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NH RN Tagore Surgical Centre

  4.6  (80 ratings)

Internal Medicine Specialist Clinic

D 52 Sammilani Park, Near APEX Nursing Home, Beside Hiland Park Big Bazaar Kolkata
1 Doctor · ₹600
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NH RN Tagore Surgical Centre   4.6  (80 ratings) Internal Medicine Specialist Clinic D 52 Sammilani Park, Near APEX Nursing Home, Beside Hiland Park Big Bazaar Kolkata
1 Doctor · ₹600
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Our goal is to offer our patients, and all our community the most affordable, trustworthy and professional service to ensure your best health....more
Our goal is to offer our patients, and all our community the most affordable, trustworthy and professional service to ensure your best health.
More about NH RN Tagore Surgical Centre
NH RN Tagore Surgical Centre is known for housing experienced Internal Medicine Specialists. Dr. Tanoy Bose, a well-reputed Internal Medicine Specialist, practices in Kolkata. Visit this medical health centre for Internal Medicine Specialists recommended by 60 patients.

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MON-THU, SAT
12:00 PM - 03:00 PM

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D 52 Sammilani Park, Near APEX Nursing Home, Beside Hiland Park Big Bazaar
Hiland Park Kolkata, West Bengal - 700075
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Doctor

Dr. Tanoy Bose

MBBS, MD - Internal Medicine, Diploma in Echocardiography, Diploma in Rheumatology
Internal Medicine Specialist
92%  (80 ratings)
13 Years experience
600 at clinic
₹50 online
Available today
12:00 PM - 03:00 PM
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Patient Review Highlights

"Professional" 1 review "Well-reasoned" 1 review "Practical" 2 reviews "knowledgeable" 2 reviews "Sensible" 1 review "Caring" 1 review "Very helpful" 4 reviews

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I am 55 year old male. For last one year my fingers and wrist gets stiff and aching while sleeping. Tests done so far have ruled out Rheumatoid Arthritis. Had hypothyroid which is under control after taking medicine. Now often my shoulders also ache. My uric acid is also often at higher border limits. Pl suggest some remedy.

MBBS, MD - Internal Medicine, Diploma in Echocardiography, Diploma in Rheumatology
Internal Medicine Specialist, Kolkata
Diagnosis of ra is not solely dependent on blood tests. If you have early morning stiffness of the small joints of your hands including the wrists then it is likely that you are suffering from rheumatoid arthritis. If I would have been your doctor, I could have given you a test dose of steroids for a short period of 5 days and if you show a dramatic improvement, I would have stamped you as ra and started the classical therapy.
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I M 24 years old. M taking steroids 4mg daily since last 5 months due to reactive arthritis. Due to which my face has swollen up N hairs also came on my face. Will d hairs coming on my face go away after I stop taking steroids??

MBBS, MD - Internal Medicine, Diploma in Echocardiography, Diploma in Rheumatology
Internal Medicine Specialist, Kolkata
I M 24 years old. M taking steroids 4mg daily since last 5 months due to reactive arthritis. Due to which my face has...
That's practically stupid to be on steroids for reactive arthritis for such a long duration. Rea is better managed with sulfasalzine at a dose of 2 to 3 gms/ day. Stop steroids slowly and talk to a rheumatologist for proper management.
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Rheumatoid Arthritis: A mystery solved with lucidity

MBBS, MD - Internal Medicine, Diploma in Echocardiography, Diploma in Rheumatology
Internal Medicine Specialist, Kolkata
Rheumatoid Arthritis: A mystery solved with lucidity

Vital notes:

  • RA is a chronic debilitating joint disease that affects small joints of hands and foot.
  • More common in females aged 20 to 50 years.
  • It is not synonymous with Rheumatic Fever which occurs in children aged less than 15 years.
  • It has got nothing to do with monthly Penicillin injections and checking ASO titre. Somebody on Penicillin injections or being checked for ASO titre should change the doctor immediately.
  • Untreated disease may cause deformity of hands and foot causing deterioration of quality of life.
  • Erosion of small joints along with loss of entire joint architecture is the basic disease process.
  • Early morning stiffness of joints along with swelling of one or more small joints of hands is very characteristic.
  • Treatment is done with Methotrexate, Hydroxychloroquine Sulfate, Sulfasalazine, Leflunomide and short courses of steroids.
  • Difficult diseases are treated with costly injections called biologics.
  • The motto of treatment is “ catch early, hit hard and achieve and maintain treatment goal “
  • Lung and cardiac complications are common in long term disease.
  • Rheumatologists but not the Orthopedicians nor neurologist are the best person to treat the disease.                    

 

Introduction:

Rheumatoid Arthritis is an autoimmune disease of mankind where the cells and molecules who are responsible for security of our body, misidentify the joint tissue as foreign substance and start destroying them similar to the way they usually do when a bacteria or virus enters the body. This misdirected attack towards our own body is called autoimmune phenomenon.

