Archive for category Rheumatologist
Painful numbness in the hand? It can be Carpel tunnel syndrome.
Posted by onkpg in Rheumatologist on December 7, 2011
A band of fibrous tissue surrounds the wrist to support it. The tight space between this fibrous band and the wrist bones called carpels is called the carpal tunnel. A nerve called median nerve passes through this tunnel. Many conditions can compress this nerve inside this tunnel causing tingling and numbness of the thumb, index, and the middle fingers, This condition is known as Carpel Tunnel Syndrome.
Common conditions that can lead to carpel tunnel syndrome are Obesity, Hyperthyroidism, many types of Arthritis, Diabetes and trauma to the wrist. Tendon injury caused by repetitive work, such as uninterrupted typing, can also cause carpal tunnel syndrome. Some rare diseases like amyloidosis, sarcoidosis, multiple myeloma and leukemia can cause this syndrome by causing deposition of abnormal substance in the carpal tunnel and by causing the compression of the median nerve.
Nerve compression initially causes numbness and tingling of the hand in the distribution of the median nerve (the thumb, index, middle, and part of the fourth fingers) predominantly at night and can awaken people from sleep. Worsening of symptoms at night may be attributed to flexed-wrist sleeping position and fluid accumulating around the wrist and hand. These symptoms may be temporary or may persist and progress.
Progression of the disease may later cause a burning sensation, and/or cramping and weakness of the hand. Reduced grip strength may lead to frequent dropping of objects from the hand. Sometimes, sharp shooting pains may occur in the forearm. In later stage wasting muscles may develop, particularly those near the base of the thumb. Tapping the front of the wrist may reproduce tingling of the hand, and is referred to as Tinel’s sign. Similarly, symptoms can be reproduced by bending the wrist forward, it is to as Phalen’s maneuver.
In carpel tunnel syndrome, nerve conduction velocity test is abnormal. It means, the nerve impulse slows as it crosses through the carpal tunnel. Certain blood tests are done to find out, which medical condition is responsible for the syndrome, these are thyroid functions, complete blood counts, blood sugar and protein analysis. X-ray and MRI tests of the wrist and hand might further be helpful in diagnosis.
Initial treatment includes rest, splinting the wrist and occasionally ice application. Modification of the occupational activities such as adjustment of co mputer keyboards and chair height. These measures, as well as periodic resting can prevent the symptoms which are caused by repetitive overuse. Specific diseases are treated individually. Fractures will require orthopedic measures. Obese individuals must reduce their weight. Rheumatoid diseases will require aggressive treatment. Wrist swelling that can be associated with pregnancy resolves in time after delivery of the baby. Vitamin B6 (pyridoxine) can help to relieve symptoms. Nonsteroidal anti-inflammatory drugs (NSAIDs) can help in decreasing inflammation and reducing pain. Corticosteroids are injected directly into the involved wrist joint for rapid relief of persistent symptoms.
Most patients do well with conservative measures and medications. However, chronic pressure on the median nerve can result in the permanent nerve and muscle damage and surgery procedure called carpel tunnel releases is considered in such a scenario to reduce the nerve pressure by cutting the band of tissue around the wrist. After carpal tunnel release, patients often undergo exercise rehabilitation. Though it is uncommon, symptoms can recur.
Truth about Rheumatoid Arthritis (RA) – from a doctor
Posted by Dr. OP Garg in Causes, Prevention, RA, Rheumatologist, Symptoms, Therapies on July 20, 2011
Frequency of Rheumatoid arthritis in general population is about 1%. Rheumatoid arthritis (RA) is a chronic inflammation of joints. The deformation continues till the inflammation is adequately controlled. It’s rare for rheumatologists to come across a case where the RA disappears without any modern treatment. Modern anti-rheumatic medications play a crucial role in controlling the symptoms of this disease and in halting the damage done by Rheumatoid Arthritis. Treatment started soon after the diagnosis is most effective. There are about 100 types of Arthritis and RA can often be mistaken for other types of arthritis. Therefore, besides the right treatment for Rheumatoid Arthritis, the right diagnosis is of utmost importance. There is new research happening for RA and new treatments are being developed so the universal knowledge about RA is constantly changing and we still have a lot to learn about this arthritic disease. Yet, there are many misconceptions about this treatable and controllable disease. In this blog post, I’m going to help break these myths.
