Rheumatology

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In: Blog, Disease information, Rheumatology, Videos

Comments Off on Diet, supplements and dietary fads in arthritis

One of the questions I’m most frequently asked by patients is whether diet plays any role in the management of arthritis.

If one were to believe what they read in the papers about dietary remedies, or in the number of books promoting diets or supplements claiming to cure arthritis, one would be forgiven for wondering whether they need to take medical treatment at all.

The idea that a simple change to diet might cure, or lessen the symptoms of a disease as potentially devastating as arthritis, is attractive. It it were only that simple….

What I have done is prepare a number of videos which addresses the available evidence for the effectiveness (or otherwise) of commonly used diets and dietary supplements. I hope you find them useful.

 

A word of caution. You should be aware that most of the claims that are made for dietary manipulation in the treatment of arthritis are based, at best, on poor quality research. Claims for the effectiveness of diet are often made in the face of weak (or absent) scientific evidence, or even worse, in the face of scientific information to the contrary.

Any of the scientific evidence that exists for benefits of diet in arthritis relates primarily to symptom improvement. The is no evidence from any of the scientific studies carried out to date, (other than perhaps weight loss diets as a treatment for osteoarthritis of the knee) that diet can slow the damage or other reduced the negative health consequences of a disease like rheumatoid arthritis. Medical treatment will usually still be required.

Where there is evidence for the effectiveness of any given diet, it may not apply to all forms of arthritis. I have done my best to address this where I can.

 

 

Last weekend I was rear ended and my sturdy 2006 Volvo V-70, which I had planned on driving for another few years, was written off. As I got out of the car, I became aware that my neck was painful but naturally declined an onlooker’s offer of calling for an ambulance. The embarrassing prospect of being placed in a cervical collar and being presented to an emergency department colleague on a stretcher did not appeal to me. Besides, I had to drop my daughter to a party.

The fact that I might have injured my neck caused some concern (and some mirth) amongst family members, who could still clearly recall my first whiplash injury — almost 40 years earlier. Having sustained what was, in retrospect, a minor neck strain (following a jump from a wall), I awoke the following day with such severe neck pain that my parents were unable to persuade me to get out of bed. The local GP was called, strong painkillers, muscle relaxants and a neck collar were prescribed and over the next few days my home bedroom was gradually converted, my younger brother recalls, into a temporary intensive care unit.

My physical and considerable emotional needs were carefully attended to by my attentive parents, my fluid balance restored with MiWadi infused through a bendy straw and my nutrition maintained with jelly and ice cream. After a time, and once I felt well enough to lift my head from the pillow, I was transferred to a lower-dependency unit located in the family TV room. After a further, lengthy period of rehabilitation, it was considered safe to allow me to return to school. My neck pain continued and over next few years, I would travel around the country see the best physiotherapists, orthopaedic surgeons and rheumatologists in the land. The advice I received from more than one specialist was that I needed to be very careful with my neck, pay extra attention to my posture and avoid contact sport at all costs.

Despite medical interventions (and perhaps precisely because they had stopped), my neck pain eventually settled. The experience, however, has given me a unique insight into my own low threshold for unpleasantness, some understanding of the non-medical dynamics of chronic pain and how completely unaware most of us are of them as sufferers.

It therefore came as a pleasant surprise that my most recent whiplash injury settled down within a few days. Could I have toughened up?

A quick Google search alerted me to a possible explanation for my speedy recovery: Doctors, it appears, are relatively immune to the long-term effects of neck injuries following rear-end collisions. A study by Ferrari published in 2001 examined the effects of whiplash injury in doctors compared to a control population. Doctors developed acute symptoms less frequently than non-doctors and injured doctors settled down more quickly than controls. They were also quicker to return to work after an injury.

The author’s proposal was that the development of chronic neck pain after a road traffic accident is largely culturally and geographically determined and that these factors are much more important than the mechanism and severity of the initial injury. Where there isn’t an expectation of the development of chronic neck pain after an accident, he argued, then it is much less likely to occur.

In ordinary circumstances, Ferrari detailed in his book The Whiplash Encyclopaedia — The Facts and Myths of Whiplash, the often frightening circumstances surrounding the initial management of a neck injury (paramedics, collars, stretchers and EDs) tend to create the impression than the injury is not benign.