The worst affected parts of the body are the joints of hands and foot. These small joints that are responsible for performance of day to day activities like eating, holding, writing, typing, washing etc become painful and swollen causing stiffness and deformity.

This results in poor quality of life and subsequent depression. Early diagnosis and continuous treatment with specific medicines is cornerstone of treatment.

 

What are the symptoms?

Symptoms vary from person to person and also from early stage to late stage of the disease.

 In early stage there may be mild pain and stiffness involving 1 to 4 small joints of the hands and feet with a typical pattern of stiffness of those joints after rising from bed. During this phase it is very difficult to diagnose the disease. But it is very important to catch the disease in this stage. Researchers have proved that joint damage and bony erosions start even before the symptoms have manifested and hence earlier the treatments better the results.

In a full blown case of Rheumatoid arthritis the picture is very classical of a middle aged female presenting with pain and swelling of hand and foot joints along with early morning stiffness that responds to steroids brilliantly. Wrists and the knuckles are predominantly involved. Patients are unable to hold a pen or open the door or do cooking etc. Gripping the wrist firmly causes pain and the hand joints are warm.

In a advanced case of the disease we often find elderly people presenting with crooked hands with areas of permanent swelling and skin changes due to chronic friction. The skin fold may contract chronic fungal infections and the joints are swollen and painful.

A few other organs are damaged in silence and they create serious problem at the advanced stage of the disease. Lungs, Heart and Blood Vessels are frequently affected. There is accelerated cholesterol deposition in arteries of heart causing increased risk of heart attack and brain stroke. These patients frequently contract infections which are difficult to treat.

Involvement of spine or low back is uncommon. However, cervical spine or the neck region is the only part of the spine that may be affected in this disease.

 

What is the difference between Rheumatic Fever & Rheumatoid Arthritis?

There is a heaven & hell difference between these two entities. Rheumatic Fever is a disease of childhood. It usually occurs in children aged less than 15 years and is characterised by excruciating pain, swelling and redness of one or more big joints of arms and legs that responds excellently to Aspirin. This disorder may cause cardiac problems and is the leading cause of Valvular Herat disease in India. It is often characterised by some skin rashes and rarely neurologic problems. The disease process, the causative agent and the clinical symptoms are completely different from that of Rheumatoid arthritis.

 

Why Penicillin injections are given on a monthly basis?

Patients of Rheumatic fever often suffer a damage to the valves of the heart during the attack of Rheumatic fever. This damaged valves are potential sites of infections that may develop in the later part of the life. This infection is called Infective Endocarditis and may cause serious complications if not addressed properly. Penicillin injections are given as a form of prevention of development of this infection and have got no relationship with the wellness or cure of the disease. People who are aged above 15 years and are being treated with penicillin for the first time for joint pain occurring in small joints of hands should immediately change their doctor and consult a rheumatologist.

 

How is Rheumatoid Arthritis diagnosed?

Rheumatoid Arthritis is diagnosed by its classical symptoms and some laboratory investigations. To identify early rheumatoid cases we usually follow a scoring system which includes counting of number of joints involved, the duration of the symptoms, checking ESR and CRP in blood and looking for the positivity of Rheumatoid Factor and Anti CP Antibody. Patients with high values of Anti CP Antibody are very much likely to suffering from rheumatoid arthritis and also they are very much likely to suffer a aggressive disease course

 

Does each and every patient of rheumatoid arthritis develop crooked hands and foot?

No. Not all patients suffer from such a devastating complications. There are important characteristics which if present predict severe destructive disease. Females, Smokers, High values of Anti CCP or Rheumatoid Arthritis, Family History of Rheumatoid Arthritis, Early evidence of Joint destruction on X Ray are a few important features who will go forward to develop destructive disease.

 

How Rheumatoid Arthritis is treated?

Continuous Physical activity of the involved joints is the corner stone of treatment. More the joints are active, less the damage.

Cessation of smoking is mandatory. Smokers tend to develop early joint destruction

Medicines that used in treating rheumatoid arthritis are together called Disease Modifying Anti Rheumatoid Drugs or DMARDs.

Methotrexate, Hydroxychloroquine Sulfate, Sulfasalazine, Leflunomide are the principal DAMRDs. Of these, methotrexate is the backbone of therapy. Methotrexate is used on a once a weekly basis starting from a dose of 5 mg to 50mg/week and a weekly 5mg of Folic Acid supplement is given to neutralise the adverse effects of Methotrexate. The detail of the drugs is mentioned below.

 

Why I am being given Steroids?

Steroids are given for a short period of increased disease activity. In rheumatoid arthritis we do not prescribe steroids in a regular basis. It is often prescribed when the patient is put on the DMARDs for the first time and when there is break through pain or active disease during the treatment.

Steroids are used in low dose in a decreasing dosage pattern over weeks and usually are not continued more than a month.

