Category Archives: Answers to questions about arthritis

At every talk I give, there are people who ask many questions about different aspects of arthritis. Here are some answers

Exercise as medicine for arthritis treatment

exerciseWhile the role of exercise in driving down blood glucose and in
improving cardiac function is well know, less is evident about it’s beneficial effects in arthritis.

Exercise is an extremely important component of the treatment of arthritis.  Low impact cardio improves blood flow to the joints.  Resistance training strengthens ligaments and tendons.  And stretching maintains flexibility. Joint health is important for maintaining quality of life. After all what good is it if your blood sugar is fine and your ticker is working if you can’t be active?

With the bulging Baby Boomer demographic, the role of exercise in maintaining health, reducing medication requirement, and ameliorating co-morbid conditions is critical.

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Bitter Kola boosts libido and beats osteoarthritis

Results of a study published in African Journal of Pharmacy and Pharmacology have confirmed that bitter kola possesses sexual enhancing effects on male rats as evidenced by the increased mounting (MF) and intromission (IF) frequencies with increased number of subsequent ejaculations over the 20 min observation period.bitter-kola

The study is titled “Effects of ethanolic extract of Garcinia kola on sexual behaviour and sperm parameters in male Wistar rats.”

Another study published in Journal of Orthopaedic Surgery and Research by medical doctors, pharmacists and nurses at Obafemi Awolowo University Teaching Hospital (OAUTH) concluded: “Garcinia kola appeared to have clinically significant analgesic/anti-inflammatory effects in knee osteoarthritis patients. Garcinia kola is a potential osteoarthritis disease activity modifier with good mid term outcome. Further studies are required for standardization of dosages and to determine long-term effects.”

The study is titled “Clinical effects of Garcinia kola in knee osteoarthritis.”

Comment: Whoa…, I think I need this.

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Can rheumatoid arthritis kill you?

Here is an email question I received recently…

“I have been in search of a very important question, can you die from RA?  It is listed on a death certificate of a person I know that did not have an autopsy and there were no doctors present when this person died. The person had RA but I am not convinced that this is true and heard you can NOT die from RA alone.  I would appreciate any information you could offer.”

Actually, this is a very interesting question because it brings up an important issue.

Rheumatoid arthritis (RA) is the most common form of inflammatory arthritis, affecting more than 2 million Americans.  It is a systemic autoimmune disease that can affect virtually any organ system.

What is not appreciated by many people, including physicians, is that RA has been associated with a significant mortality risk.

It has been estimated from a number of studies that uncontrolled or poorly controlled RA can shorten life span by ten to fifteen years. Despite the many treatment advances made in recent years, early mortality from rheumatoid arthritis remains a significant concern.

So why is that?

The answer lies in the chronic inflammation caused by the RA. The inflammation sets up an autoimmune situation that is perpetually turned on.  Essentially there is no “off-switch.”

Elegant studies done by Dr. Gerald Weissman and colleagues at the New York University School of Medicine implicate chronic gingival inflammation as the underlying trigger.

In any event, this chronic inflammation leads to early atherosclerotic cardiovascular disease. Heart attacks and strokes are the end result.  While this affects all patients, the effect seems to be most pronounced in women.

Some investigations have provided evidence that aggressive intervention with disease modifying anti-rheumatic drugs (DMARDS) and biologic agents may reverse the tendency to early heart attack and stroke.

Another cause of early death can be lung involvement leading to fibrosis and destruction of lung tissue.

Early crippling and disability is rarely seen nowadays.  However, in the past, this too was a significant cause of early death.

Rheumatoid vasculitis is a devastating complication of RA.  This problem occurs as a result of inflammation of blood vessel walls.  The inflammation causes closure of blood vessels to major organs and that obviously can cause major problems.  Immunosuppressive therapy has had mixed results as far as resolution of the problem.  Occasionally, high dose steroids and biologics have been used with some modicum of success.

This discussion would not be complete without a mention of early death related to treatment.  Non-steroidal anti-inflammatory drugs (NSAIDS) used to treat pain and inflammation can cause stomach ulcers, gastrointestinal bleeding, as well as liver and kidney damage.