Myth: Rheumatoid arthritis is just like ‘regular arthritis.’
Truth: RA is not “regular arthritis.”, What is commonly known to the general population as “regular arthritis” is osteoarthritis which results by injury or as a result of normal wear-and-tear on aging joints. Osteoarthritis is the most common joint disease in the senior citizens. By contrast, RA occurs as a result of abnormality in immune system initiated by a so far unknown trigger, the body makes antibodies that attack its own joint tissue. It mostly affects the joints, although other body systems can also be affected. Once disease begins, it causes continuous joint inflammation. In some people it can result in intermittent episodes of painful and swollen joints. In some individuals otherwise doing well with the medications, sudden or acute episodes of joint inflammation results, these are called ‘Flares’.
Myth: Only old people suffer from rheumatoid arthritis.
Truth: RA generally starts between the ages 25 to 55, but even teenagers can develop it.
Myth: Rheumatoid Arthritis is not such a serious disease.
Truth: RA is very serious. It can rapidly damage and deform your joints, involve other organ systems and even shorten your life span by few years, if it’s inadequately treated. Many people downplay RA as just ‘Grandma’s rheumatism,’ and they miss the boat completely. They delay seeing a Rheumatologist, often for months or years and a lot of joint damage happens during that time. RA needs prompt diagnosis and regular treatment to protect joints from harm. RA also increases the risk for certain other conditions like cardiovascular diseases, infections and lung disease etc.
Myth: People with rheumatoid arthritis will end up in a wheelchair because nothing can be done other than consuming pain killers & undergoing physiotherapy.
Truth: RA takes a different course in different people, but most people will go on living independently without pain and joint damage if treated early with modern medicines under the supervision of a rheumatologist (Joint physician).
RA has been known to cause much disability in people and this information comes from 20 to 30-year-old studies done before we started treating early RA with methotrexate, before we had the new biologic and other DMARDs (Disease modifying anti Rheumatic drugs. Extra ordinary strides have been made in recent times towards the excellent treatment of this disease. Today, an overwhelming number of people under treatment for rheumatoid arthritis are doing excellent and they regain their independence and mobility. But these results are only true for patients treated by a Rheumatologist. A recent study suggests that 94% of people with rheumatoid arthritis continued to perform all their normal activities independently even after living 10 years with the disease.
Myth: Most people with RA will be unable to work.
Truth: This myth may have been true in an earlier era, prior to the current treatments. Some people may need allowances at work, or will have to limit some activities during disease flares but a large proportion of people suffering from RA will continue working. In fact, in one large study of people who had had rheumatoid arthritis for more than 10 years, their employment rates were no different than their counterparts without RA.
Myth: As RA treatment can be toxic, it’s best to wait until the disease progresses.
Truth: This can prove to be the most dangerous thing to do. In fact, treating rheumatoid arthritis early prevents joint damage and disability. Ideally, aggressive treatment should start as soon as a positive diagnosis. Delaying treatment can worsen the situation. Numerous studies suggest that early treatment could delay full-blown rheumatoid arthritis from developing in some people. Although medications used to treat RA can have side effects but these side effects can be efficiently detected and treated through close monitoring by the rheumatologist and is definitely not worse than untreated rheumatoid arthritis. Simple blood tests and doctor’s visits can detect many of the serious side effects of rheumatoid arthritis medications.
Myth: Most people with rheumatoid arthritis get cancer too.
Truth: RA itself increases the risk for developing lymphoma (blood cancer), but the risk is low overall. For blood cancer, the lifetime risk is about twice as high in people with RA. It’s not clear why; perhaps because of chronic persistent inflammation. But the fact is that only a small minority of people with RA get blood cancer. For example, in one study, after following over two thousand people with rheumatoid arthritis for about eight years, 11 of them developed blood cancer. Most people with RA do not get cancer. Methotrexate, the new biologics, or both may partially increase this risk. However, you have to weigh the risks and the benefits. Untreated rheumatoid arthritis is frequently devastating, while blood cancer is uncommon, often slowly progressing and treatable. On the bright side, the risk of one cancer, colorectal cancer is actually reduced by up to 40% in people with RA. One theory says that the use of anti-inflammatory medicines called NSAIDs in this condition helps to prevent cancer in the colon.