The initial lack of response to treatment by various therapists and specialists (where attention is repeatedly drawn to the symptoms), and subsequent frequent misattribution of symptoms to abnormalities seen on imaging, all tend to further amplify and reinforce the apparent seriousness of the injury. The additional influence of compensation, he argued (the MiWadi, jelly and ice cream of my own experience) can lead to worse outcomes. He pointed out that in countries where ‘no-fault compensation’ has been introduced (and where financial compensation for continued suffering was removed), the incidence and severity of chronic symptoms in this setting has improved.

Most people injured in this setting will be oblivious, as I was, to the influence that all of these factors will have on perpetuation of their symptoms.

It makes sense, though, that doctors are less likely, by the nature of their training and knowledge, to be susceptible to these influences, or to be fortunate enough to avoid exposure to them in the first place. Ferrari has also published similar positive and early recovery outcomes in rodeo riders who have been involved in road traffic accidents — another group with an expectation, based on personal experience, that neck sprains are pretty common and will usually settle down.

As I write, I feel a twinge of pain in my neck. Maybe I should have an MRI scan…

This article was originally published in The Medical Independent

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In: Blog, Rheumatology

Comments Off on Mindfulness Resources for Chronic Pain

What is Mindfulness based meditation?

Mindfulness based meditation has been around for thousands of years. Whereas modern mindfulness practice has some origins in the Buddhist tradition, one does not need to subscribe to any particular faith to practice it. Mindulfness is defined as “the intentional, accepting and non-judgemental focus of one’s attention on the emotions, thoughts and sensations occurring in the present moment”. Don’t let the language used to describe it put you off….

On first look, the idea of paying MORE attention to ones pain may not initially make sense to someone suffering from it. But by paying attention to pain, Professor Mark Williams (writing in his introduction to the book, ‘Mindfulness for Health’) we become aware of the“very subtle processes which switch on automatically to turn up the volume of the very pain you want to get rid of. It is because these aggravating factors switch on automatically, without your awareness, that the spotlight of attention is needed. If it all happens ‘in the dark’ you remain lost and alone with your pain. But if you can shine a light of attention upon your suffering, then it begins to dissolve.”

There’s evidence of its effectiveness in the treatment of the symptoms of arthritis, fibromyalgia and low back pain, and also in depression and anxiety.

Most studies of the use of this type of Mindfulness are based on the work of Jon Kabat-Zinn a Massachusetts based scientist. His work demonstrated the effectiveness of mindfulness in reducing pain and the emotional reaction to pain in the setting of an 8 week course. Meditation Courses like this (i.e. specifically designed for chronic pain sufferers) are not widely available but thankfully there are now a number of web-based  / distance learning programmes available (see resources below).

There’s also variety of helpful guided meditation apps, CD’s and books. Although most of the available evidence that confirms the effectiveness of Mindfulness is based on those attending formal classes with a teacher (we don’t yet know how effective other means of learning mindfulness are yet), these resources are an excellent place to start.

Firstly, Here’s some videos I recorded about Mindfulness and pain management.

Resources:

Books

Please support your local bookseller by purchasing these locally. Dubray books don’t charge for postage if you pick up in-store.

Mindfulness for health – Vidyamala Burch and Danny Penman

This book is based on an 8 week course designed specifically with sufferers of chronic pain in mind. Written by two people who have used mindfulness to help ease their pain and help them cope with it, this an excellent book and primer for those interested in learning more. Included with the book is a CD with guided meditation to get you started.

Wherever you go there you are – Jon Kabat-Zinn

Jon Kabat Zin is the Massachusetts based scientist and researcher who is largely credited with introducing mindfulness to Western Medicine.

Mindfulness on the go – Padraic O’Morain (Padraic’s Website, with details of courses and an excellent blog also worth a look)

 Apps

Headspace (Paid app after 10 days free). This is a really user friendly app (iPhone and Android) with great video animations which help explain mindfulness. Not specifically for chronic pain but excellent modules on stress and anxiety. I use this one myself daily.

