagnosis and around 30% of RA patients will show RA factor negative. So a negative RA factor may not mean that a patient does not have RA and vice versa. RA is an aggressive disorder causing severe pain, deformity and disability. It is also a very destructive disease and disfigures the joints in a short time if untreated. Unfortunately many patients have become permanently handicapped by this disorder.
The good news is that RA can now be treated effectively. Modern medicine has made progress in the treatment of RA. There is no need for patients to suffer from this disease anymore. The usual pain killers reduce pain but are unable to control the disease and stop the destruction. Treatment of RA is with a special group of drugs called DMARD’s (Disease Modifying Anti-Rheumatoid Drugs). These drugs not only control pain but also stop the disease process. So patients have a reduction in swelling and stiffness. These medicines prevent the destruction and deformity of joints. Permanent handicap can be prevented. These are strong medicines and patients need to be monitored for side effects. In spite of this, I recommend patients to take these medications as the benefit outweighs the risk from side effects. These medications typically take 1-2 months to take effect. Also your doctor may change the combinations to find the medicines that best suit your body. Most patients tolerate these medications well for many years. We need to understand that there is no cure for RA. The disease can only be controlled like blood pressure or diabetes. So it is important for patients to continue these medications for a long period of time. Most failures in treatment are because patients stop taking the medication.
Patients who have severe pain in multiple joints accompanied my swelling and morning stiffness should visit a doctor to check if they are suffering from RA. Patients suffering from RA should take treatment with DMARD’s and continue treatment for many years if necessary. They should regularly visit their doctors to manage dosage and monitor side effects. For advanced stages of arthritis, especially of the hip and knee, joint replacement (hip replacement / knee replacement) is a boon.
To conclude, patients of RA don’t need to suffer anymore. With modern medicine, deformities and handicap can be prevented and patients can remain pain free.