Myth: Painful, stiff joints from rheumatoid arthritis need to rest most of the day.
Truth: In contrast joints affected by RA need stretching and exercise. Immobility can be counterproductive. Joints become painful and stiff making the patient immobile. Immobility sets up a vicious cycle. Muscles around a joint contribute a large part of the joint’s strength and stability and these require regular activity to stay healthy. Everyone with rheumatoid arthritis can perform some kind of exercise. Stretching exercises require minimal exertion and help keep joints flexible. Low-impact aerobic exercise improves joint health. High-impact exercises are to be avoided.
Rheumatoid Arthritis (RA) Explained Part I
Posted by Dr. OP Garg in Juvenile Rheumatoid Arthritis, Prevention, RA, Rheumatologist, Therapies on May 6, 2011
Rheumatoid arthritis is commonly associated with old age. How common is the condition in the young people?
Rheumatoid arthritis is a chronic persistent inflammatory polyarthritis mainly involving the small joints of hands and feet, although large joints such as knee and hip joints can also be affected. It usually affects young women of reproductive age, ie, 20-40 yrs. Elderly individuals can also be affected. Male to female ratio is 1: 5.
What causes rheumatoid arthritis?
Rheumatoid arthritis is an autoimmune disease. Exact cause is still not known. But it is known that something in the body goes awry. Our own immune system which targets the nonself substances such as bacteria and viruses, recognizes them and fights with them to eliminate them from the body. In Rheumatoid arthritis our immunity starts recognising the joint tissue called synovium, a lining of joint cavity, starts manufacturing the antibodies against this tissue. These antibodies, recognised in the blood test as Rheumatoid factors and anti CCP antibodies, start attacking this tissue and cause inflammation manifesting itself as joint swelling and then it is called arthritis.
The youngest patient who came to me seeking treatment…
Although inflammatory arthritis commonly occurs in children also, but then this is called Juvenile inflammatory arthritis, which may or may not progress to rheumatoid arthritis in aduldhood. I have seen such type of arthritis even in 02 yrs old. But the term Rheumatoid arthritis is a term to be used when it occurs in individuals of > 16 yrs of age. In that sense I have seen a patient even 17 yrs old developing rheumatoid arthritis.
What’s the common treatment protocol?
In case of Rheumatoid arthritis, once diagnosed by a rheumatologist based on established diagnostic criteria, in addition to nonsteroidal anti inflammatory drugs, immunomodulators are to be used as early as possible to control the autoimmune inflammation if joint deformities are not desired. To begin with, we start methotrexate and hydroxychloroquine in combination. Various other immunomodulators used are sulfasalazine, D-Penicillamine, Leflunomide. Sometimes help is also taken from steroids, cytotoxic drugs with sole aim of controlling autoimmune related inflammation. Latest drugs with the same aim are biologics such as anti TNF agents ( infliximab, etanercept) and other anticytokine and B cell and T cell therapies. Management of RA is like management of diabetes mellitus, in which we control blood sugar level to save the target organs, in the same way we control level of inflammation in RA to save the joints from ongoing damage.
What are the current advances made in the treatment?
Current advances as enumerated above, are targeted therapies to target various inflammation causing molecules (cytokines) such as anti TNF, IL6, IL1 etc, and to target cells involved in the perpetuation of inflammation, such as Rituximab against B cell, and Abatacept against T cell. A lot more are being researched and yet to enter the market.
What dietary restrictions a patient should adhere to?
Dietary restrictions: No dietary restriction has proved to substantially reduce the inflammation of RA and stop the ongoing joint damage. However, patients are adviced so many drugs which are likely to cause gastric inflammation, therefore, it’s better to reduce the intake of spicy food. As being overweight is detrimental to the health of joints, patients are adviced to reduce weight by cutting down their calorie intake. (S)he is also adviced to have a balanced diet containing lots of fruits and salads which are full of antioxidants. It will be better to expose the skin to the sun for at least 1/2 hr at appropriate time of the day so that the required Vitamin D can be made by the skin. If that is not possible, Vitamin D fortified foods or Vitamin D supplements are to be added in the diet. New research is showing that Vitamin D defficiency may initiate and perpetuate auto immune diseases.
