Archive for 2011 January
AS: if you don’t know what to look for, how are you going to treat it?
by Irwin Lim, Rheumatologist
Many patients with Ankylosing Spondylitis are relieved when they finally get a diagnosis. Relief, mixed with frustration.
Usually, Ankylosing Spondylitis sufferers spend many years dealing with doctors, chiropractors, physiotherapists, herbalists, osteopaths, massage therapists, naturopaths, etc. It’s a difficult condition to diagnose as the symptoms can initially be non-specific and the pain episodic.
Hands-on, manual therapy does feel good, but the effect is typically short-lived and the treatment needs to be repeated and repeated. While this can be good for business for some therapists, more often than not, the therapists themselves are frustrated by the lack of long term improvement.
The amount of training on ankylosing spondylitis (and all common rheumatic disease, such as rheumatoid arthritis) is very poor at undergraduate level for physiotherapists. It’s almost non-existent at a postgraduate level. I assume that this sorry state of affairs would be similar in the other allied health fields.
Again, rheumatologists should be doing more to address this.
BJC Health will start this process. We have organised a seminar on inflammatory rheumatic diseases, with an emphasis on ankylosing spondylitis. It’s titled “AS You See It”.
A physiotherapist I talked to last week remarked that she doesn’t think she has seen many ankylosing spondylitis patients in her career to date. I suggested that she might have missed diagnosing a fair few.
If you don’t actually know what to look for, how are you going to recognise the disease, and importantly, how are you going to treat it correctly?
Dr Irwin Lim is a rheumatologist and a director of BJC Health. BJC Health provides coordinated, comprehensive, and colocated multidisciplinary care to achieve effective solutions for patients. We call this model of care, Connected Care. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.
This blog focuses on musculoskeletal disease, healthcare in general, and our Connected Care philosophy. Read More.
Stop Press: For Physiotherapists only. Attend the BJC Health Professional Development Seminar on February 20, 2011. Register to attend and link or join the professional page on Facebook. Our Hootcourse will also be online soon. Details on Facebook.
Am I a better doctor if I wore a tie?
I stopped wearing a tie to work at the start of 2004. It was summer and I was hot.
Its much more comfortable working without a tie, particularly in my job. Its easier to examine patients, its easier when I need to perform a medical procedure. I’m sure you can see how a dangling tie would get in the way.
I’ve also lost quite a few ties, sadly enough, to spillage, followed by dry cleaning. Dry cleaning and silk ties don’t mix well. The tie comes out worse for wear and never again, does it look quite right.
I wonder then how people clean their ties? I guess that the answer is that they don’t.
A tie could possibly be a source of infection. Imagine your doctor seeing patient after patient, either in the hospital or in their rooms, with that dangling tie. Later that week or the next week, he may wear the same tie, probably after the tie has been sitting in a drawer somewhere at home, and almost certainly, without any attempt at cleaning. I am sure there are proper scientific studies on these but I must admit I’ve not bothered to hunt for them. It seems common sense and provides me enough extra vindication for what I do.
Many of my friends are tie-wearing doctors. They’re probably not so keen on this blog. Most would not like to give up this very traditional symbol of male authority. Some would even say that the tie (and a suit or the Doctor’s white coat) enhances patients’ satisfaction and confidence. To look like the wise and experienced consultant, some will argue that you need this part of the uniform.
I hope not. I’ll wear a nice shirt and pants because I like to and being less dressed would seem quite inappropriate. I hope that I make a good enough first impression with my practice settings, our clinic’s attention to detail, and my manner that my patients don’t mind my lack of a tie.
Back Pain: Inflammatory vs Mechanical
by Roberto Russo, Rheumatologist & Nuclear Medicine Physician
Spinal pain is one of the most common afflictions to affect modern man, with 12-33% of the adult population having low back pain at any given time.
Back pain is essentially divided into 2 groups:
- Mechanical back pain
- Inflammatory back pain
Differentiating between the two entities is vitally important since the long term outcome and therefore, the treatment approach are significantly different.
Mechanical back pain is much more frequent and refers to pain that arises from an injury to a specific structure within the spine. The two structures often implicated as the cause of the back pain are the intervertebral discs and facet (zygopophyseal) joints. Although not definitive, pain that is aggravated by flexion of the spine is more likely to reflect discal pathology whereas pain worsened by extension movements is more in keeping with pain from the facets.
However, it is often difficult to be certain regarding the cause of the pain and this is why the entity is referred to as Non-Specific Back Pain. The majority of those with mechanical back pain can expect a full recovery within the first few weeks, with approximately half of the remainder resolving by 12 months.
Irrespective of the cause a major factor that predisposes to mechanical low back pain is weakness of the core stabilizing muscles, including the abdominal and gluteal muscles. As a result a key focus of treatment is the strengthening of these muscle groups. This has been shown to result in up to a 70% reduction in the recurrence of pain. This is particularly important in this population. The other treatments primarily aim to lessen the sufferers’ pain, whilst awaiting the favorable prognosis of the condition to evolve.
It should be noted that the causes of mechanical back pain can lead to compression of adjacent neural tissue, either within the spinal canal or at the intervertebral foramina. This can result in radiating pain in a dermatomal distribution as well as a constellation of neurological symptoms such as paresthesia. Peri-neural injection of corticosteroid is often helpful in this situation with surgery often the last resort.