 

What are Biologic agents? Why they are so costly?

Biologic agents are highly specific molecules who directly block the action of the culprit chemicals in our body that cause the joint destruction. They are highly researched molecule an d is manufactured abroad. They are usually available in injection formats and have their own side effect profile which includes reactivation of Tuberculosis and other opportunistic infections. Usually patients are checked for latent Tuberculosis Infections, HIV, Hepatitis B and C before the treatment is started.

Biologics cause excellent response to the disease causing alleviation of pain and swelling and sense of well being but unfortunately they do not provide any cure. Hence, if biologics are stopped then there are chances that the disease activity may worsen requiring more biologics or aggressive treatment with DMARDs.

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A Back Pain that's not due to old age

MBBS, MD - Internal Medicine, Diploma in Echocardiography, Diploma in Rheumatology
Internal Medicine Specialist, Kolkata
A Back Pain that's not due to old age

Understanding Ankylosing Spondylosis

 

When the cells and chemicals who are responsible for the security [immunity] of the body from external virus, bacteria and other micro-organisms misdirect their target and start attacking our own normal and healthy tissues considering them to be external to the body, a phenomenon is created which is called  AUTO IMMUNITY. This process goes uncontrolled as the cellular security mechanism fail to realise that the tissue under attack are of their own and the very same body and the civil war continues causing damage to healthy tissue and its adjoining structures. In a healthy human body this destruction is characterised by five unique symptoms known as

 

1.  Pain [Lat: Dolour],

2. Redness of the affected area [Lat: Rubor],

3. Swelling of the local site [Lat: Tumour],

4. Rise in local temperature [Lat: Calor] and

 5. Loss of function [Lat: Functio Lussa]

 

These 5 symptoms and signs together comprise a pathological entity called INFLAMMATION.

From now onwards these two terms AUTO IMMUNITY and INFLAMMATION will be quite frequently used in explanation of different Rheumatological disorders. It is worth mentioning that the intensity of INFLAMMATION can roughly be quantified by checking few blood investigation parameters e.g. CRP [C - reactive protein] and ESR [Erythrocyte Sedimentation Rate].

 

The above explanation was necessary to discuss Ankylosing Spondylosis as the disease is an AUTO IMMUNE INFLAMMATORY disorder where the affected tissue or area is the Sacro-Iliac Joints and Lumbo-Sacral Joints of young healthy individuals where boys are more affected than girls. The diagram underneath points out the area of involvement.

 

Fig 1: Location of Sacro-Iliac Joints                                                Fig 2: The line joining the pelvis & Sacrum is called Sacroiliac Joint

 

                                                  

                                                                                                               

 

 

Fig 3: Sacro-iliac Joint Magnified                                                     Fig 4: X Ray appearance of Sacroiliac joint viewed from the front.

 

 

 

COMMON SYMPTOMS:

 

Having back pain is a common finding among most of the individuals and almost 90% of these back pains are caused due to mechanical problem i.e. due to excess weight bearing, trauma, poor posturing, excess body weight etc. There is no mechanical component in back pain of Ankylosing Spondylosis. The pain is purely caused due to an Autoimmune Inflammation of previously healthy uninjured normal Sacro-iliac joints. Hence the back pain of Ankylosing Spondylosis is often termed as INFLAMMATORY BACK PAIN which has the following characteristics:

  1. Pain & Stiffness most severe in early morning
  2. Pain can disturb sleep especially during the latter half of the entire sleeping duration
  3. Pain improves with walking or activity but recurs after prolonged state of inactivity
  4. Pain may radiate to either of the buttocks and may have alternate buttock pain
  5. Response to Pain killers is excellent
  6. Often there is a family history of similar pain in young age
  7. Often there is a family history of a skin disease called Psoriasis, Inflammatory Bowel Disease, Uveitis [An eye problem caused by redness and pain of eyes].

 

Apart from INFLAMMATORY LOW BACK PAIN, there may be involvement of one or two large joints e.g. ankle, knee or wrist in asymmetrical manner. This component of the disease is called PERIPHERAL ARTHRITIS.

 

Apart from joint involvement there may be symptoms of organ involvement other than joints e.g. Redness and Pain of eyes [due to UVEITIS], Skin disease [Psoriasis] and Gastro intestinal problems [Inflammatory Bowel Disease characterised by Painful passage of Stool which is often mixed with Blood and Pus and sometimes along with fever] and Lung Disease [Interstitial Lung Disease characterised by progressive shortness of breath, chest tightness and loss of elasticity of the lungs]These group of disorders are often coined together as EXTRA-ARTICULAR SYMPTOMS.

 

Ankylosing Spondylosis usually affects the age group of 18 to 30 years and Boys or Men are more affected than Females. The presentation is very typical of a Low back Pain which is severe in early morning after waking up from bed and gradually improves on walking or activity and again comes back during prolonged period of rest of on the second half of the sleep. Often there is radiation of the pain into buttocks [Hips] causing alternate buttock pain.