Acupuncture and Fibromyalgia
Posted by Dr. OP Garg in Fibromyalgia, Healthcare Personalised, Prevention, Rheumatologist, Therapies on February 17, 2011
I get many queries in my practice about acupuncture and it’s benefits. This blog is for the benefit of all who are undergoing acupuncture as an alternative therapy for fibromyalgia.
- Some research studies have looked at the efficacy of the acupuncture as a treatment for fibromyalgia. Although a few have shown significant benefit in pain while some have not.
- But in studies that have shown some benefit, relief lasted from a few days to a few weeks. Some people reported pain relief for up to six months, but was not long lasting in any of the reports.
- In case you want to try acupuncture for fibromyalgia, try three-four sessions. If you get benefit continue up to 6-10 treatment sessions. By then you can decide whether acupuncture is cost-effective and helpful enough to continue further.
Please note that
- Even if you find acupuncture helpful, it should not be your primary treatment for fibromyalgia.
- It is to be used along with other therapeutic modalities. Acupuncture must be combined with regular exercise, tricyclic antidepressants and other similarly approved medications for fibromyalgia, pain medication and a good dose of meditation.
- You must give your body timely and adequate sleep.
- You must reduce your weight to a normal level as it will reduce the stress on various body systems.
- Increase your dietary intake of vegetables, reduce refined sugar and processed foods in your diet.
- Stop smoking and stay away from alcohol and caffeine.
If you follow the above given tips, most likely you will be benefited. In most cases, if patients do not see good results; it is because they do not follow the treatment closely as advised by their doctor for an advised time period. As soon as they start feeling a difference or get better they stop or reduce the dosage on their own J I’m sure a lot of you are smiling at this time for good reason. Last but not the least, before embarking on any alternative therapies and before spending your hard earned money, please consult your Rheumatologist first, for confirmation of diagnosis and for planning the most adequate treatment for yourself.
10 Things To Help You Reduce The Chances Of Contracting An Autoimmune Disease
Posted by Dr. OP Garg in Fibromyalgia, Juvenile Rheumatoid Arthritis, OA, Prevention, RA, Rheumatologist, SLE / Lupus, Therapies on January 16, 2011
Chances of getting an autoimmune disease like RA, SLE etc is 1 in 11 in the female population. This is much more than the chances of getting a DDA (Delhi Development authority) apartment in the Indian Govt. housing scheme ie, 1 in 47 which was 1 in 140 last year. So I advice all my readers and followers who want to remain ambulant throughout their life to:
1. Maintain a healthy lifestyle.
2. Maintain a balance between your physical, social and psychological life.
3. Get at least 15-20 min. sun exposure in a day.
4. Walk 4-5 km daily.
5. Maintain optimum weight.
6. Do away with stress at the earliest.
7. DO NOT smoke.
8. Clean habits help avoiding autoimmunity triggered by infections.
9. Ensure good cross ventilation at your homes.
10. Eat healthy food and a balance diet will help.
NEWS – Darvon/Darvocet has been pulled off the market by FDA
Posted by Dr. OP Garg in Prevention, Rheumatologist on November 21, 2010
The maker of Darvon and Darvocet have announced on Friday that it will stop marketing the painkillers in the U.S. because of a new study that links the active ingredient in the drugs to serious and sometimes fatal heart rhythm abnormalities.
Xanodyne Pharmaceuticals Inc. have agreed to the ban at the request of the Food and Drug Administration (FDA) which also asked makers of generic versions of the drugs’ core compound, known as propoxyphene, to stop selling it in the U.S.
The decision to ban propoxyphene in the U.S. comes after the regulatory ban in Britain and the European Union which pulled the drug from the market more than a year ago.
The suggested study by the US before it banned it took a stand to ban the drug, showed that the drug increases risks for heart arrhythmias even in the healthy patients.
The FDA urged doctors to stop prescribing it immediately but had advised patients to continue taking propoxyphene, till their doctors prescribe them an alternative medicine.