Disease-modifying drugs such as methotrexate used to slow disease progression may also present problems.  And biologic therapies, even though they have revolutionized our approach to RA, because of their profound effects on the immune system, can also cause complications leading to death.

Nonetheless, when RA is treated appropriately, the benefits of therapy, I think, outweigh the negatives.

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What are my options for shoulder pain?

The shoulder has the honor of being is the largest, most complex, and most mobile joint in the body.  And it is this reason that makes it the most vulnerable to overuse.

The shoulder consists of three bones: the humerus (upper arm bone), clavicle (collarbone), and scapula (shoulder blade).

The rotator cuff muscles and tendons are responsible for movement and stabilization of the shoulder.

In addition, there are other muscles and a complex array of ligaments that also serve to ensure stability.

Another tendon, the biceps tendon, originates from the glenoid (the cup of the shoulder blade where the humerus sits) and extends down the humerus.  It is responsible for certain arm and shoulder movements.

The ironic fact is that a patient who complains of shoulder pain may have nothing wrong with the shoulder!shoulder-pain

For example, many medical conditions such as gall bladder disease, pneumonia, and ectopic pregnancies can present with shoulder pain.  Also, neck conditions often cause referred pain to the shoulder.  Patients with heart disease who are experiencing a heart attack may complain of pain in the left shoulder and arm.

Shoulder ailments fall into three major groups.  The first is trauma.  An example may be a skier who falls on an extended arm.  The impact can drive the head of the arm bone into the socket and cause damage to the cartilage, the bone, as well as the rotator cuff tendons. If the ligaments are stretched or torn, the shoulder can dislocate.  While the shoulder can be “relocated”, once dislocation occurs, the patient is at increased risk for another dislocation. Significant impact can cause damage to the cartilage that cushions the head of the femur as well as the “cup” of the scapula.  This cup is referred to as the glenoid.  The glenoid also has a lip of tougher cartilage that can be torn with impact injuries.

Trauma, if significant enough, can cause dislocation of the joint joining the collar bone to the shoulder blade. The common term for this is a “separated shoulder.”

A related but different type of ailment is wear and tear.  Because so many of the structures that permit shoulder movement and provide stability are made of connective tissue, it stands to reason that over time, they can begin to wear out.  And that is exactly what happens.  Tendons- the ropes that connect muscles to bone-, ligaments, and bursae (fluid filled sacks that cushion joint movement) all are prone to injury as a result of overuse.

When this occurs, conditions such as tendinopathy (previously known as tendonitis), bursitis, and ligament strain ensue.

While inflammation may be present, the overwhelming problem is tissue breakdown.

The last ailment that affects the shoulder is arthritis.  The three bones that make up the shoulder interact with each other at two specific points.  At these two points, there is a joint where two bones whose ends are covered with cartilage articulate.  The two joints are the glenohumeral joint- the joint that joins the shoulder blade and the humerus and the acromioclavicular joint that joins the collarbone to the shoulder blade.

Arthritis at these two areas can develop as a result of systemic disease such as rheumatoid arthritis or as a result of wear and tear- osteoarthritis.

The treatment of shoulder disorders depends upon both the underlying problem as well as the amount of patient discomfort and the impact on quality of life.

For traumatic disorder where there is obvious tissue disruption, surgery is usually required.  The type of surgery will be up to both the surgeon as well as to the individual who has the problem. The shoulder is a complex joint so it’s important to ensure whoever works on the shoulder is an expert.

For most wear and tear problems, non-steroidal anti-inflammatory medicines (NSAIDS) are sometimes, but not always, helpful. Ice and rest also can be useful.

Patients may require a steroid injection. For people who don’t respond to medicines, injections, and physical therapy, surgery may be an option. Ultrasound guidance is important.

Regenerative medicine techniques can be used for shoulder issues.  An example would be a procedure called percutaneous needle tenotomy which can be used to treat rotator cuff tendinopathy and tears.