Insight timer Free app for iPhone and Android with a variety of different meditation teachers and styles of meditation and a handy meditation timer. In-app purchases available

Web

There is a great article written by Galway (NUI Galway) psychologist Michael Hogan describing the research on the use of mindfulness in pain management. Michael and his team have done some research on the effectiveness of a Web based pain management programme using mindfulness. Links to the audio files used as part of the course are also online.

www.Breathworks-mindfulness.org.uk

This is the organisation who run the courses on which the Mindfulness for Health book are based. Great resource (mainly UK)

 

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In: Blog, Medical Independant, Rheumatology, The practice of Medicine

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I’ve just returned from my specialty’s annual scientific meeting in Boston. The meeting truly is the ‘Virgin Megastore’ of our specialty, with over 15,000 delegates, 3,000 scientific abstracts, hundreds of oral presentations, ‘meet the professor’ and review sessions.

Whereas very few unexpected medical breakthroughs are ever revealed at the meeting, it is a unique opportunity to catch-up with all of the latest developments in our specialty and always worth the trip.

Here’s some of my highlights from this year’s meeting.

Year in review

 Location: Forum (bar-restaurant), Boylston St, Boston MA

Format: Dinner and a beer with many of my Irish specialty colleagues whom I don’t see from one end of the year to another.

Topics discussed: Getting older, managing complex disease, medical gossip, how to get a neurosurgical patient admitted to Beaumont Hospital, the future of our specialty, vasectomies, politics, cookery courses and box-sets.

‘Meet the professor’ session

 Location: Main entrance to exhibition area, MCCA Convention Centre

Format: One-on-one intimate mentoring session with an expert in the area of life, rearing teenage kids and rheumatology.

Topics for discussion: Retirement planning, the art of the perfect holiday, keeping cool with teenagers and making the best of downtime at conferences (without succumbing to feelings of guilt).

 Read more at The Medical Independent 

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In: Blog, Medical Independant, Rheumatology, The practice of Medicine

Comments Off on The humbling art of medicine — the right to be wrong

I was at a wonderful presentation by a senior colleague recently. Close to retirement, he had been invited to offer some pearls of wisdom to those attending. In doing so he presented a litany of misdiagnoses, delayed diagnoses, mistreatments and treatment failures he had made over the years. We all cringed, squirmed and groaned on his behalf (and our own) but it was an important acknowledgement of how humbling the art of medicine can be, and of the therapeutic benefits of a good confession.

Over my own career, I’ve cocked-up more than a few times. I like to think though, that I’ve learned something from my mistakes. Apologies though, to those patients who I diagnosed as having rheumatoid arthritis who later turned out to have gout (always check the uric acid).

My regrets to the couple of patients I misdiagnosed as having sciatica, who later turned out to have hip osteoarthritis (examine the hips in patients with sciatica — even when your clinic is running an hour behind).

Mea culpa to the GP’s wife whose metatarsal stress fracture I injected with corticosteroid (not everything in the foot that is tender is arthritis), and to the man who’s spinal osteomyelitis I missed (ask about red flag symptoms in all patients with low back pain — especially when your clinic is running an hour behind).

The error from which I learned most happened fairly early in my career as a consultant. I had just set up my practice in Galway, having recently returned from the UK, where I had completed my specialist training. I received a letter from a local GP seeking a second opinion on a patient who had previously been seen and treated by a general physician with ‘an interest’ in my speciality. The treating physician was having difficulty controlling the patient’s symptoms and the patient was getting frustrated.

“Here we go… ” I thought to myself, as I sent for the patient.

Like me, my patient had recently returned from the UK, where she saw a specialist who had made her original diagnosis. After spending a few minutes with her, it became obvious to me that original diagnosis (of rheumatoid arthritis) had been incorrect.

The patient had numerous explanations for her pain other than rheumatoid arthritis and the investigation that was likely to have prompted her original diagnosis (a positive rheumatoid factor test) was due to the fact that she had Sjogren’s syndrome. Because of an incorrect diagnostic label, the poor woman had been taking a whole variety of toxic drugs for years and had spent a fortune seeing the physician privately.

My specialist pride congratulated itself on making such a clever diagnosis and for being smarter than either the physician who had cared for her of late or the rheumatologist who had made the original diagnosis. Gosh, I’m good, I thought.

A conversation ensued.

“That’s wonderful news doctor. You mean I don’t have rheumatoid arthritis after all?”

“Not in my opinion, you don’t.”

“It’s great to see someone who knows what he’s talking about. Do you mind me asking where you did your training?”

“In the UK. In Cambridge mainly.”

