We’re impotent with this deforming arthritis


By Dr Irwin Lim, Rheumatologist

These are my grandmother’s hands.

Nodal OA

She does not have rheumatoid arthritis or psoriatic arthritis.

And I am sad to say that there’s not much a rheumatologist can do to change the shape of her hands.

She has nodal osteoarthritis.

Osteoarthritis affecting the hands is really very common. Thankfully, most hands do not end up looking like these.

Despite all the many advances in the treatment of inflammatory arthritis and I’ve proudly declared on this blog that rheumatologists are more potent in their ability to bring about much better outcomes in these forms of arthritis, we remain quite impotent with this very common cause of deforming arthritis.

With osteoarthritis of the hands, there isn’t a window of opportunity (when compared to a disease like rheumatoid arthritis).

There’s no clear early intervention that will slow down or prevent the disease.

It brings this rheumatologist back down to earth.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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The Other Body Parts Ankylosing Spondylitis affects


By Dr Roberto Russo, Rheumatologist

Recently I have been involved in the development of an education program for GPs regarding Rheumatoid Arthritis (RA) and one issue that had stimulated discussion was the data regarding extra-articular manifestations (EAMs).

In a bygone era, prior to the early use of Disease Modifying Anti-Rheumatic Drugs (DMARDs), EAMs were definitely more common. However, with the current approach of introducing DMARD therapy early there has seen a reduction in the frequency of these consequent conditions.

These include entities such as scleritis (inflammation of the lining of the eye), pleuritis (inflammation of the lining of the lungs), and Felty’s syndrome (a combination of RA, enlargement of the spleen, and a reduction in the number of neurtrophils, a specific type of white blood cell important in immune defence). Nevertheless, we Rheumatologists continue to ask our RA patients for any symptoms that may indicate the presence of these conditions.

Acute Anterior Uveitis	 Accessed from http://lifeinthefastlane.com/uveitis/
Acute Anterior Uveitis
Accessed from http://lifeinthefastlane.com/uveitis/


Therefore, it was with interest that I read a recent article on the epidemiology of EAMs in another common rheumatic disease, Ankyolising Spondylitis (AS).

AS is a chronic inflammatory disease with an estimated prevalence in western populations of about 0.6%. It is characterized by inflammation of the spine and not infrequently of peripheral joints; however, multiple other organ systems can become affected by the disease process.

The most common sites include the eye, bowel, and skin. At these sites the disease manifests as acute anterior uveitis (AAU), inflammatory bowel disease (IBD), and psoriasis. The presence of these EAMs is of relevance because they impact upon the patient’s quality of life and upon our treatment decision.

Psoriasis on the elbow

Psoriasis on the elbow


Stolwijk et al found:

1. AS patients were 2 to 20 times more likely to develop these diseases compared to the normal population

  • Men were more likely than women to either develop an EAM or have one present at diagnosis
  • However, the prevalence of EAMs decreased with age, except for psoriasis where age was not a factor

2. A significant proportion of these EAMs were present prior to the date of AS diagnosis

  • 12% had AAU (0.5% in controls)
  • 5% had Psoriasis (2.5% in controls)
  • 4% had IBD (0.6% in controls)

3. The likelihood of developing an EAM continued over time, such that 20 year cumulative risk increased to

  • 24% for AAU
  • 10% for Psoriasis
  • 7.5% for IBD

4. The risk of developing an EAM was highest in the 1st year after diagnosis of AS

  • Risk dropped to baseline levels after 5 years for Psoriasis and 10 years for IBD.

In difference to RA, the findings of this recent study suggest that the incidence and prevalence of these common EAMs in AS has remained stable when compared to previous cohorts.

A possible explanation for this may be that the time to diagnosis of AS remains prolonged in comparison to RA and there continues to be a delay in the time to commencing treatments that may alter the natural history of the disease.

However, interestingly, the prevalence of these EAMs is seen to a similar degree in those who have non-radiographic axial spondyloarthritis (ie. in those where spondylitis is present without evidence of radiographic joint damage), suggesting that in a proportion of patients with inflammatory spinal disease the phenotype includes inflammation at those target tissues.