Inflammatory back pain, on the other hand, is characterized by pain which is exacerbated by rest, relieved by activity, and is often associated with early morning stiffness. The morning stiffness generally lasts for more than 30 minutes. This pattern of back pain is most commonly related to an inflammatory spondyloarthropathy. The classical spondyloarthropathy is the condition termed Ankylosing Spondylitis. As the name implies the spine becomes fused (ankylosed) over time if left untreated, highlighting the importance of early recognition and treatment of the disorder. The mechanisms by which to identify this population at an early as possible stage is a current topic of research, since generally the time to diagnosis is often longer than 7 years.
The treatment approach is based upon anti-inflammatory medication and exercises, the latter of which aiming to maintain flexibility and therefore range of motion. Immunosuppressant therapy, such as Salazopyrin and Methotrexate, has been used for many years with variable response. The recent introduction of therapy that blocks the action of TNF-? (a pro-inflammatory molecule) has demonstrated marked improvements in disease control, and as a result, improvements in symptoms, function, and retardation of disease progression.
Back pain in the paediatric population always warrants further investigation.
Inflammatory spondyloarthropathies do occur in the juvenile population but more commonly the culprit pathology for their pain is spondylolysis. This refers to a defect, either congenital or due to repetitive stress, of the pars interarticularis. A common precipitant is sport, particularly those that transmit a large rotator force through the spine, as occurs in tennis, cricket, and soccer. Treatment involves rest, strengthening of core muscles, and a graduated supervised return to sport.
Finally, spinal pain that is constant, severe, nocturnal, and with no obvious cause necessitates further investigations to exclude a malignant or infective cause.
Dr Roberto Russo is both a rheumatologist and a nuclear medicine physician, as well as a director of BJC Health. BJC Health provides coordinated, comprehensive, and colocated multidisciplinary care to achieve effective solutions for patients. We call this model of care, Connected Care. Our clinics are located in Parramatta, Chatswood and Brookvale. Contact us.
“You can’t lose weight while on Prednisone”….Yes you can
relayed by Irwin Lim, Rheumatologist
This morning, I received a typed note from a patient. It was unexpected and such a pleasant way to start the day, that I had to ask her to allow me to share it with you.
The following words are Leonie’s:
Imagine my frustration when prescribed Prednisone for my Polymyalgia Rheumatica. I had just finished a course of Prednisone for a respiratory problem, and I was aware that, in spite of its undoubted spectacular effectiveness, it would just continue to add to my burgeoning weight problems.
After breast cancer, I had put on 15 kg in three years, and that was just part of the continuing steady weight gain over the years. I was now aged 75 and tipped the scales at 117 kg. It was difficult enough I figured, to control my weight at this age while having mobility problems.
I knew (doesn’t everyone know?) that nobody can lose weight while on Prednisone. Not only that. I knew that I would continue to pile on the kilos while on this wonder drug. I say that is what I KNEW. In reality, that is what I BELIEVED…erroneously!
I knew that I had to accept the challenge given to me at this time by Dr Irwin Lim.
After all, there were other crises happening in my health life at this time, all of them somehow weight related. In the space of a few weeks, I was diagnosed with Atrial Fibrillation, Type 2 Diabetes, moderate kidney failure, as well as Polymyalgia Rheumatica.
But it was a huge challenge. And after consulting with Alison, the dietician, and Suzy, the exercise physiologist, both on the team at BJC, I started on the long road to recovery through change. Not easy, but not impossible.
Initial success helped me to unlearn my beliefs. Although I discovered that Prednisone complicates control of blood glucose levels, I also discovered that, with care, weight gain can be controlled while on Prednisone. Patient encouragement from Suzy and Alison saw me gradually taking control of my own destiny.
Now… where am I?
Now nearly three years down the track, I am taking almost nil Prednisone. But what has happened? Diabetes is under excellent control with exercise and no medication. Blood Pressure is under control. Atrial Fibrillation is under control. Kidney Failure is no longer a problem. And my joints and muscles are more or less in working order at last.
Now aged 78, my weight is 80kg and continuing to fall slowly. I value and appreciate the weekly sessions at the gym with Suzy. And I look forward to an active old age, but not yet.
Leonie is a patient at BJC Health. BJC Health provides coordinated, comprehensive, and colocated multidisciplinary care to achieve effective solutions for patients.
Sciatica: After the 1st month
Dry Needling
5 Saturdays have passed since my wife, M, developed acute right-sided buttock and lower leg pain. Her progress has been interesting to study.
M’s situation is unusual in that she has a rheumatologist for her husband, a physiotherapist for a brother-in-law, and access to the multidisciplinary team at BJC Health. Access to advice and treatment was not an issue. Compliance was mandatory.
She’s “drug-free”, with the last pill, an anti-inflammatory, taken on Christmas day. She attended physiotherapy twice weekly for the 1st two weeks, then weekly since. On the last 2 occasions, dry needling was performed.
M has never been very good with homework. She performs about 10 minutes of stretching and strengthening daily. She should be doing more, but such is the reality of life with 3 young children. Of course, the motivation of pain is also gradually fading as she improves.
Numbness and tingling stopped completely after the 1st week. The right thigh pain became a discomfort and then slowly disappeared. The right buttock continued to ache for 3 weeks. Around this time, she noted mild pain across the lower back. This mild discomfort continues, and serves as a reminder.
She’s able to drive, able to clean and cook, and has returned to work.