Pain and stiffness in the joints are the most common symptoms. The pain is usually more after exercise and when you put weight or pressure on the joints. If you have Osteoarthritis, your joints probably become stiffer and harder to move over time. You may notice a rubbing, grating, or crackling sound when you move the joint. The phrase morning stiffness refers to  relatively increased  pain and stiffness after waking up in the morning. This increased stiffness usually subside in less than 30 minutes. It is improved by warming  up the joint. During the course of the day, the pain may get worse when you’re active and feel better when you are resting. After a while, the pain may persist all the time. It may even disturb your sleep. Some people might not experience any symptoms, even though x-rays might show the changes of OA.

What does the Doctor/ Rheumatologist find after examining you?

Your doctor may find the following symptoms on examination:

1. Cracking or grating sound on the Joint movement, called crepitus
2. Joint swelling (bones around the joints may seem to be larger than normal)
3. Range of motion (ROM) may be decreases.
4. There may be tenderness on pressing the joints.
5. Moving the joint may be painful.

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1. Be  active, do  regular optimal exercises without damaging the joints further.  Ask your doctor to prescribe you a tailor made home exercise routine. Water exercises, such as swimming are extremely helpful.
2.  Applying heat and cold as per your preference.
3. Eat a healthy and balanced diet.
4. Resting is a good idea for your joints if they pain. Exercise optimally.
5. Lose weight if you are overweight. Losing weight may prevent, reverse & delay the OA process.
6. Supporting the joints may protect the joints from further damage.
7. Making changes around your house in terms of staircases and other things that put strain on your joints will help in reducing some stress off your joints thus relieving some of the joint pains.
8. Work sometimes, can cause stress in joints, you then have to adjust your work area or change work schedule.

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What initiates Osteoarthritis?

Osteoarthritis occurs because of the loss of cartilage between bones. Cartilage is a firm rubbery tissue that cushions bony ends at the joints and allows bones to glide over each other smoothly. If the cartilage starts breaking down and wearing away, the cushioning effect reduces. This puts more stress and strain on the structure between cartilage and bone called transitional or subchondral bone, thereby leading to the changes resulting in hardening of this tissue. This reduces the smooth transition of the pressure from the cartilage to bone. Thus cartilage starts degenerating in the process. After some part of the cartilage has worn away, the bony ends start  rubbing against each other, which causes pain. In the wearing away process, the cartilage fragments are separated and fall into the joint cavity. The human body tries to remove these fragments through the inflammatory process. This is what causes the joints to swell. If one side of cartilage wears down more than the other, it causes deformities which leads to angulations of the affected joints. Pain and stiffness is also experienced because of deranged biomechanical properties of the joints due to the stretch of the structures around the joints. As there remains no cartilage, the bones try to expand at the bony ends to reduce the pressure per unit area by forming bony spurs or extra bone which are called osteophytes visible on the X-Rays.

What are the risk factors which initiate development of Osteoarthritis?

1. It may be familial, running in families.
2. Overweight increases the risk of OA in the hip, knee, ankle, and foot joints because extra weight causes more wear and tear.
3. Fractures or other joint injuries may start  OA later in life
4. Jobs involving kneeling or squatting for more than an hour a day put a joints  at the highest risk. Jobs that involve lifting, climbing stairs, or walking also put you at risk.
5. Sports involving direct impact on the joint (such as football), twisting (such as basketball or soccer), or throwing  increase the risk of developing osteoarthritis.
6. Bleeding disorders  causing bleed in the joint, such as Hemophilia.
7. Disorders that block the blood supply to  a joint lead to avascular necrosis and thereby OA
8. Chronic gout, pseudogout, Rheumatoid arthritis and other autoimmune rheumatic diseases also lead to rapid development of the OA.
9. Endocrine disorders like hypothyroidism can accelerate the process of developing the OA
10. Hypermobility of the joints, which runs in families, especially when associated with heavy work and overweight tends to cause early osteoarthritis.

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A great visual message about what I have been saying for all these years to my patients. The single best thing you can do to stay health is ‘Stay Healthy’ – Exercise, Eat Good Food, Stay Fit, Don’t Smoke.

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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.

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All Pasteurized and Dairy Products

Egg Plant / Brinjal

Potatoes

Tomatoes

Corn

Bacon & Pork

Oranges

Refined Sugars

Chemical Sugar Sweetners

MSG (Monosodium glutamate)

Alcohol

Caffeine

Red Meat

Processed food

Common salt

Tobacco

Food to Eat:

Salmon

Flax Seeds

Walnuts

Green Tea

Black Tea

Cherries

Papaya

Bell peppers (yellow, red and green)

Broccoli

Brussel sprouts

Strawberries

Canteloupe

Kiwifruit

Cauliflower (boiled)

Grapefruit

Raspberries

Cod – baked or broiled

Shrimp – steamed or boiled

Snapper – baked or broiled

Tuna – yellowfin, baked or broiled

Halibut – baked or broiled

Salmon – chinook, baked or broiled

Calf’s liver – braised

Whole egg

Turkey breast

Lamb loin – roasted

Barley – cooked

Whole grain oats – cooked

Chicken breast – roasted

Beef tenderloin (lean) – broiled

Garlic

Brown rice – cooked

Tofu – raw

Avacado

Grape Fruit

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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.

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This issue has yet not been resolved. RA is not a genetic disease but you can say that RA patients generally have genes which may facilitate the  production of certain antibodies after exposure to certain triggers (in environment, stress and other unknown triggers). Even if a person has susceptible genes, it is not necessary to develop the disease without triggers. So, generally the disease is multifactorial.

How common is the misdiagnosis of RA?

That is quite common especially by Non-rheumatologists. Laymen and many doctors who don’t specialise in rheumatology think that there is only one type of arthritis. But, in fact arthritis should be considered only as a symptom arising out of 100 causes. RA gets misdiagnosed so often as Osteoarthritis and Gout. And sometimes nonspecific aches and pains also get misdiagnosed as RA. For example in cases of Diabetes, hands get stiff and mildly painful but get diagnosed as a case of RA.

Is it seasonal, will it flare up in change of seasons?

Yes, for unknown reasons, RA tends to flare up periodically, despite consumption of appropriate medications. Adjustment of medications or additions in prescription like steroids are required to control of symptoms.

Will changing our current lifestyle help?

People should reduce weight to decrease the burden on the dysregulated immune system. Patient needs regular excercise within the limit of tolerance to maintain the muscle strength and to maintain the range of motion. Smoking is big NO, NO. Always have a positive attitude. Consumption of fresh fruits and vegetables will always be good. Meditation is recommended.

Is it a condition with which a patient has to live with like Diabetes and it can only be moderated and not cured?

Yes, at present there is no cure for this disease as there is no cure for other majority of diseases except a few infections. As in the case of diabetes, a proper control of blood sugar can be achieved and the damage of various organ systems can be avoided by doing this. In the same way, in case of RA, target of the treatment is controlling the autoimmune inflammation by appropriate medicines so that damage to the joints can be halted and pain can be ameliorated. And as in case of Diabetes, the job of controlling blood sugar is best done by an Endocrinologist, for RA, it is best done by a Rheumatologist.

What will be repurcussion, if RA is not treated or countered?

If Inflammation caused by RA is not controlled, it will continue to damage the affected joints and it can cripple you within a few years, and with proper control of inflammation by a Rheumatologist, joints can be saved from the adverse affect of this inflammation for decades and patients can continue walking through their lifetime without undergoing joint replacement. Early correct diagnosis and treatment by Rheumatologist is of paramount importance in modern times.

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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.

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