In this procedure, a small needle is introduced using local anesthetic and ultrasound guidance. The needle is used to irritate the tendons of the rotator cuff and induce inflammation. Then, platelet-rich plasma, obtained from the patient’s whole blood is injected into the area where the tendons have been irritated. Ultrasound guidance here is mandatory. Platelets are cells in the blood that contain many growth and healing factors. This stimulates the production of new strong tendon tissue.

Another example of a regenerative medicine technique is the use of autologous stem cells (a patient’s own stem cells) for glenohumeral arthritis.

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What’s a “sausage finger” or “sausage toe”?

Many types of arthritis can cause a sausage digit.  The technical term for this is “dactylitis.”sausage-toe

This is not the kind of sausage you would have with your eggs and pancakes.

Sausage digits are typically seen in conditions such as psoriatic arthritis (the arthritis that accompanies psoriasis), Reiter’s disease, inflammatory bowel disease, and occasionally ankylosing spondylitis.  Of these, psoriatic arthritis is probably the most common culprit. Dactylitis means inflammation of an entire finger or whole toe.

It is caused by inflammation involving the synovium (lining of the joint) as well as the lining of the tendon sheath.  Tendons are tough fibrous bands that connect muscles to bones.  Most tendons glide through a lubricated sheath lined with synovium. When the synovium in the joint and the tendon sheath becomes inflamed, the entire finger or toe will swell.

The tendons that are most often affected are the tendons that allow a person to bend or flex their fingers or toes.

If a patient has dactylitis, their prognosis is poorer in that the joints are more likely to sustain damage.  The presence of dactylitis indicates a greater chance for disease progression.

Early on, dactylitis may be extremely painful.  However, over time, as destructive changes occur, the inflamed tissue is replaced with bony deformity and the dactylitis no longer causes severe pain.  However, the swelling persists.

The presence of dactylitis should prompt a diagnostic workup.  Diagnosis can be substantiated by magnetic resonance imaging (MRI).  Recently, diagnostic ultrasound has also been found to be helpful.

The treatment of dactylitis depends on the number of digits affected.  If only a few fingers or toes are involved, ultrasound-guided steroid injection can be helpful for the acute situation.

However, the more important part of treatment is to initiate disease modifying therapy as soon as possible.

Generally, the dactylitis is often accompanied by enthesitis.  This is inflammation at tendon insertions such as the Achilles tendon, patellar tendon (the tendon that connects the kneecap to the tibia-lower leg bone, and the iliac crest.

Every disease that causes dactylitis is a systemic disease.  This is because the underlying pathology involves an abnormal immune response. So other organ systems can become affected.  An example is the eye where uveitis- inflammation of the middle layer of the eye- can occur.  Uveitis is a potentially serious complication that can lead to blindness.

Institution of drugs like methotrexate or sulfasalazine (Azulfidine) may be useful.

However, most patients will require the use of biologic therapies.

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Rheumatoid arthritis drugs… which ones are friendly to the heart and which ones aren’t!

Rheumatoid arthritis (RA) is a chronic, autoimmune systemic disease which affects approximately two million Americans. While the symptoms that bring the patient to the doctor are the joint swelling and pain, the area of most concern may not be the joints.  It is well established that cardiovascular risk is markedly increased in RA and in fact it is this complication that shortens lifespan by between ten to fifteen years.

A number of clinical studies have retrospectively examined the relationship between certain medications and the risk of cardiovascular events.  The report card has provided some real surprises.heart-attack_0

For example, methotrexate, the workhorse disease modifying anti-rheumatic drug (DMARD) of choice reduces cardiovascular mortality by almost 70 per cent. The mechanism is felt to be due to a reduction of atherosclerotic plaque formation as well as increased clearance of foam cells (Solomon DH, et al. Circulation 2003; 11: 1303-1307).

The other major player in the treatment of RA is the TNF inhibitor group.  These are used in more than 50 per cent of RA patients in the US. These drugs apparently reduce the risk of cardiovascular events by almost 50 per cent (Gonzalaz A, et al. Ann Rheum Dis. 2008; 67: 64-69). Why this occurs is still not clearly understood.