 

In peripheral arthritis one or more large joints of the body is affected causing pain and swelling along with early morning stiffness. Usually ankles and knees are affected but it is not uncommon for elbows and wrists to be affected.

 

IN UNTREATED DISEASE:

 

If the disease is not addressed early and chronic therapy is not started then this disease can cause severe debilitation, deformity, tremendous deterioration of quality of life and ultimately death. Progressive Inflammation of the Sacro Iliac joints may cause ultimately fusion of the Sacrum with Ileum and this phenomenon of obliteration of joint space causing fusion of the two bones over a joint is called ANKYLOSIS. This process of bony fusion gradually proceeds upwards involving each segment of the Spinal Column or the Vertebra causing impaired movement of the lumbar region of the spine [Reduced and painful movement of back leading to complete loss of any movement of low back]. The patient takes a complete erect posture and sometime hyper- erect posture. The process of bony ankylosis gradually proceeds upwards towards the thoracic spine and up to cervical spine [Upper mid back to Back of Neck] causing a straight and rigid body posture with complete loss of neck movement. Often the X Ray of Spine taken at this time looks like a BAMBOO SPINE. [Vide Figures 5 to 7]. Patients are dependent on manual support or walker to move around. There may be difficulty in breathing due to poor movement of the rib cage and may cause severe oxygen shortage of lungs, pneumonias and ultimately death.

 

 

Fig 5: Normal Spine                                            Fig 6: Bamboo Spine                                          Fig 7: Natural Bamboo

MANAGEMENT:

 

One should seek consultation from Experienced Rheumatologist at the earliest as the treatment of Ankylosing Spondylosis is getting updated every 3 to 4 years and new treatment guidelines are coming. Recently the researchers have separated Ankylosing Spondylosis from Peripheral Arthritis and Self Limiting Inflammatory Low back pain that resolves automatically without any damage. However, the treatment remains the same.

 

To diagnose the disease classical symptoms as discussed above are strong enough to create a high index of suspicion. A genetic marker called HLA B27 is often asked for and almost 90% of patients of Ankylosing Spondylosis have this test as POSITIVE. If the results are positive along with the symptoms then an MRI of Sacro-Iliac Joints is often asked for. MRI can identify changes in the joint much ahead of X Rays as it can visualise the cartilage, the soft tissue within the joint and even the bone marrow of the adjoining bones. Bone Marrow edema of the adjoining joints is the earliest sign of Sacro-Ilitis and helps the rheumatologists to catch the disease early in the course and start management. MRI can grade the intensity of Sacro-ilitis which is necessary to follow up the treatment response. Plain X Rays of the Sacro Iliac Joints cannot detect any changes in early disease but any bony changes can readily be detectable. A normal X Ray is not necessary to be repeated within next 2 years for confirmation of the same diagnosis.

 

Blood Parameters such as CRP [C – Reactive Protein] and ESR [Erythrocyte Sedimentation Rate] are frequently measured as these parameters give an idea of the amount of inflammatory activity persisting in the body. The treatment is directed towards relief of symptoms, arrest of disease activity and achieving minimal inflammatory state of the body [or the joints]

 

  1. PHYSICAL THERAPY or PHYSIOTHERAPY

 

All patients of Ankylosing Spondylosis should be physically active all throughout the day. The disease demands more activity in the person than his peers. A normal sacro-iliac joint hardly permits any movement in human body as these joints are formed by apposition of two flat bony surfaces. Hence, the inflammatory chemicals easily get stagnant inside the joint space in highly concentrated amount and can cause easy joint damage. Excessive activity in form of dynamic exercises and games such as contact games [Football, volleyball, kho kho, kabaddi, hockey, basketball, tennis etc] causes jerky movement of body and results in small amount of movement of the sacro-iliac joints. This movement of the sacro-iliac joints results in gradual movement of the inflammatory chemicals out of the joint into blood and fresh joint fluid which is low in inflammatory chemical concentration pours into the joint cavity and thus the intensity of the joint damage is reduced. However, if the disease has progressed a bit it is advisable to avoid jerky movements of the body and start dedicated and guided physical therapy instead.

 

  1. PAINKILLERS

 

We use ETORICOXIB tablets to control the pain. The dose ranges from 60 to 120 mg per day. It has got its own battery of side effects such as gastritis, gastric ulcers, kidney injury and worsening of cardiac pre-existing cardiac problem. But, kindly note that this is the only medicine that can reduce the intensity of inflammation in the sacro-iliac joint and arrest or reverse erosion. Hence for a person suffering only from inflammatory back pain without involvement of any other peripheral joint, this is the medicine of choice. We prescribe concomitant antacids for gastric protection and execute caution in persons who are suffering from Cardiac and Renal Ailments.

