Posts Tagged ‘Arthritis’
In the last 24 hours some guidelines have been published by the Irish Society for Rheumatology (ISR) which offer advice additional advice (to the Stay at Home advice offered by the HSE) to patients on immunosuppressive therapies.
Because patients who are on treatments which suppress their immune systems are at higher risk than others, additional restrictions have been recommended to keep them safe.
Firstly, the guidelines help identify the medications which put patients at risk (see the blue box at the bottom of the graphic).
This list includes standard immunosuppressive therapies, biologic medications, and steroid medications.
High Risk Group
The guidelines also help identify those who are, because of their age, underlying medical problem(s), or steroid intake at especially high risk.
It recommends that those at especially high risk Cocoon.
Examples of those in the very high risk category would be those over 70 yrs, those taking regular steroids (prednisolone / deltacortril), those with underlying heart or lung problems, high blood pressure, recurrent infections, or those with diabetes.
Increased Risk Group
Those on immunosuppressive treatments who do not fall into the high risk group still need to be careful. They still need follow the HSE stay at home guidelines, can exercise outside, but two additional recommendations are made; that they limit social contact, and that they do avoid shopping.
It is Cocooning advice but with an allowance for exercise.
The Government have identified certain categories of workers who are deemed essential, many of whom are keen to stay at work despite the fact that they are immunosuppressed. This is very challenging. Many of those who are in this category who are under my care, have been calling because they are either keen to remain at work, or anxious to remain at home.
My feeling on this is that those who are immunosuppressed should not be in any work environment where they could be exposed to someone with Corona Virus infection.
As there are so many who could be infected, even without symptoms of Corona Virus, any contact is a potential source of infection.
Anything other than staying at home is going to increase their risk. Home working seems to be the obvious solution where practical for most.
This is going to be an increasing problem for those working in healthcare over the among months. I’m not sure I have a simple solution for this – but expect that if you are on any of immunosuppressive treatments on this list – and you inform your employer (and you should), it is likely you will be sent home.
Updated safety information
Over the coming weeks, we will begin to get a sense of the impact of Corona Virus infection for rheumatology patients from an international research project which aims to define the risk more clearly. Until we know more, I would err on the side of caution.
Many of you attending the practice are on treatments that increase could your risk of infection and are appropriately trying to stay close to home. With social distancing and stay home advice, attending appointments in person can be difficult.
However those with arthritis and other related conditions, are all too aware that flare ups can occur at any time (especially at times of stress). People will remain unwell from their underlying conditions regardless of whether they develop a Corona virus infection. There are certain problems can wait, but others that require more urgent medical attention.
We are trying to offer a service that is both appropriate to acute medical needs of our patients but also one that is as safe as possible. We have therefore put a number of measures in place to allow us to continue to help our patients as safely as possible.
Firstly, this to reassure you that our office is still open. All of your team are available to answer your queries and concerns by phone or by email.
However, In addition to strict office staff adherence to the Health Protection Surveillance Centre (HSPC) guidance on social distancing and hygiene in the workplace, we have put in place a number of other measures to reduce the likelihood of Corona virus infection in our office.
These are to allow us to maintain essential medical services for our patients while ensuring the safety of our patients and staff.
Postponing Non Urgent Visits
Only patients with semi-urgent, urgent problems, or emergencies are being seen in person. All non-urgent appointments have been postponed or are being performed remotely using video consultations or phone visits. Each patients problems will be assessed in their own right but we will be erring on the side of caution where infection risk is concerned.
Video Consultations and Phone visits
All efforts are being made to carry out visits over internet based video consultations and phone to minimise unnecessary visits to the office. This in turn will reduce the number of patients attending the office in person and traffic through the waiting room area.
Minimising likelihood of exposure to Corona Virus infection for those who need to attend in person.
Suite 19 is in a part of the building separated from main hospital by a lobby and restaurant (which is currently restricted to staff). The Galway Clinic is not a designated receiving hospital for patients with Corona Virus infections and is not receiving visitors.
All patients who need to attend in person are pre-screened within 24 hours of attendance for common symptoms or risk factors of Corona Virus infection including; recent travel abroad, contacts with those infected (or suspected of being infected) with Corona Virus.
All patients screened again at main entrance of the hospital by Galway Clinic staff. Those with symptoms or risk factors will be asked to phone office and assessed by doctor before entering office.
The practice is following HSE / HSPC guidelines in relation to management of health care workers, and measures are in place to reduce the potential risk of spread of infection between members of staff and between staff the our patients.
Waiting room measures
- All those attending will be asked to wait in their car and will be contacted when it is time to come to office to reduce minimise spent in the waiting room.
- Appointments are also spaced appropriately to reduce congestion in the waiting room.
- All waiting room chairs are spaced 2 meters apart.
- All patients asked to clean hands on entry at reception with alcohol gel and on leaving.
- Protective screens have been put in place to limit contact between patients and staff in the office and all of non-essential paper work between patients and staff has ceased.
Doctors assessing patients will wear appropriate protective masks, gloves, aprons and goggles and maintain appropriate social distancing except where close physical examination or a procedure are required.
All relevant surfaces will be disinfected between patient visits
Appointment visit times will be kept to a minimum to reduce any potential exposure to infection.
These measures may change over the coming weeks so please check back here for further updates.