Steroids have been used to treat RA since the early 1950’s.  Steroids have been shown to worsen cardiovascular risk because of their effects on both blood pressure as well as blood glucose.  Steroid use in RA has been associated with increased carotid plaque formation as well as increased arterial stiffness.  So what dose is a safe dose?  The answer is still unknown.

Non-steroidal anti-inflammatory drugs (NSAIDS) raise blood pressure.  Randomized clinical trials have shown that cardiovascular risk is associated with COX-2 inhibitors but also with non-selective COX drugs also.  The upshot? All NSAIDS regardless of class, are associated with increased cardiovascular risk.

Hydroxychloroquine, a drug often used to treat mild RA, is associated with a decrease in diabetes and may also improve lipid status.  Actemra increases lipid profile but the long term effects are still unknown.  Leflunomide (Arava) increases blood pressure.  The eventual effects are still a subject of conjecture.

So what about aspirin?  This medication is used for cardiovascular prophylaxis.  In higher doses it also has anti-inflammatory effects although these are limited by the potential gastrointestinal side effects known to be caused by high dose aspirin. It is well known that other NSAIDS should not be used in patients taking aspirin for cardiovascular prophylaxis since they blunt that effect.

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Prevention is the best treatment for osteoarthritis?

A work group called the Osteoarthritis Management Initiative (COAMI) met in 2012 to discuss osteoarthritis management and what could be improved.  The thrust of the meeting was aimed at developing new strategies for prevention of the disease.osteoarthritis-knee-2

Risk factors for osteoarthritis include obesity, aging, genetics, family history, major injury or surgery to the joint, and misalignment of the joint.

According to Dr. Rowland Chang, professor of medicine at the Northwestern University School of Medicine, rheumatology is where cardiology was in the 1950′s.  More attention should be placed on disease prevention.  That includes lifestyle changes. He states, “If we could wipe out obesity, … we might be able to prevent about one-third of all the knee osteoarthritis we have in the world.”

My comment is this: It’s an admirable undertaking but making people change their lifestyle is going to be difficult.  However, with the aging Baby Boomer population, it’s certainly worth a try.

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Patients over 70 do well after minimally invasive spinal stenosis surgery

Rosemary Frei writing in Pain Management News reported on a study led by Raja Rampersand, MD at the Spinal Program of the Toronto Western Hospital and the University of Toronto. Analysis of data from 2008 to 2011 compared patients aged 40 to 69 with patients past the age of 70 who underwent surgical decompression for lumbar spinal stenosis.  There were no differences in adverse events between the two groups, although patients in both groups took longer to recover if a fusion accompanied the decompression. lumbar-spinal-stenosis-old-man

Comment: Spinal stenosis is one of the most common low back syndromes seen in rheumatology practice.  Although epidural steroid injections and physical therapy can be effective for many patients, many people with this malady go on to have surgery. This study provides encouraging news for patients with spinal stenosis.

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How to protect your back when you lift… another lesson in arthritis treatment

While arthritis is a frequent cause of low back pain and can be treated medically, most low back pain comes from simple daily activities such as lifting. In this case, prevention is the best treatment.low-back-pain-2

Lifting things the wrong way can cause severe low back problems including sprain, strain, and disc herniation.

Here are nine tips to help you prevent a problem:

  1. Plan ahead. Avoid sudden movements by clearing the path and ensuring you have a plan in mind.
  2. Stand with your feet shoulder width apart.
  3. Bend from your hips and knees, keeping your back straight.
  4. Use your core. Focus on trying to make your belly button meet your spine.
  5. Bring what you’re lifting as close to your body as possible both before and during lifting.
  6. Lift using your legs.  Push up from the heels.
  7. Ask for assistance if the object is heavy.
  8. Avoid twisting at the waist.  Keep the nose aligned with the toes. Move the feet.
  9. If pain does follow lifting and continues for more than 24 hours, see a physician.