Other pain killers like ACECLOFENAC, DICLOFENAC, TRAMADOL, PIROXICAM, MELOXICAM and PARACETAMOL are prescribed to control breakthrough pain or when ETORICOXIB is not available but it is ETORICOXIB that scores beyond others as it is the only group of drug that can reverse the process of joint destruction

 

  1. PARACETAMOL

 

PARACETAMOL is not a pain killer per se. It is an antipyretic or a drug that reduces fever. But at a dose of 1000mg four times a day, it can address painful conditions. PARACETAMOL has got no role in reversal of the disease process. It is prescribed when ETORICOXIB is not available or is contraindicated as in patients with Kidney disorder or Cardiac Problems.

 

  1. SULFASALAZINE

 

SULFASALZINE is actually an antibiotic and at a dose of 2 to 3 Gms per day in divided doses it has shown promise in addressing peripheral joint involvement. Researchers have failed to show any benefit with the use of SULFASALAZINE in only axial disease or in only back pain conditions.

 

The common side effects of SULFASALAZINE is gastritis, nausea, heart burn, hypersensitivity, photo dermatitis, rashes, bone marrow suppression, liver problems and sometimes haemolytic anaemia [in patients who are deficient with a specific enzyme called Glucose 6 Phophatase (G6PD)]. Following precautions should be taken while taking SULFASALAZINE

  1. Take the medicine in empty stomach. It is well absorbed
  2. Gradually increase the dose from 500mg once daily up to 2gms to 3gms per day
  3. Check for Glucose 6 Phosphatase levels before starting the drug
  4. Avoid the medicine who are known to be allergic to SULFUR
  5. Periodically monitor Blood Counts and Liver function to look for any adverse effects
  6. Any kind of allergic phenomenon of rash should immediately be reported.

 

  1. METHOTREXATE:

 

METHOTREXATE was first discovered for its efficacy against different cancers. Currently it is used in treatment of quite a few cancerous conditions. It has got excellent role in management of RHEUMATOID and PSORIATIC ARTHRITIS but unfortunately researchers have failed to show any benefit of its use in ANKYLOSING SPONDYLOSIS. Hence, use of METHOTREAXATE is not recommended in this disease

 

  1. BIOLOGICS:

 

Biologics are highly specific molecules which have come into the picture in last decade. The mechanism of action of the biologics is by directly blocking the action of the pro inflammatory chemicals that cause damage to the joint and its structures directly. Due its highly specific action, these dugs are costly. Commonly prescribed biologics in Ankylosing Spondylosis are

1. ETANERCEPT

2. INFLIXIMAB

3. ABATACEPT

4. TOCILIZUMAB

5. ADALIMUMAB

 

These medicines can reverse the process of joint damage and arrest the progression of the disease. They are administered in once a week to once a month dosing basis and have a common class of side effects. Due to their targeted action against the chemicals that mediate inflammatory damage, their use may be associated with opportunistic infection of the other organs of the body. This is because of the blockade of inflammatory chemicals that are also responsible for normal human defence mechanism against external bacteria or virus.

 

The common infections that can occur are Tuberculosis, Hepatitis, fungal and other bacterial infections. Hence, it is always recommended to screen for Latent Tuberculosis Infection and Hepatitis and HIV infection in the body.

 

  1. SUPPORTIVE THERAPY:

 

The bones near the area of inflammation and as well as the entire human skeleton undergoes a process of accelerated osteoporosis. Hence we often provide CALCIUM supplementation and anti bone resorptive treatment with BISPHOSPHONATES. These are group of medicines which is used to treat OSTEOPENIA and OSTEOPOROSIS

 

  1. COUNSELLING:

 

ANKYLSOING SPONDYLOSIS is a non curable disease. The current medical and physical treatment is directed towards slowing down of the joint damage, improve mobility of the spine, reduce morbidity and improve the quality of life. Since it affects the young age group, proper guidance, education and counselling is necessary for coping up with the disease and its complications.

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I am having swelling and pain just above my knee and can climb up the stairs but it pains with every step I get down the stairs. I am 55 yers and recently my blood test for rheumatoid arthritis came nil. If I wear knee cap there is little relief. What could be the cause and cure for this?

MBBS, MD - Internal Medicine, Diploma in Echocardiography, Diploma in Rheumatology
Internal Medicine Specialist, Kolkata
I am having swelling and pain just above my knee and can climb up the stairs but it pains with every step I get down ...
Likely a case of osteoarthritis and the permanent cure is total knee replacement. Else you must go through vigourous physical therapy and weight losing exercises. Try to contact a rheumatologist for replacement of knee joint fluid
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Sir, my mother has diabetes along with arthritis. Morning and evening walk is essential for her, but due to arthritis she can't walk much. Give me some suggestions.