If you have any concerns of questions about your visit or these measures please email us on firstname.lastname@example.org
Version Created by Dr. Ronan Kavanagh March 30th 2020. Updated 2/4/2020
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.
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.
Please support your local bookseller by purchasing these locally. Dubray books don’t charge for postage if you pick up in-store.
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.
Jon Kabat Zin is the Massachusetts based scientist and researcher who is largely credited with introducing mindfulness to Western Medicine.
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
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.
This is the organisation who run the courses on which the Mindfulness for Health book are based. Great resource (mainly UK)
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).
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.
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.
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).
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
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.
There’s a nice video summary of the research here (I wish all researchers would produce on of these)
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 arthroplasty: Laffosse 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.
I really don’t mind if you do. Although joint injections in the my hands aren’t too painful, the first time a doctor put a needle into my knee I swore*. The expletives popped out of me, just like they did when I splashed petrol in my eyes filling up the lawnmower, or when I cut my finger chopping chillies.
I had always assumed that swearing occurred as a reflex in response to pain but there is also some research that suggests that swearing may have some pain killing effects too.
Researchers from Keele University examined pain responses in those who were encouraged to swear on exposure to placing a hand in cold water to pain responses in those who simply uttered a non-swear word. Here’s what they found;
- Those who swore were able to tolerate the pain for longer (on average, 31 seconds) and rated their pain lower than those who uttered an alternative non-swear word. The swear words used were not listed in the paper (the schoolboy in me checked).
- Those who swore developed higher pulse rates than those who didn’t swear, prompting the authors to speculate that the act of swearing somehow revs up the physiological ‘fight or flight’ response to pain and in turn eases it. They also suggest that more research needs to be done to clarify this.
- Swearing doesn’t work for everybody – those with a high daily swearing frequency didn’t get as much relief; if you tend to swear alot anyway, it may be less effective to swear when you actually need to.
- Swearing may be less effective as a pain killer in men who are prone to catastrophise. (To catastrophise is have irrational thoughts which suggests that things are much worse than they are).
There are some limitations affecting the broad applicability of the results of this study. Firstly, it only examines one kind of pain – that induced by cold. It would be interesting to see whether it held true for pain induced by heat or, for example electric shocks.
Whereas it studied the effect of swearing as an analgaesic on acute pain, it excluded those with chronic painful conditions. It is unclear therefore, whether swearing would have any lasting effect on those with chronic painful conditions like arthritis.
More research is needed before I’ll be prescribing swearing as part of the treatment for my patients. I’m sure its widespread use will continue nonetheless….
What do you think?
*I have had my knees injected on a few occasions, usually with very little discomfort. The first time I had it done was when I was working in research (examining joint fluid from non-arthritic joints) by a fellow trainee. His injection skills have improved a lot since then but then so have mine.
There used to a be small record shop in my home town called Zhivago Records. It’s owner, Pat Pyne, stocked most of the stuff in the music charts, some ‘The Cure’ and ‘Led Zepellin’ T shirts, blank audio cassettes, and a ‘local interest’ section comprising (largely dodgy) Irish music for tourists. Although I sometimes found the limited selection of music available frustrating, choosing was easy and it largely satisfied my musical tastes at the time. Zhivago went out of business 2 years ago.
My first visit to Tower Records in London’s Picadilly Circus in the 80’s, opened my mind to a new world of musical posibilities that I didn’t even know existed. The 25,000 sq ft shop in Picadilly Circus housed what seemed to be an infinite collection of music and catered to every imaginable taste.
Although the having so much more music to choose from was exhilarating, I confess that I also found the the experience made me anxious (that I might miss THAT one special album or make a choice that was deeply unfashionable), frustrated (not knowing where to start looking or forget what it was I came into buy in the first place) and even a little hostile towards the knowledgeable (but sometimes patronising) shop assistants working within the genre subsections of the shop.
What should have been the ultimate shopping experience sometimes ended in my leaving rather overwhelmed and disappointed by the experience and feeling guilty that I didn’t make a purchase at all.
Despite years of growth and expansion, Tower records is now gone too. Like everyone else these days I buy all of my music online. Tower record’s once impressive calatogue is now dwarfed by what’s available from iTunes’ 20 million plus online song library.
What makes this iTunes so successful is not just the wide choice of music available, but the incredible sophistication of the filtering system that helps me choose what I want to buy. Using my previous purchase history, iTunes has worked out my musical tastes and from that presents similar kinds of music to me. When I choose a track for download, I get to see what other people who have purchased this music have also bought, exposing me to new music and thereby broadening my own musical tastes. It seems to know what I want, even before I realise it myself.
This week, I’m ‘shopping’ at EULAR in Berlin, one of the Megastore medical meetings for my specialty, for information. Information that I hope will improve the lives of my patients and my working day. Like the 15,000 other delegates who’ve travelled distances and who have taken time off work to attend, I will be presented with an impressive choice of hundreds of presentations and over 3000 cutting edge scientific abstracts to choose from.
The curators of the meeting have gone to some trouble to divide up the meeting in to specific disease ‘genres’ sections, have put together a number of ‘Whats Hot’ plenary sessions, summary sessions and even a searchable app.
And yet, I’m beginning to get a familiar feeling…
Lets just hope that I bring home something that I like.