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“Ooohhh, My Aching Knee!” Insider Secrets on How You Can Get Relief Quickly and Easily!

When your knee hurts, getting relief is all that’s on your mind. Getting the right relief, though, depends on knowing what’s wrong. The correct diagnosis will lead to the correct treatment.

Know Your Knee!knee-arthritis

The knee is the largest joint in the body. It’s also one of the most complicated. The knee joint is made up of four bones that are connected by muscles, ligaments, and tendons. The femur (large thigh bone) interacts with the two shin bones, the tibia (the larger one) located towards the inside and the fibula (the smaller one) located towards the outside. Where the femur meets the tibia is termed the joint line. The patella, (the knee cap) is the bone that sits in the front of the knee. It slides up and down in a groove in the lower part of the femur (the femoral groove) as the knee bends and straightens.

Ligaments are the strong rope-like structures that help connect bones and provide stability. In the knee, there are four major ligaments. On the inner (medial) aspect of the knee is the medial collateral ligament (MCL) and on the outer (lateral) aspect of the knee is the lateral collateral ligament (LCL). The other two main ligaments are found in the center of the knee. These ligaments are called the anterior cruciate ligament (ACL) and the posterior cruciate ligament (PCL). They are called cruciate ligaments because the ACL crosses in front of the PCL. Other smaller ligaments help hold the patella in place in the center of the femoral groove.

Two structures called menisci sit between the femur and the tibia. These structures act as cushions or shock absorbers. They also help provide stability for the knee. The menisci are made of a tough material called fibrocartilage. There is a medial meniscus and a lateral meniscus. When either meniscus is damaged it is called a “torn cartilage”.

There is another type of cartilage in the knee called hyaline cartilage. This cartilage is a smooth shiny material that covers the bones in the knee joint. In the knee, hyaline cartilage covers the ends of the femur, the femoral groove, the top of the tibia and the underside of the patella. Hyaline cartilage allows the knee bones to move easily as the knee bends and straightens.

Tendons connect muscles to bone. The large quadriceps muscles on the front of the thigh attach to the top of the patella via the quadriceps tendon. This tendon inserts on the patella and then continues down to form the rope-like patellar tendon. The patellar tendon in turn, attaches to the front of the tibia. The hamstring muscles on the back of the thigh attach to the tibia at the back of the knee. The quadriceps muscles are the muscles that straighten the knee. The hamstring muscles are the main muscles that bend the knee.

Bursae are small fluid filled sacs that decrease the friction between two tissues. Bursae also protect bony structures. There are many different bursae around the knee but the ones that are most important are the prepatellar bursa in front of the knee cap, the infrapatellar bursa just below the kneecap, the anserine bursa, just below the joint line and to the inner side of the tibia, and the semimembranous bursa in the back of the knee. Normally, a bursa has very little fluid in it but if it becomes irritated it can fill with fluid and become very large.

Is it bursitis… or tendonitis…or arthritis?

Tendonitis generally affects either the quadriceps tendon or patellar tendon. Repetitive jumping or trauma may set off tendonitis. The pain is felt in the front of the knee and there is tenderness as well as swelling involving the tendon. With patellar tendonitis, the infrapatellar bursa will often be inflamed also. Treatment involves rest, ice, and anti-inflammatory medication. Injections are rarely used. Physical therapy with ultrasound and iontopheresis may help.

Bursitis pain is common. The prepatellar bursa may become inflamed particularly in patients who spend a lot of time on their knees (carpet layers). The bursa will become swollen. The major concern here is to make sure the bursa is not infected. The bursa should be aspirated (fluid withdrawn by needle) by a specialist. The fluid should be cultured. If there is no infection, the bursitis may be treated with anti-jnflammatory medicines, ice, and physical therapy. Knee pads should be worn to prevent a recurrence once the initial bursitis is cleared up.

Anserine bursitis often occurs in overweight people who also have osteoarthritis of the knee. Pain and some swelling is noted in the anserine bursa. Treatment consists of steroid injection, ice, physical therapy, and weight loss.