“Really, doctor? Were you in Addenbrooke’s then?”

“I trained there for four years.”

“That’s amazing. That’s where I was told I had rheumatoid — by an Irish doctor who was training there.”

With that she thanked me, stood up to leave and just before she left the room, she paused, turned to me and said: “I knew you looked familiar.”

It’s never a bad idea to get a second opinion — even if it’s from yourself.

Originally published in The Medical Independent

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Comments Off on Paging Dr Beat the headbanger

As my 50th birthday party celebration approaches, my teenage kids grow increasingly anxious about the prospect of watching their dad ‘getting down’ on the dance floor on the big night. I understand completely. It’s not an attractive sight.

Spare a thought then for the family of a 50-year-old ‘dad dancer’ who sustained a subdural haemorrhage as a result of ‘headbanging’ at a Motörhead concert in Germany. Thankfully, according to the article in the The Lancet , he was quickly diagnosed, treated and has made a full recovery. I can only hope that if the man has teenage children, that they weren’t there to witness the spectacle.

Although it seems unlikely that this man was up to speed on the medical literature on the risks of headbanging at the time, there has been plenty published on its dangers over the years. I have a personal interest in the area, having sustained a self-induced whiplash injury and severe headache after spending just three-and-a-half minutes’ furious head-shaking while playing air guitar to Black Betty by Ram Jam at a Medsoc party in the early 1980s. (I also developed a mysterious plum-sized bruise on my neck in the course of the same night out — the aetiology of which remains uncertain.)

‘Headbanger’ is a term initially used to describe fans who were seen banging their heads on the stage in time to the music at a Led Zeppelin concert in the late 1960s. The technique has evolved somewhat over the years and is now used to refer to “violent and rhythmic movement of the head synchronous with music, most commonly heavy metal music”. Headbanging was taken to a new level in the 1970s by fans of the speed metal band Motörhead. Pushed along by the frantic bass playing of their toothless and legendary lead singer Lemmy, Motörhead play very loud and very fast. It would have taken more than a hot-water bottle and a day in bed for an amateur like me to have recovered from even a minute’s headbanging to Motörhead in their heyday (or mine).

Rock of ages: Motorhead’s Lemmy

It seems I may have been right to avoid headbanging after that first ill -fated attempt. Three other cases of subdural haemorrhage (including one death) associated with headbanging have been described in the literature. One headbanger seems to have managed to develop an atlantoaxial subluxation doing it, there’s been a case of vertebral artery dissection described, and another metal-head seems to managed to give himself a pneumothorax. Lemmy has got a lot to answer for.

In what must be the authoritative study (and one of my favourite Christmas BMJ articles of recent years), two enterprising Australian researchers took it upon themselves to attend “several” hard rock and heavy metal concerts in the interests of exploring the health and safety issues of the practice. They identified and studied four types of headbanging technique; the up-down, the circular swing, the full body, or the side-to-side. They also carefully studied the biomechanics of headbanging and held detailed focus group discussions with the characters ‘Beavis and Butthead’.

Their recommendations for reducing the likelihood of injury included: educating headbangers on limiting the range of neck motion before a concert; wearing a neck brace; headbanging to every second beat; and finally substituting easy-listening music (eg, Michael Bolton, Celine Dion, Enya) for heavy metal music. It’s a meticulously detailed and very worthwhile piece of research.

Although I will embarrass my kids by taking to the dance floor (with a dancing style heavily influenced by Sting in The Police’s Walking on the Moon video) at my 50th, I’m sure they’ll never speak to me again if I appear clad in a sleeveless denim jacket, hook my thumbs into my Wrangler flares and go all ‘metal’ to Motörhead’s Ace of Spades. Perhaps I’d better invite a couple of neurosurgeons.

Originally published in the Medical Independent

My patient is a middle aged professional, with no symptoms what so ever.

He is fit and healthy, a non smoker, has good teeth, eats well and has no family history of arthritis or autoimmune disease. So why is he seeing a rheumatologist?

He’s concerned about some results he has received from a genetic screening test. The test results suggest that his risk of developing two autoimmune diseases – rheumatoid arthritis and Scleroderma, conditions I frequently treat, is increased.

I’m at a slight disadvantage as this is the first time I’ve had has to counsel a patient in this situation.

There’s an additional complicating factor. The patient is me.

