While driving...

I was driving home to Pasig yesterday through the regular Friday night traffic of Manila, along a favorite route with less cars. Here is to share some observations and thoughts (with arthritis and rheumatism interface, of course):

1. During red lights, motorbikes invariably get ahead of your car and position themselves in front of all cars, so they go first on green. I counted 7 bikes in the UERRMM stop lights, 3 bikers with asymmetric backs, one shoulder carried higher than the other - this may create pain and discomfort over one side of the back and shoulder.

2. Officers manning traffic: some are, some are texting - the texter's thumb is a painful condition of the first finger due to overuse injury.

3. Jeepney drivers along side my car, or overtaking me: sitting almost sideways, either right shoulder or left shoulder rotated to the front. This may result in lowback pain and pain on one side of the back.

4. Street children threading in and out of rushing jeepneys, between cars and 18-wheelers! This one is life and limb matters - not arthritis or rheumatism! One wonders how far the DSWD programs trickle to the streets. By the looks of it, the programs do some and leave some on paper. Marvel at how we Filipinos thrive on lack [luck]!

5. Drivers driving and phoning/texting huhummmmm. Again, a matter of life and limb, but for those who survive, its still neck pains, stiff neck and texter's thumbs for you!

Back to the achievable and doable with results:

Check your riding posture! You may NOT need the doctor or pain medications at all!

Diarrhea, urine infection, colds and arthritis: Any connection?

Could that have been just another cold and sore throat?

Was that just a mild diarrhea you had?

Well, some of these common infections can be followed by pain in the heel, swelling and pain of the ankles and knees, red eyes and some weird skin rash. This arthritis that follows a common cold, or a passing diarrhea, or infection in the urine, can be what is known as reactive arthritis (ReA). This condition is more common among young individuals, more in males, and can involve inflammation not just in the joints but also in the eyes and skin.

Infections cause arthritis in several ways:

1. infectious arthritis - bacteria from infections found in other parts of the body like decayed tooth, infected gums and sinuses, skin, urinary tract etc., find their way into the joints through the blood circulation
2. reactive arthritis - prior infection causes inflammation of joints, without bacteria actually growing in the joint. This can be associated with inflammation of the eyes and skin.
• common sources
• urinary tract infection
• diarrhea due to specific bacterai like yersinia and shigella
• strep infection of the throat or the "strep throat"
3. infection-associated arthritis - when arthritis is part of the disease, though uncommon, the following diseases can include arthritis as part of the general presentation of the disease
• hepatitis and other viral infections

Arthritis that arise from infections, whether infection in the joint per se, or as a reactive process, require specialty treatment.

1. Infectious arthritis is a rheumatologic "emergency" and needs to be seen by an orthopedic surgeon or a rheumatologist.
2. Reactive arthritis, likewise needs to be recognized fast, since the disease can be very disabling and recognizing its self- limiting nature is therefore very important. It can have a prolonged course and needs to be treated appropriately to avoid disability. A rheumatologist is the best doctor to consult for these types of arthritis.

Excerpts from "Diagnostic Pitfalls in Rheumatology"

The Philippine Academy of Family Physicians hosted a very successful annual meeting last February 16- 20. I was invited to do this lecture and  while the title of the talk is "pitfalls", it really talks of misdiagnosis or missed diagnosis. In a nutshell, I identified four states where diagnosis is either difficult to come by, or actually missed, here are some excerpts:


 A. The monoarthritis muddle:

• Gout is commonly overdiagnosed (other arthritis diagnosed as gout)
• Psoriatic arthritis and pseudogout are usually missed for gout
• Crystal arthritis (gout and pseudogout) are settings for misdiagnosis of septic/ bacterial arthritis
• some cases get operated on
• antibiotics are given
• some would recommend management of acute monoarthritis as infectious arthritis until proven otherwise
• Crystal arthritis can be complicated with bacterial arthritis
• TB arthritis diagnosis is usually either delayed or missed. In reports, it is only considered once NSAIDs and antibiotic treatment fail.

