Rheumatoid arthritis or RA as we Rheumatologists commonly call it, is an autoimmune condition. Contrary to common belief, it is very well treated now-a-days with conventional and newer therapies and anyone who is living with RA can lead a normal life with treatment.
So, what exactly is RA? It is the most common type of arthritis. In fact, about 1% of the population suffers from this condition. It is more commonly seen in females and starts at a younger age in Indians compared to the western population, many cases having an onset from their 1stor 2nddeliveries in the postpartum period. Many patients complain of pain and swelling of the joints of the hands and wrists but other joints of the body are also commonly involved. Along with pain and swelling, there is also stiffness which is usually worse in the mornings and can last for 2-3 hours or sometimes even the whole day. Activity of the joints usually lessens the pain. If caught at an early stage and treated adequately, joint deformities can be prevented. Early treatment is the reason why those ghastly images of crippled and twisted hands and feet, which were seen ages ago when there was no proper treatment of RA, is hardly seen now-a-days. However, not only the joints, but other organs like the lung, heart, eyes, etc. can be affected. Other symptoms apart from joint pain can be fatigue, weight loss, low grade fever, dryness of the eyes and mouth and firm nodules over the body.
RA happens due to a problem in the immune system that is responsible for the infection fighting capability of the body. Neither over-activity nor under-activity is the cause, but there is altered activity in which our own body tissues are perceived as foreign (like bacteria or viruses) and attacked by the immune system. Although this is most commonly seen in joints as pain and swelling, other tissues are also silently affected by this process. Hence, this is a systemic disease i.e. it affects the body as a whole and the joints in particular. It is common to have a relative with the same disease suggesting a genetic basis; however, genes, alone, are not responsible and other factors like infections and environmental factors also do have a role in the development of RA.
Diagnosis of RA is clinical, that means symptoms and signs are enough to diagnose RA. However, certain tests like Rheumatoid Factor or Anti CCP antibody are helpful and aid in the prognosis of this disease. It is common to have a mildly reduced Hemoglobin in very active disease as well as an increased ESR or CRP which are markers of inflammation and tell us how severe the inflammation is. X-rays of hands and feet may be done to see if there is any damage to the bone and if present tells us that the disease is severe and longstanding. An ultrasound or MRI is helpful especially when the arthritis is not clearly evident on examination. Some tests like the complete blood count and liver function tests may be needed to be done frequently to monitor drug side effects.
Treatment of RA has greatly evolved over the past 3 to 4 decades. There are now many drugs which can halt the progression of RA. However, it is important to understand that THERE IS NO CURE! Having said that, it is possible for a person to lead a normal life on treatment. Similar to lifestyle diseases like Diabetes and Hypertension where one needs to be on some medications to control the disease, RA medications need to be taken regularly for both symptom relief and for halting disease progression. Medications used most commonly include Methotrexate, Leflunamide, Sulfasalazine and Hydroxychloroquine. These drugs are Disease Modifying Anti Rheumatic Drugs or DMARDs. Steroids like Prednisolone or Methylprednisolone are used in the early stages when disease is active to control inflammation rapidly as DMARDs make take up to 3 months to act. So it acts as a bridge between acute symptoms and chronic control, however, due to good efficacy of medications in controlling disease progression, long term steroids are avoided due to the numerous side effects like diabetes, hypertension and osteoporotic fractures to name a few. Apart from these conventional medications, newer DMARDS including “Biologic agents” like Anti TNF therapy (Infliximab, Adalimumab, Etanercept) and anti B cell therapy (Rituximab) and small molecule inhibitors like Baricitinib and Tofacitinib have shown tremendous efficacy in RA. The cost of these medications as well as a higher chance of certain infections while living in a developing country like India, preclude common use. Nonetheless, these offer a chance for relief when common therapies fail.
Medications alone do not constitute treatment of RA. A proper and adequate knowledge of RA is must for the patient as well as the caregivers. Physiotherapy and exercises help the patient to cope, build muscle mass, confidence and help in the prevention of joint contractures and also instill a sense of well being in the patient. In active inflammatory phase of disease, it is better to have more rest than exercise; however, in remission, low impact aerobic exercises like walking and swimming are advised.
Last, but not the least, finding that you have a chronic illness can be a life changing event and being in a depressed state of mind for a short time is expected. Taking help of near and dear ones as well as your doctor may help. But it is important to ACCEPT the fact that you have RA, as acceptance alone can further guide you in the path of proper treatment.
Adhesive capsulitis, more commonly known as Frozen Shoulder Syndrome (FSS), is a commonly encountered musculoskeletal problem. It is a condition that causes shoulder pain and restricts the mobility of the shoulder joint. Seen in 2-5% of the general population, it is more common in diabetics with a prevalence of 10-20%. Females are affected more often and it usually is seen in the age group of 40 to 60 years. Patients generally complain of difficulty in raising the arm, dressing, washing hair or sleeping on the side as the shoulder pain.
There may not be a precipitating factor for FSS, in which case, it is called as primary or idiopathic. Secondary causes of FSS are more commonly seen, being most prevalent in diabetes. Thyroid disorders, Parkinson’s disease, prolonged immobilization, stroke or any muscle, ligament or bony injury around the shoulder joint can lead to this condition.
This condition is chronic, meaning it may take months to years to recover completely. FSS has three stages. In the first stage, called the ‘Freezing stage’ or ‘Painful phase’, the patient generally complaints of severe disabling and diffuse shoulder pain that is worse at night. This is due to inflammatory fluid in the shoulder joint. It can last for 2 to 9 months. Following this stage, the ‘Frozen stage’ or ‘Stiffening phase’ ensues, which is characterized by reduction in the pain but persistent stiffness. Patient may experience pain at the extremes of motion, but is still unable to carry out all movements at the joint. Stiffness may worsen at this stage. This is caused due to thickening and shrinkage of the shoulder joint capsule, with adhesion formation. This phase may last for 4 months to a year. The last phase called the ‘Thawing stage’ or ‘Resolution phase’ can take for up to 2 years and is characterized by gradual increase in range of motion and return to normal state.
Generally only one shoulder is involved, but patients who have suffered this condition are prone to develop FFS in the other shoulder in future. This condition is diagnosed clinically, however, Ultrasound or MRI of the shoulder may be done to rule out any underlying cause. Blood sugar test to rule out diabetes is done in suspected patients.
Treatment of FSS involves treating the underlying condition. This condition is, in most cases, self-limiting. Symptomatic treatment in the form of analgesics, or painkillers can be given in the initial phase when pain is severe. Heat application in the form of hot packs is useful, especially before physical therapy. Injections of anesthetics and steroids are also given into the shoulder joint, which relieves pain temporarily. Physiotherapy (PT) is an important modality of treatment in FSS and the type of therapy differs according to the phase of the disease. In the initial phase, any activities that cause pain are avoided and the patient is encouraged to do simple pain free exercises rather than intensive physical therapy. During the Frozen stage, the focus of PT should be to improve the range of movement of the shoulder by aggressive stretching exercises. Low load and prolonged stretches are recommended. During the third stage, the PT should be progressed by increasing the frequency and duration of stretches while maintaining the same intensity, as tolerated by the patient. Manual techniques and ultrasound application is also done, but needs the help of a physiotherapist. If all options fail, there is a place for surgical interventions in certain conditions.
In conclusion, it is necessary to remember that FSS is a common condition, especially in diabetes; can last for months to years, and is mostly self-limiting. It is thus, necessary, to be patient, continue physiotherapy and not give a cold shoulder to this problem.