Eric Topol, in his book, The Creative Destruction of Medicine, describes how genetic health screening will be one of the key drivers of a shift towards personalised medicine. So, a few months back, I signed up to a service provided by the genetic screening company 23andMe, which offered a personalised screening test for $178 (On the request of the FDA, 23andMe no longer offer a health screening service).

Shortly afterwards, a courier collected a small vial of my saliva and then delivered it to a US based lab. 6 weeks later an email arrived with the results.

In arranging for the test to be performed, I broke two of my usual rules as a doctor; don’t try and practice medicine on yourself (I usually outsource my personal medical care to my excellent GP) and don’t request a test where you don’t know what to do with the answer.

I went to medical school and learnt about DNA, RNA and Mendelian inheritance. Through osmosis at medical conferences and by reading the background literature, I have acquired enough genetics knowledge to bluff at a dinner party of non geneticists. But with the exception of ‘need to know’ knowledge (specific to a fairly small number of diseases) my genetics knowledge is fairly limited.

Unfortunately these tests have not yet been validated in a clinical setting so there’s no real guidance for physicians like me trying to interpret these tests; What are the pitfalls and likelihood of a false positive or a false negative test? What is predictive value of a positive test? How reassuring is a negative test and how do these genetic risk factors interact with environmental factors to increase the risk of developing a specific disease like RA or scleroderma?

If I struggle as a doctor to put this information in context, how can I counsel and guide my patient? Until I have some I’m inclined to avoid answering. I’m going to get my patient to come back and see me in a few years’ time.

Further reading
NEJM series on Genomic Medicine
Dr. Robert West’s personalised medicine blog

Despite the fact that herbal cannabis is being used by many patients for arthritis symptom relief, and although the medical use of cannabis has been legalised in certain countries, most doctors (including me) know very little about the subject.

This years American College of Rheumatology meeting included an excellent and timely update which could be summarised as follows;

Lab based research

There is some evidence to suggest that cannabis derived substances (cannabinoids) may alter certain types of pain response, and reduce some of the immune response, in animal models of arthritis. Altering the processing of ‘endocannabinoids’ (substances which are made naturally in response to pain) may also alter the response to pain in this setting.

Despite this promising evidence from the laboratory, no good quality research (a randomised controlled trial) has yet been performed using herbal cannabis in humans. There have been a couple of small, uncontrolled studies which have suggested possible improvements in certain arthritis symptoms (pain and sleep for example) but with significant side effects (see below).

Part of the problem is that herbal cannabis contains over 60 cannabinoids (and hundreds of other compounds) and it is not yet certain which of these might be effective. Also, the strength of these components varies widely between products and their absorption varies considerably from person to person. Thus far, it hasn’t been possible to separate the analgesic properties from the psycho-active ones.

A more targeted approach has involved the use of certain subtypes of synthetic cannabinoids.

Rheumatoid arthritis and Fibromyalgia

Studies performed using these compounds in rheumatoid arthritis (an oral spray called Nabiximols – containing the cannabinoids, THC and cannabidiol) and in fibromyalgia (an oral preparation known as Nabilone) resulted in some improvement in pain and sleep but were still associated with significant side effects – especially drowsiness. These formulations are not licensed for the treatment of arthritis pain but are available in certain countries for the treatment of other conditions (such as MS and neuropathic pain).

Side effects.

Whereas there is a common perception that smoking or ingesting cannabis is relatively safe, information presented at the meeting suggests that regular use can result in significant side effects  which are listed below.

Driving problems

Cannabis results drowsiness, reduced short term memory, selective attention and reduced reaction times for up to 5 hours after using. Whereas this may not be perceived as a problem for recreational users, it may pose significant problems for those using cannabis regularly for pain relief who want to drive. Use of cannabis doubles the risk of dying in a road traffic accident, and is the most commonly used drug in up to 7.6% of people seriously injured in motor accidents.

Heart problems

Smoked or ingested cannabis can cause hypotension (low blood pressure) and increases the risk of having a myocardial infarction by a factor of five. For those who already have angina, it reduces exercise capacity by 50%. There is evidence suggest that regular cannabis smoking doubles the risk of lung cancer and may damage the lungs over time (especially regular use begins earlier in life).