Note: This information is highly valuable to those residing in countries where the drug has not been banned yet. Some doctors might still be unaware of this recent development and would be continuing in prescribing this medicine. So in case your doctor had prescribed you propoxyphene or you face a prescription in the future, please ask the doctor to prescribe an alternative to it.
NEWS – New Oral Pill “Tasocitinib” in sight: May Offer Alternative to Injectibles biologics in Rheumatoid Arthritis
Posted by Dr. OP Garg in RA, Rheumatologist, Therapies on November 13, 2010
In resistant cases of RA, injectable biologics which include Enbrel, Humira, and Remicade can cost as much as $1,500 a month and carry a risk of infection.
The new pill of Tasocitinib is given orally, and if approved, it will become the first new oral drug for rheumatoid arthritis since Arava was okayed in the late 1990s. Tasocitinib belongs to a new class of oral drugs, known as JAK inhibitors, that inhibit immune system cells that are thought to cause inflammation.
In rheumatoid arthritis, the immune system is inappropriately turned on, causing inflammation, predominantly in the joints. This, in turn, can cause pain and lead to permanent joint damage.
Tuberculosis, or the opportunistic infections, that we’ve seen with [other drugs for RA] has not been encounterd with this drug, however other serious infections were associated with this new drug in 4 % of cases.
Tasocitinib is also being studied for the treatment of several other disorders, including psoriasis, Crohn’s disease, and ulcerative colitis. No price has been set.
Most commonly misunderstood terms in Rheumatology
Posted by Dr. OP Garg in Fibromyalgia, Rheumatologist on September 13, 2010
Here is a post to clarify the meaning of various terms used in Rheumatology. I keep getting asked, these question in my daily practice so here it is once again.
What is Arthritis?
When there is an inflammation of inner structures of joints especially of the synovial membrane which lines the joint cavity, it is called arthritis and this is usually associated with joint swelling and pain during all the joint movements.
What is Rheumatism?
Rheumatism is a layman’s term. This term is used by non-medical people. It is used for general aches and pains which usually shifts from one region of the body to another within a span of few hours to few days. General public also call it as “Bai”. It is a nonspecific term and may include all the causes of musculoskeletal pains. In this context, there are more than 100 causes of rheumatism including arthritis. If some doctor/ medical professional tells you that you are suffering with Rheumatism, please walk out the door at that instance as he/she does not have any knowledge about it.
What is Fibromyalgia?
Fibromyalgia as name suggests, it is ‘algia’ meaning ‘pains’. ‘Fibro’ means fibrous tissue which means, the part of the muscle that attached it to the bone. So fibromyalgia means pain arising out of the fibromuscular tissues. Patients usually complain of pain around these structures. Often, there are tender spots that become painful on pressure and on usage. This causes a lot of nuisance to the patients. It can range from slight pain to severe pain making the patient, sometimes, bedridden. Risk factors for fibromyalgia are obesity, diabetes and hypermobility of the joints.
A future approach to Rheumatoid Arthritis in sight sooner than later
Posted by Dr. OP Garg in RA, Rheumatologist, Therapies on August 16, 2010
Rheumatoid arthritis is an autoimmune disease of joints, especially involves small joints of hands and joints, if its course is not halted in time, it may damage your joints pretty fast and may cripple you for life. It has been found that the immune cells called macrophages, which in normal circumstances are supposed to die after they attack an invading virus or bacteria; live, go rogue, proliferate in the blood, build up in the joints and invade cartilage and bone. Currently, there is no effective, nontoxic way to stop them.
MISBEHAVING IMMUNE CELL IN RHEUMATOID ARTHRITIS” MACROPHAGE”
A Completely new approach which has been tested on mice, seems to halt and reverse the rheumatoid arthritis without the side effects of the current treatments. The study has been published in the February issue of Arthritis & Rheumatism.
“This new therapy stopped the disease progression in 75 percent of the mice,” says Harris Perlman, the lead author and an associate professor of medicine at Northwestern University Feinberg School of Medicine. “The best part was we didn’t see any toxicity. This has a lot of potential for creating an entirely new treatment for rheumatoid arthritis.”