The semimembranous bursa can be affected when a patient has fluid in the knee (a knee effusion). The fluid will push backwards and the bursa will become filled with fluid and cause a sensation of fullness and tightness in the back of the knee. This is called a Baker’s cyst. If the bursa ruptures, the fluid will dissect down into the calf. The danger here is that it may look like a blood clot in the calf. A venogram and ultrasound test will help differentiate a ruptured Baker’s cyst from a blood clot. The Baker’s cyst is treated with aspiration of the fluid from the knee along with steroid injection, ice, and elevation of the leg.

Knock out knee arthritis… simple steps you can take!

Younger people who have pain in the front of the knee have what is called patellofemoral syndrome (PFS). Two major conditions cause PFS. The first is chondromalacia patella. This is a condition where the cartilage on the underside of the knee cap softens and is particularly common in young women. Another cause of pain behind the knee cap in younger people may be a patella that doesn’t track normally in the femoral groove. For both chondromalacia as well as a poorly tracking patella, special exercises, taping, and anti-inflammatory medicines may be helpful. If the patellar tracking becomes a significant problem despite conservative measures, surgery is need.

While many types of arthritis may affect the knee, osteoarthritis is the most common. Osteoarthritis usually affects the joint between the femur and tibia in the medial (inner) compartment of the knee. Osteoarthritis may also involve the joint between the femur and tibia on the outer side of the knee as well as the joint between the femur and patella. Why osteoarthritis develops is still being scrutinized carefully. It seems to consist of a complex interaction of genetics, mechanical factors, and immune system involvement. The immune system attacks the joint through a combination of degradative enzymes and inflammatory chemical messengers called cytokines.

Patients will sometimes feel a sensation of rubbing or grinding. The knee will become stiff if the patient sits for any length of time. With local inflammation, the patient may experience pain at night and get relief from sleeping with a pillow between the knees. Occasionally, locking and clicking may be noticed. Patients with osteoarthritis may also tear the fibrocartilage cushions (menisci) in the knee more easily than people without osteoarthritis.

So how is the arthritis treated? An obvious place to start is weight reduction for patients who carry around too many pounds.

Strengthening exercises for the knee are also useful for many people. These should be done under the supervision of a physician or physical therapist.

Other therapies include ice, anti inflammatory medicines, and occasionally steroid injections. Glucosamine and chondroitin supplements may be helpful. A word of caution… make sure the preparation you buy is pure and contains what the label says it does. The supplement industry is unregulated… so buyer beware!

Injections of the knee with viscosupplements – lubricants- are particularly useful for many patients. Special braces may help to unload the part of the joint that is affected.

Arthroscopic techniques may be beneficial in special circumstances. Occasionally, a surgical procedure called an osteotomy, where a wedge of bone is removed from the tibia to “even things out,” may be recommended. Joint replacement surgery is required for end stage knee arthritis.

Research is being done to develop medicines that will slow down the rate of cartilage loss. Targets for these new therapies include the destructive enzymes and/or cytokines that degrade cartilage. It is hoped that by inhibiting these enzymes and cytokines and by boosting the ability of cartilage to repair itself, that therapies designed to actually reverse osteoarthritis may be created. These are referred to as disease-modifying osteoarthritis drugs or “DMOADs.” Genetic markers may identify high risk patients who need more aggressive therapies.

Newer compounds that are injected into the knee and provide healing as well as lubrication are also being developed. And finally, less invasive surgical techniques are also being looked at. Recent technological advances in “mini” knee replacement look very promising.

The technology that will revolutionize our approach to knee osteoarthritis is the use of mesenchymal stem cells.  These are stem cells derived from “non-blood” tissues such as fat, bone marrow, or even the lining of the joint. Studies in both animals as well as humans have shown great potential for these cells to regenerate cartilage.

For more information on arthritis treatments and other arthritis problems,  go to:

Arthritis Treatment

And don’t forget to sign up for  free weekly arthritis tips and a free copy of our special report “The Consumer’s Guide to Arthritis”

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