Psychiatric illness

Whereas cannabis can reduce the symptoms of anxiety in some, it can cause anxiety or depression in others. This is particularly true in those with either a personal history or family history of mental illness.

The Bottom line

Evidence suggests that manipulating the cannabinoid system may be a useful approach for the relief of certain symptoms in rheumatic disease but the session concluded that more research should be done to clarify the mechanisms of these effects.

This risk benefit profile of inhaled herbal cannabis indicates that it should not be recommended for the treatment of pain arising from arthritis.

Where used, cannabinoids should be reserved  for patients with pain refractory to standard medical treatment.

Pharmacologic preparations are more desirable than largely uncontrolled herbal use.

Who should avoid cannabinoids?

Because of these risks (and others) the presenters suggested that these compounds should be especially avoided in the following;

Young people, especially those under the age of 25 (who are particularly at risk of dependance)

Anyone with a history of psychiatric illness or substance abuse (or those taking another psycho-active drug)

Those with history of cardiac disease or liver disease

‘Medical Marijuana and the Rheumatologist’ was presented by Dr. Jason McDougall and Dr. Mary Ann Fitzcharles at the American College of Rheumatology Annual Scientfic Meeting October 2013

 

 

 

 

 

 

Not being able to have sex, or struggling to enjoy it because of arthritis is a big deal to a lot of people. 50% of our patients with hip arthritis will have some difficulty having sex as a result of pain and stiffness and 20% of those who end up having a hip replacement have severe or extreme difficulties with their sex lives. Up to10% have to abstain altogether.

Thankfully total hip replacement usually results in good relief of hip pain and will restore the sex lives of most. Many recovering from a hip replacement can therefore look forward to getting ‘back onto the playing field’ after surgery – but many may also be apprehensive as to how far to push things (so to speak) with their new hip. 

Researchers from Geneva have gone to considerable trouble on their behalf by producing valuable research which sheds light on those sexual positions most likely to cause damage to their new hip.

Armed with an energetic young couple, motion capture and CAD software, an MRI and a CT scanner, the authors were able to simulate the effect that any one of 12 different sexual positions might have on a hip replacement.

The results indicate that the news is good for those who favour a more ‘traditional’ style of sexual intercourse  – the study did not flag up any problems with the missionary position. But those a little more adventurous may have to adjust their love-making style to reduce the risk of strain on the new hip or that of the ultimate passion killer, hip dislocation.

Women, it seems are likely to be more at risk than men. Those positions which result in a lot of hip flexion combined with abduction and external rotation (this is easier to visualise than describe – by looking at positions 5,8, and 10 on the diagram). For men, those positions which involve a lot of ‘external rotation of the hip’ ( e.g. positions 3,5 and 8) may cause problems. This might exclude a few positions from the menu but thankfully still leaves plenty to choose from. The helpful diagram also includes a few positions that some may not yet have had the chance to try.

NewImage

There’s a nice video summary of the research here (I wish all researchers would produce on of these)

Further information here and here

 References 

Sexual activity after Total hip Arthroplasty: A Motion Capture Study. Charnonnier et al (doi:10.1016/j.arth.2013.07.043)

Sexual function before and after primary total hip arthroplastyLaffosse et al (doi:10.1016/j.jbspin.2007.05.006)

 

 

 

 

 

 

 

The late comedian, Bill hicks has a hilarious routine on the perils growing old. Although its probably best not reproduce the actual wording here, he remarks how, if he were to be given extra years in life (he wasn’t), he’d rather have them in the middle of his life rather than at the end. He had a point.

Its a pity he isn’t around to see ‘Ping Pong’, the movie documentary about 8 elite table tennis players competing in the Veteran world table tennis championships. It follows these remarkable individuals (all of whom are over 80, including an Australian lady of 100) in their homes, nursing homes and gymnasiums around the world in preparation.

It details training routines consisting of free weights, press ups at the side of the road, jogging, ping pong marathons and some swearing. The competitors overcome disabilities including metastatic cancer, heart disease, lung disease, arthritis and strokes to compete.

It is a celebration of life, old age, friendship, humanity, stories, the benefits of exercise, and to say it is inspirational doesn’t do it justice.

I can’t remember myself enjoying a piece of film this much.

It is currently available for download and the producers have even put together a pack which includes the DVD, a table tennis net and some tips designed to get older people watching it to start playing.