B. The polyarthritis puzzle 

• Underdiagnosis of polyarticular gout ("diuretic" gout)
• among elderly females on antihypertensive medications with hydrochlorothiazides ( usually a "co" prefix or"plus"  suffix of common drugs for hypertension),  - for rheumatoid arthritis
• Missed diagnosis of connective tissue diseases where arthritis is initial presentation, and other signs and symptoms take years to manifest
• examples are systemic lupus erythematosus, scleroderma, mixed connective tissue disease

C. The early arthritis enigma - in the advent of technology and concepts of treat to target and personalized treatment, patients with early arthritis (less than 3 months to a year or 2 of arthritis) can be a treatment enigma, and the question is - do we treat aggressively to catch the reversible phase of joint destruction or wait for more symptoms and risk permanent joint destruction?    

• Treatment entails expense and adverse events and these are the known outcomes of early arthritis:
• 1/3 to half of cases resolve
• another third develop to full blown rheumatoid arthirtis
• less than a third of cases become other forms of arthritis

D. The similar sounding diagnoses (lay or medical personnel misuse of terms)

• "rheumatic arthritis", rheumatic fever and rheumatoid arthritis
• osteoarthritis (joint disease with bone thickening and cartilage thinning, etc) vs. osteoporosis (bone thinning, predisposing to fracture)
• rheumatic heart disease vs. rheumatic fever

World political climate and continuing medical education

Just 4 years back, the Asia Pacific League of Associations for Rheumatology (APLAR) picked Syria as the site of the 2012 APLAR Convention. This convention sees rheumatologists -clinicians, researchers and academics, from the region and the rest of the world come and sit around to discuss the future of rheumatology. It is held every 2 years. Hongkong hosted the 2010 meeting, which saw over 2000 delegates from all over the world. The Damascus meeting was much anticipated. There was a special value added to  learning rheumatology in the "seat of civilization".

Then came the Arab spring. There was not the faintest hint to this phenomenon, the extent of the upheaval, the geographic and human toll, and the global economic repercussions it would bring on an already unsettled world. Syria joined the fray, and the APLAR sat and waited for the sand storm to settle. As the rest of the Arab world claps the dust off their backs and tries to stand and get back on track, this would not be in Syria. To date, the internal war rages on, causing literally, internal hemorrhage - as media would show it.

We are in prayer for our friends there, the doctors, the rest of the citizens of Syria, as they go through this painful process of change- prayer for end of conflict so its citizens will again live in peace. We in the rheumatology community feels a special tinge of sadness on what we are seeing in Syria. We continue to hope that in the years to come, we can still get that chance to sit on the "seat of civilization" and learn.

Arthritis and complementary and alternative treatment

Complementary and alternative medicine or CAM became a formal and recognized body of treatment for many diseases, including the arthritides. CAM joined mainstream medicine and has been offered as part of the medical curriculum by the mid 80's.

CAM include such diverse modes  of treatment- from balneotherapy, massage, acupuncture and other physical applications to plant products as herbal concoction either applied or taken in. CAMs was reviewed in the Philippine Rheumatology Association(PRA) Recommendations for the Medical Treatment of knee osteoarthritis (OA).

Natural is not necessarily safe, so it is important for prospective users to look for seal of approval by reputable organizations (ex. Arthritis Foundation) or certifications for specific standards of manufacturing (ex. ISO). Like other treatment forms, CAMs can have side effects. We still warn against CAMs markated as a panacea. There have been reports of sideeffects to the heart, liver, kidneys and infections that arise with indiscrimate use of some of these agents.

Among the CAMs reviewed by the PRA were those with scientifically conducted trials and research for its effects on knee OA pain and function.  The following is part of the 25 recommendations published in the Philippine Compendium of Medicine, 2010.