MBBS, MD - Internal Medicine, Diploma in Echocardiography, Diploma in Rheumatology
Internal Medicine Specialist, Kolkata
Sir, my mother has diabetes along with arthritis. Morning and evening walk is essential for her, but due to arthritis...
Try quadriceps drill and isometric hamstring exercises. Exercises of stomach and hands can be done in excess amount to compensate walking e. G. Pranayam and yoga ask her to walk in neck deep water in a pool for 1 hour [if feasible] as the buoyancy will off load her knees static cycling does not put much load on the knees.
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A brief discussion of Rheumatoid Arthritis

MBBS, MD - Internal Medicine, Diploma in Echocardiography, Diploma in Rheumatology
Internal Medicine Specialist, Kolkata
Vital notes:
 RA is a chronic debilitating joint disease that affects small joints of hands and foot.
 More common in females aged 20 to 50 years.
 It is not synonymous with Rheumatic Fever which occurs in children aged less than 15 years.
 It has got nothing to do with monthly Penicillin injections and checking ASO titre. Somebody on Penicillin injections or being checked for ASO titre should change the doctor immediately.
 Untreated disease may cause deformity of hands and foot causing deterioration of quality of life.
 Erosion of small joints along with loss of entire joint architecture is the basic disease process.
 Early morning stiffness of joints along with swelling of one or more small joints of hands is very characteristic.
 Treatment is done with Methotrexate, Hydroxychloroquine Sulfate, Sulfasalazine, Leflunomide and short courses of steroids.
 Difficult diseases are treated with costly injections called biologics.
 The motto of treatment is “ catch early, hit hard and achieve and maintain treatment goal “
 Lung and cardiac complications are common in long term disease.
 Rheumatologists but not the Orthopedicians nor neurologist are the best person to treat the disease.

Introduction:
Rheumatoid Arthritis is an autoimmune disease of mankind where the cells and molecules who are responsible for security of our body, misidentify the joint tissue as foreign substance and start destroying them similar to the way they usually do when a bacteria or virus enters the body. This misdirected attack towards our own body is called autoimmune phenomenon.
The worst affected parts of the body are the joints of hands and foot. These small joints that are responsible for performance of day to day activities like eating, holding, writing, typing, washing etc become painful and swollen causing stiffness and deformity.
This results in poor quality of life and subsequent depression. Early diagnosis and continuous treatment with specific medicines is cornerstone of treatment.

What are the symptoms?
Symptoms vary from person to person and also from early stage to late stage of the disease.
In early stage there may be mild pain and stiffness involving 1 to 4 small joints of the hands and feet with a typical pattern of stiffness of those joints after rising from bed. During this phase it is very difficult to diagnose the disease. But it is very important to catch the disease in this stage. Researchers have proved that joint damage and bony erosions start even before the symptoms have manifested and hence earlier the treatments better the results.
In a full blown case of Rheumatoid arthritis the picture is very classical of a middle aged female presenting with pain and swelling of hand and foot joints along with early morning stiffness that responds to steroids brilliantly. Wrists and the knuckles are predominantly involved. Patients are unable to hold a pen or open the door or do cooking etc. Gripping the wrist firmly causes pain and the hand joints are warm.
In a advanced case of the disease we often find elderly people presenting with crooked hands with areas of permanent swelling and skin changes due to chronic friction. The skin fold may contract chronic fungal infections and the joints are swollen and painful.
A few other organs are damaged in silence and they create serious problem at the advanced stage of the disease. Lungs, Heart and Blood Vessels are frequently affected. There is accelerated cholesterol deposition in arteries of heart causing increased risk of heart attack and brain stroke. These patients frequently contract infections which are difficult to treat.
Involvement of spine or low back is uncommon. However, cervical spine or the neck region is the only part of the spine that may be affected in this disease.

What is the difference between Rheumatic Fever & Rheumatoid Arthritis?
There is a heaven & hell difference between these two entities. Rheumatic Fever is a disease of childhood. It usually occurs in children aged less than 15 years and is characterised by excruciating pain, swelling and redness of one or more big joints of arms and legs that responds excellently to Aspirin. This disorder may cause cardiac problems and is the leading cause of Valvular Herat disease in India. It is often characterised by some skin rashes and rarely neurologic problems. The disease process, the causative agent and the clinical symptoms are completely different from that of Rheumatoid arthritis.

Why Penicillin injections are given on a monthly basis?
Patients of Rheumatic fever often suffer a damage to the valves of the heart during the attack of Rheumatic fever. This damaged valves are potential sites of infections that may develop in the later part of the life. This infection is called Infective Endocarditis and may cause serious complications if not addressed properly. Penicillin injections are given as a form of prevention of development of this infection and have got no relationship with the wellness or cure of the disease. People who are aged above 15 years and are being treated with penicillin for the first time for joint pain occurring in small joints of hands should immediately change their doctor and consult a rheumatologist.