This relatively high frequency of EAMs can actually be of clinical relevance in the diagnosis of inflammatory spinal diseases in those presenting with chronic low back pain.

It is common practice for Rheumatologists to enquire for symptoms of these EAMs, whereby a history of AAU is strongly suspicious for SpA in those with chronic back pain (Likelihood ratio (LR) of 13.9).

The presence of psoriasis and IBD in those with chronic low back is also suggestive of SpA, albeit to a lesser degree (LR of 3.8 and 4.3 respectively).

Finally, the results of the study also remind us to continue to vigilantly observe for the development of these conditions in those with an established diagnosis.

For any health professionals reading, I wonder if you have ever been prompted to consider an inflammatory spinal disease in a patient you’ve been treating for chronic low back pain on the basis of one of the conditions discussed above?

Stolwijk C, Essers I, van Tubergen A, et al. The Epidemiology of Extra-articular Manifestations in Ankylosing Spondyloarthritis: A population-based matched cohort study. Annals of Rheumatic Diseases, 2014: published online March 21. DOI: 10.1136/annrheumdis-2014-205253

Lumpy Rheumatoid


By Dr Irwin Lim, Rheumatologist

photo 1

It’s been a while since I’ve seen these many lumps on a rheumatoid arthritis (RA) patient.

He’s had not-so-well controlled RA for decades and just presented from St Elsewhere.

These lumps are rheumatoid nodules. There are firm and felt under the skin, usually close to joints, and often close to areas which get exposed to trauma for example the hands, knuckles, and elbows.

Often you can move the nodules but sometimes, the nodules are firmly connected to the tissues under the skin.

photo 4

Rheumatoid nodules can also be found in areas distant from joints – the lungs, heart and other internal organs.

They can range in size, think a pea to a walnut. They can be painless but some people find them uncomfortable and irritating, particularly if they get bumped a lot.

photo 3

Rheumatoid nodules are thought to be present in up to 20%-30% of RA patients, and are thought to be associated with more severe disease. Most patient with rheumatoid nodules have a positive rheumatoid factor (RF).

Smoking is thought to increase nodules. Methotrexate use has uncommonly been linked to increased development of rheumatoid nodules.

I don’t get to see these very often nowadays, certainly not in 20-30% of my RA patients. Maybe it’s because I get to see patients relatively early in their disease course or our treatments are more effective. I don’t know.

Happy to hear what you guys think.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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How does Ankylosing Spondylitis affect your sleep?

Image courtesy of graur codrin/ FreeDigitalPhotos.net

Image courtesy of graur codrin/ FreeDigitalPhotos.net


By Dr Irwin Lim, Rheumatologist

This post is a special request from Barry, a regular contributor.

Barry is happy for me to share with you that he has spondyloarthritis (SpA), with both Ankylosing Spondylitis (AS) and Crohn’s disease.

He’s on TNF-inhibitor therapy (Cimzia) as well as an anti-inflammatory medication to help his problems, including a number of other medications.

Barry’s major issue is sleep disturbance and he’s allowed me to quote him:

“The night sweats occur for a few day period once every month or so. I wake up in constant thirst from sweating, and with chills. It occurs during about half of my flare ups. None of my doctors have a good explanation as to the cause, or advice about dealing with night sweats.

The topic I wanted to address is more broad than night sweats. During “good periods” (a very relative term), I wake up 3 or 4 times a night, due to stiffness. During severe flares, I wake maybe 10 – 15 times a night. (I bet many of your patients experience this to some degree. It SHOULD be addressed on your patient survey.)

This level of sleep interruption greatly effects my physical and mental health. It’s depressing. It aggravates all of my conditions, more than any other single factor.

Apart from the flare ups, there are other night time issues. How do you get yourself comfortable to sleep? As mentioned before, I cannot sleep on my front or back due to my spine. I position pillows in front and behind me to keep on my side. But sometimes I have significant hip pain. This is a dilemma.”

I imagine some portion of your patients experience this to some degree. I’m curious what nighttime issues they face and how they deal with them. Do they have advice for my issues? This has potential to be a very beneficial topic for your followers. And you might learn a bit about what difficulties your patients face. I can’t be the only one with these issues, right?”