Recommendation for Complementary and Alternative Medicine (CAM)

A. Recommended
1. Herbal preparations
The use of concentrated standardized ginger preparation is recommended for its moderate effect in the control of pain and improvement of function in knee OA. Patients should be warned of gastrointestinal adverse reactions that can occur with this preparation.
Level of evidence: Moderate

2. Acupuncture
Manual or electroacupuncture is recommended as additional therapy to achieve pain relief lasting a few weeks in patients with moderate knee pain due to OA.
The procedure must be adequate and performed by a trained and experienced acupuncturist.
Level of evidence: High

B. Insufficient Data to recommend
1. Spa or balneotherapy
There is insufficient evidence to recommend spa treatment for the control of pain and improvement of function in knee OA.
Level of evidence: Low
2. Tai Ch’i
There is insufficient evidence to recommend Tai ch’i for the control of pain and improvement of function in knee OA.
Level of evidence: Low
3. Yoga
There is insufficient data to recommend yoga to control pain and improve function in knee OA.
Level of evidence: Low
4. Herbals
There is insufficient data on comfrey, Chinese herbal recipe, Chinese pills, rose hip, devil’s claw, to recommend their use in knee OA.
5. Massage
There is insufficient evidence to recommend massage (standard Swedish) for the treatment of knee OA.
Level of evidence: Low

Arthritis in the throat (not the typical sore throat)

No, not the virus,  not strained vocal cords, not the singer's nodes on the vocal cords, but cricoarytenoiditis - what? Supercalifragilistiexpialidocious- yes, its arthritis of the joints between the two small laryngeal bones that hold the vocal cords and the larger cricoid bones of the throat, the cricoarytenoid joints.

Cricoarytenoiditis is felt as pain in the throat and hoarseness and can be part of rheumatoid arthritis, a systemic disease which causes pain and swelling in many joints of the body - wrists, fingers, ankles, knees. While rare, the condition adds to the already debilitating effects of this generalized form of arthritis.

A rheumatology clinic is the best setting for the treatment of rheumatoid arthritis. Optimum treatment will improve crycoarytenoiditis, as well as, the arthritis of the rest of the joints. Treatment is complex and consists of one or more drugs in combination - pain killers and low dose steroids as "bridge treatment" and disease modifying drugs, both synthetic and biologic. This is the best shot a patient can have to avoid disability arising from destruction of the peripheral joints as well as,  the throat joints.

Go, ask your doctor about it!

Summer and rheumatism?

It's January yet, but the sun in Manila is already threatening to be blistering hot in another month or two! Thanks to the occasional cloud cover and some cold air, we still have a very lovely weather.

Summer and rheumatism? 

from clip art

Many believe that rheumatism/ arthritis  is linked to cold weather (2nd only to the Bean Story - several posts back). Some even say that arthritis is caused by cold weather (what? so all humans living in Iceland, Canada, etc have arthritis?)

I hear these complaints more during the short cold months that the Philippines have, but surely, the same patients come any time of the year with bad arthritis, weaving stories of other causes for the pains - ate this, drank that, hexed, etc.

Truth of the matter is that, patients truly feel the tightening and pain in the joints, arms, legs and back, during the cold season. This is partly due to a phenomenon called allodynia. This is that  condition where one reacts with  pain when exposed to otherwise non-painful sources, like cold weather, draft from the airconditioner or open window and even, touch. Allodynia is commonly observed in chronic pain conditions, including rheumatism and arthritis.

During the hot months of summer, indeed, a form of rheumatic disease - lupus- can be exacerbated by exposure to sun. This condition carries with it arthritis, skin rashes ( specially on sun exposure), and even kidney, lung and brain disease. This is an uncommon condition, though among the brown and black race, this disease can be seen more often. Lupus patients are advised to:

1. avoid sun exposure or wear enough sun screen if they have to (absolutely no sun bathing!)
2. check with their rheumatologist regularly
3. comply with maintenance medications. 

Once lupus is controlled, patients can be back working, marrying and having children, etc.

Cold weather and arthritis? Not really...

Summer and arthritis? Why, yes...