How is Rheumatoid Arthritis diagnosed?
Rheumatoid Arthritis is diagnosed by its classical symptoms and some laboratory investigations. To identify early rheumatoid cases we usually follow a scoring system which includes counting of number of joints involved, the duration of the symptoms, checking ESR and CRP in blood and looking for the positivity of Rheumatoid Factor and Anti CP Antibody. Patients with high values of Anti CP Antibody are very much likely to suffering from rheumatoid arthritis and also they are very much likely to suffer a aggressive disease course

Does each and every patient of rheumatoid arthritis develop crooked hands and foot?
No. Not all patients suffer from such a devastating complications. There are important characteristics which if present predict severe destructive disease. Females, Smokers, High values of Anti CCP or Rheumatoid Arthritis, Family History of Rheumatoid Arthritis, Early evidence of Joint destruction on X Ray are a few important features who will go forward to develop destructive disease.

How Rheumatoid Arthritis is treated?
Continuous Physical activity of the involved joints is the corner stone of treatment. More the joints are active, less the damage.
Cessation of smoking is mandatory. Smokers tend to develop early joint destruction
Medicines that used in treating rheumatoid arthritis are together called Disease Modifying Anti Rheumatoid Drugs or DMARDs.
Methotrexate, Hydroxychloroquine Sulfate, Sulfasalazine, Leflunomide are the principal DAMRDs. Of these, methotrexate is the backbone of therapy. Methotrexate is used on a once a weekly basis starting from a dose of 5 mg to 50mg/week and a weekly 5mg of Folic Acid supplement is given to neutralise the adverse effects of Methotrexate. The detail of the drugs is mentioned below.

Why I am being given Steroids?
Steroids are given for a short period of increased disease activity. In rheumatoid arthritis we do not prescribe steroids in a regular basis. It is often prescribed when the patient is put on the DMARDs for the first time and when there is break through pain or active disease during the treatment.
Steroids are used in low dose in a decreasing dosage pattern over weeks and usually are not continued more than a month.

What are Biologic agents? Why they are so costly?
Biologic agents are highly specific molecules who directly block the action of the culprit chemicals in our body that cause the joint destruction. They are highly researched molecule an d is manufactured abroad. They are usually available in injection formats and have their own side effect profile which includes reactivation of Tuberculosis and other opportunistic infections. Usually patients are checked for latent Tuberculosis Infections, HIV, Hepatitis B and C before the treatment is started.
Biologics cause excellent response to the disease causing alleviation of pain and swelling and sense of well being but unfortunately they do not provide any cure. Hence, if biologics are stopped then there are chances that the disease activity may worsen requiring more biologics or aggressive treatment with DMARDs.
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Iam suffering from RA since 2 years whether there is any permanent treatment is there.