As a rheumatologist, I know that my SpA patients can be sleep-disturbed, and I do ask some rudimentary questions about this. If patients have night sweats, I would typically worry about:

a) Infection
b) Blood disorders/malignancy
c) Very active, poorly controlled inflammatory/autoimmune disease

I don’t know Barry’s history in any significant detail. I of course don’t want to be providing personalised advice on social media as it would not be appropriate. Barry understands this. But he would like general help from readers of this blog.

He tells me he has great doctors who he has faith in, and I am sure they’ve already excluded any nasties. He’s from the USA, so it’s likely that he has been thoroughly investigated rather than under-investigated.

In addition, the recurrent and long term nature of these nocturnal symptoms would suggest that they are part of his “regular” medical issues.

AS/SpA can of course cause significant stiffness and discomfort at night. My experience is that this improves a lot once the disease is controlled with NSAIDs and/or TNF inhibitor therapy (when effective).

But do these problems continue even when your rheumatologist tells you the disease is under control? And, what about the night sweats?

Barry, and I, would love to hear your experiences.

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
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Improving how I introduce myself as a rheumatologist


By Dr Irwin Lim, Rheumatologist

33 members of our BJC Health team just completed a tiring weekend learning about HealthChange Methodology.

Our physiotherapists, exercise therapists, massage therapists, dieticians, rheumatology care coordinator, admin & reception staff, and our rheumatologists all together. Confronted by information and tools to help us improve our ability to help our clients/patients change behaviour.

The truth is compliance in healthcare is poor. I’m not sure what the best available stats are but I have an inkling that compliance with taking medication is probably around the 50% mark. I’d imagine compliance with exercise prescription and dietary changes are likely to be lower. Follow through with smoking cessation advice is likely to be abysmal.

So, we wanted to learn how we could improve patient/client compliance and adherence. We wanted to learn how to better engage patients in their own care. Basically, to be more effective in delivering good outcomes.

A core component of what we learned was the need to be much more Client Centred. Clients/patients need to be given choice and control. The way we conduct consultations need to become much more Client Centred.

I still have to process the stuff we learned over the coming weeks and months.

But I thought I’d share one simple change I’m going to make.

Seeing patients day-in day-out, I’m guilty of forgetting that for patients coming to see a rheumatologist for the 1st time, there may be quite a degree of anxiety and uncertainty.

Is this the right doctor for me? Why do I have to see another health professional when I’ve seen so many already? What is he going to do different? What is a rheumatologist?

We actually sat down to try and work out how best to address this at the start of the consultation, quickly and efficiently. How should I introduce myself? How should I allay these fears?

I’ve been a doctor for 18 years. This shouldn’t have been as hard as it seemed. Good thing my colleagues were there to help & we had good facilitators.

Anyway, this is the workflow/spiel we came up with:

(I walk to the waiting room & call out the patient’s name)

Mr David Smith…

Hello, my name is Irwin (handshake)

Please come this way. Please have a seat.

Can I start by finding out what you would like to be called/addressed?

I am a rheumatologist. Have you seen one before? 
(usually not)

Well, let me explain my role. I’m a specialist in arthritis; in problems affecting bones, joints, muscles & tendons; and in immune diseases.

(helps reinforce that the patient is seeing the correct doctor)

David, could I please ask what’s your understanding of why you are here?

Good. Well, by the end of this consultation, what I hope you’ll take away is a better understanding of the problem and a plan to help you manage that problem. I’m here to work together with you to develop this plan.

Is that what you are expecting?

(Benefit statement -> patients should know what’s in it for them. The patient should also feel involved & respected)

What do you think of getting this style of introduction? Does it help you as a patient to have the specialist you are seeing describe what they do up front? Is it obvious they are there to help you or does it actually help if the health professional actually articulates how they plan to help?

Dr Irwin Lim is a rheumatologist and a director of BJC Health. You should follow him on twitter here.
Arthritis requires an integrated approach. We call this, Connected Care. Contact us.
This blog focuses on arthritis, healthcare in general, and Connected Care. Please subscribe to keep in touch:
Enter your email address: Delivered by FeedBurner

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