Perlman discovered that immune cells in rheumatoid arthritis are low in a critical molecule called Bim, whose job is to order the cells to self-destruct. To correct that shortage, Perlman developed an imitation of the molecule, called BH3 mimetic. When Harris injected his drug into mice with rheumatoid arthritis, it floated ghostlike into their macrophages and bam!, the abnormal immune cells was self destructed. This molecule has been nicknamed Casper the Ghost, can float undetected into overactive immune cells responsible for rheumatoid arthritis, causing them to self-destruct.
Harris shows that Casper the Ghost could prevent the development of rheumatoid arthritis as well as could trigger a remission of the ongoing disease disease. After the drug was injected in animals with the disease, joint swelling subsided and bone destruction decreased.
Current treatments for rheumatoid arthritis include low-level chemotherapy and steroids. These are not always effective, however, and they are frequently associated with the side effects.
A newer class of therapy, which is sometimes used in combination with chemotherapy and steroids, is called biologic response modifiers like Etanercept and Infliximab. These are antibodies or other proteins that reduce the inflammation produced by the hyperactive immune cells. These biologics don’t work for everyone and can be associated with side effects, including the risk of infection.
Perlman says the next step is to develop nanotechnology for a more precise method of delivering the drug. His research was supported by the National Institute of Arthritis, Musculoskeletal and Skin Diseases and the National Institute of Allergy and Infectious Disease.
Northwestern University news: www.northwestern.edu/newscenter/
So hold your breath and have hope that a new treatment may be at the horizon to cure Rheumatoid Arthritis.
What is Rheumatic fever and how it is related to Rhuematoid Arthritis (RA)?
Posted by Dr. OP Garg in RA, Rheumatologist on August 11, 2010
Rheumatic fever is an inflammatory disease that occurs following a kind bacterial infection (GroupA), such as sore throat or scarlet fever. It is believed to be caused by antibody cross-reactivity to heart, joints, skin and brain. The illness typically develops 2-3 weeks after the bacterial infection. Acute rheumatic fever commonly affects children between 5 to 15 years of age, with only 20% occurring in adults. It is quite similar in clinical presentation to Rheumatism (Bai in layman’s language), hence named rheumatic fever. But has nothing to do with Rheumatoid arthritis (RA). RA is an erosive and deforming disease for joints but rheumatic fever does not cause erosive joint disease.
What are Major and Minor Jones Criteria and how are they related to Rhuematic Fever?
A firm diagnosis of Rhuematic Fever requires the presence of two major or one major and two minor criteria. Also, the evidence of a recent streptococcal infection must be present. I’m going to list the criteria below as requested on the facebook page.
Major Criteria
- Carditis: All layers of cardiac tissue are affected (pericardium, epicardium, myocardium, endocardium). The patient may have a new or changing murmur, with regurgitation being the most common followed by aortic insufficiency.
- Polyarthritis: Migrating arthritis that typically affects the major joints like knees, ankles, elbows and wrists. The joints are very painful and symptoms are very responsive to anti-inflammatory medicines like asprin.
- Chorea: Also known as Syndenham´s chorea, or “St. Vitus´ dance”. There are abrupt, purposeless movements in this condition. This may be the only manifestation of Acute rheumatic fever and its presence is diagnostic. It may also include emotional disturbances and inappropriate behavior.
- Erythema marginatum: A non-pruritic rash that commonly affects the trunk and proximal extremities, but spares the face. The rash typically migrates from central areas to periphery, and has well-defined borders.
- Subcutaneous nodules: Usually located over bones or tendons, these nodules are painless and firm.
Minor Criteria:
- Fever
- Arthralgia (only pain in the joints, no swelling)
- Previous rheumatic fever or rheumatic heart disease
- Acute phase reactants (these substances are manufactured by the body to fight against the invading organism): Leukocytosis, elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)
- Prolonged P-R interval on electrocardiogram (ECG)
Evidence of preceding streptococcal infection: Any one of the following is considered adequate evidence of infection:
- Increased antistreptolysin O or other streptococcal antibodies
- Positive throat culture for Group A beta-hemolytic streptococci
- Positive rapid direct Group A strep carbohydrate antigen test
- Recent scarlet fever