MBBS, MD - Internal Medicine, Diploma in Echocardiography, Diploma in Rheumatology
Internal Medicine Specialist, Kolkata
Mr. Kumar, Rheumatoid Arthritis does not have a permanent cure. Only 8 to 14% of patients may get back to normal that too within first 4 years of the disease. Go through this article for brief knowledge of Rheumatoid Arthritis Vital notes: RA is a chronic debilitating joint disease that affects small joints of hands and foot. More common in females aged 20 to 50 years. It is not synonymous with Rheumatic Fever which occurs in children aged less than 15 years. It has got nothing to do with monthly Penicillin injections and checking ASO titre. Somebody on Penicillin injections or being checked for ASO titre should change the doctor immediately. Untreated disease may cause deformity of hands and foot causing deterioration of quality of life. Erosion of small joints along with loss of entire joint architecture is the basic disease process. Early morning stiffness of joints along with swelling of one or more small joints of hands is very characteristic. Treatment is done with Methotrexate, Hydroxychloroquine Sulfate, Sulfasalazine, Leflunomide and short courses of steroids. Difficult diseases are treated with costly injections called biologics. The motto of treatment is “ catch early, hit hard and achieve and maintain treatment goal “ Lung and cardiac complications are common in long term disease. Rheumatologists but not the Orthopedicians nor neurologist are the best person to treat the disease.Introduction: Rheumatoid Arthritis is an autoimmune disease of mankind where the cells and molecules who are responsible for security of our body, misidentify the joint tissue as foreign substance and start destroying them similar to the way they usually do when a bacteria or virus enters the body. This misdirected attack towards our own body is called autoimmune phenomenon. The worst affected parts of the body are the joints of hands and foot. These small joints that are responsible for performance of day to day activities like eating, holding, writing, typing, washing etc become painful and swollen causing stiffness and deformity. This results in poor quality of life and subsequent depression. Early diagnosis and continuous treatment with specific medicines is cornerstone of treatment. What are the symptoms? Symptoms vary from person to person and also from early stage to late stage of the disease. In early stage there may be mild pain and stiffness involving 1 to 4 small joints of the hands and feet with a typical pattern of stiffness of those joints after rising from bed. During this phase it is very difficult to diagnose the disease. But it is very important to catch the disease in this stage. Researchers have proved that joint damage and bony erosions start even before the symptoms have manifested and hence earlier the treatments better the results. In a full blown case of Rheumatoid arthritis the picture is very classical of a middle aged female presenting with pain and swelling of hand and foot joints along with early morning stiffness that responds to steroids brilliantly. Wrists and the knuckles are predominantly involved. Patients are unable to hold a pen or open the door or do cooking etc. Gripping the wrist firmly causes pain and the hand joints are warm. In a advanced case of the disease we often find elderly people presenting with crooked hands with areas of permanent swelling and skin changes due to chronic friction. The skin fold may contract chronic fungal infections and the joints are swollen and painful. A few other organs are damaged in silence and they create serious problem at the advanced stage of the disease. Lungs, Heart and Blood Vessels are frequently affected. There is accelerated cholesterol deposition in arteries of heart causing increased risk of heart attack and brain stroke. These patients frequently contract infections which are difficult to treat. Involvement of spine or low back is uncommon. However, cervical spine or the neck region is the only part of the spine that may be affected in this disease. What is the difference between Rheumatic Fever & Rheumatoid Arthritis? There is a heaven & hell difference between these two entities. Rheumatic Fever is a disease of childhood. It usually occurs in children aged less than 15 years and is characterised by excruciating pain, swelling and redness of one or more big joints of arms and legs that responds excellently to Aspirin. This disorder may cause cardiac problems and is the leading cause of Valvular Herat disease in India. It is often characterised by some skin rashes and rarely neurologic problems. The disease process, the causative agent and the clinical symptoms are completely different from that of Rheumatoid arthritis. Why Penicillin injections are given on a monthly basis? Patients of Rheumatic fever often suffer a damage to the valves of the heart during the attack of Rheumatic fever. This damaged valves are potential sites of infections that may develop in the later part of the life. This infection is called Infective Endocarditis and may cause serious complications if not addressed properly. Penicillin injections are given as a form of prevention of development of this infection and have got no relationship with the wellness or cure of the disease. People who are aged above 15 years and are being treated with penicillin for the first time for joint pain occurring in small joints of hands should immediately change their doctor and consult a rheumatologist. How is Rheumatoid Arthritis diagnosed? Rheumatoid Arthritis is diagnosed by its classical symptoms and some laboratory investigations. To identify early rheumatoid cases we usually follow a scoring system which includes counting of number of joints involved, the duration of the symptoms, checking ESR and CRP in blood and looking for the positivity of Rheumatoid Factor and Anti CP Antibody. Patients with high values of Anti CP Antibody are very much likely to suffering from rheumatoid arthritis and also they are very much likely to suffer a aggressive disease course Does each and every patient of rheumatoid arthritis develop crooked hands and foot? No. Not all patients suffer from such a devastating complications. There are important characteristics which if present predict severe destructive disease. Females, Smokers, High values of Anti CCP or Rheumatoid Arthritis, Family History of Rheumatoid Arthritis, Early evidence of Joint destruction on X Ray are a few important features who will go forward to develop destructive disease. How Rheumatoid Arthritis is treated? Continuous Physical activity of the involved joints is the corner stone of treatment. More the joints are active, less the damage. Cessation of smoking is mandatory. Smokers tend to develop early joint destruction Medicines that used in treating rheumatoid arthritis are together called Disease Modifying Anti Rheumatoid Drugs or DMARDs. Methotrexate, Hydroxychloroquine Sulfate, Sulfasalazine, Leflunomide are the principal DAMRDs. Of these, methotrexate is the backbone of therapy. Methotrexate is used on a once a weekly basis starting from a dose of 5 mg to 50mg/week and a weekly 5mg of Folic Acid supplement is given to neutralise the adverse effects of Methotrexate. The detail of the drugs is mentioned below. Why I am being given Steroids? Steroids are given for a short period of increased disease activity. In rheumatoid arthritis we do not prescribe steroids in a regular basis. It is often prescribed when the patient is put on the DMARDs for the first time and when there is break through pain or active disease during the treatment. Steroids are used in low dose in a decreasing dosage pattern over weeks and usually are not continued more than a month. What are Biologic agents? Why they are so costly? Biologic agents are highly specific molecules who directly block the action of the culprit chemicals in our body that cause the joint destruction. They are highly researched molecule an d is manufactured abroad. They are usually available in injection formats and have their own side effect profile which includes reactivation of Tuberculosis and other opportunistic infections. Usually patients are checked for latent Tuberculosis Infections, HIV, Hepatitis B and C before the treatment is started. Biologics cause excellent response to the disease causing alleviation of pain and swelling and sense of well being but unfortunately they do not provide any cure. Hence, if biologics are stopped then there are chances that the disease activity may worsen requiring more biologics or aggressive treatment with DMARDs.
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