Dr. Bodhisatwa Choudhuri

Normally, the body’s immune system recognizes any foreign body as an antigen and produces what are known as antibodies. However, in autoimmune disorders, the body produces antibodies against the body’s own tissue. This is an abnormality and depending on what factor is triggering the production of antibodies, there are various types of autoimmune disorders (AID). When we look at the musculoskeletal system, there are quite a few, the top 4 being:

1. Scleroderma
2. Systemic lupus erythematosus
3. Sjogren’s syndrome
4. Rheumatoid arthritis

In all these conditions, the body produces antibodies against its own tissue, producing these conditions.

Causes:

1. Family history is definitely an attribute to developing autoimmune diseases
2. Environmental pollution
3. Lifestyle including lack of exercise, smoking, excessive alcohol use

Know more about these:

1. Scleroderma: Can be localized or generalized, the upper layers of the skin get thicker (sclerosis). This can be nodular or diffuse, and can also affect children. The skin and muscles are usually affected, but in severe cases, it can affect internal organs such as lungs and heart.
2. Systemic lupus erythematosus: SLE, as it is often called, is very common and can be diagnosed as scleroderma in the initial stages. It can also occur with other autoimmune conditions and some of the types include cutaneous lupus, systemic lupus, drug-induced lupus, and neonatal lupus.
3. Rheumatoid arthritis: The most common autoimmune rheumatic disease is RA, which causes inflammation of the joint spaces. There would be pain, stiffness, and swelling of the joints. This needs to be segregated as RA, as the symptoms are similar to any other form of arthritis. Treatment includes a combination of pain killers, heat and cold therapy, massage, steroid injections, and immune controlling agents.
4. Sjogren’s syndrome: The symptoms are characteristic with dry mucous membranes including those of the eyes, mouth, and vagina. There could be accompanying pain and redness, significant fatigue, fibromyalgia, and complications relating to other organs.

Diagnosis: Autoimmune diseases are tricky to diagnose as other diseases with similar symptoms need to be ruled out first. In some cases, there are specific antibodies, and checking their levels can help identify the underlying condition.

Management: For all the rheumatic autoimmune diseases, treatment is a multipronged approach with lifestyle changes, drugs, and alternative therapies.
Lifestyle changes: A healthy diet, regular exercise, and adequate vitamin and mineral supplementation is a must.

Drugs: Some drugs used are:

1. Anti-inflammatory drugs
2. Steroids
3. ACE inhibitors
4. Immunomodulatory therapy
5. Stem cell transplants

Alternative therapies such as massages with herbal oils, acupuncture, and cold therapy are widely used to control inflammation. In addition, alcohol and smoking and exposure to environmental pollution need to be controlled.

Back pain is a common problem that most of us have suffered from. A pain anywhere in the spine- upper, middle or lower back – are all classed under the category of back pain. It’s a large category but it’s important to note that back pain can be caused due to a number of factors.

Causes

The causes of back pain can be varied because the human vertebra is composed of a complex structure of muscles, ligaments, tendons, disks and bones. Disks are cartilage-like pads that cushion the vertebrae, and problems with any of these can lead to back pain. Some of the common causes of back pain are:

1. Changes in the bony lumbar spine
2. Problems in discs between the vertebrae like hernias, bulges etc.
3. Problems in ligaments around the spine and discs
4. Due to changes in spinal cord and nerves
5. Weakened lower back muscles
6. Problems in abdomen and pelvic internal organs
7. Osteoporosis
8. Posture and lifestyle

Some of the other factors that can cause back pain are:

• Age: You can suffer from back pain at any age but the older you get, the more your chances of getting back pain. It is significantly more common among adults aged 35 or above. Strain is the most common cause of back pain. It can be due to strained muscles, ligaments or a muscle spasm caused due to lifting something too heavy or not using the correct posture when lifting something. It can also be caused due to an abrupt and awkward movement Arthritis can also cause back pain as it may cause a narrowing of the space around the spinal cord known as stenosis. Abnormal curvature of the spine can also cause back pain.
• Other reasons: Issues such as Cauda equina syndrome which affects the bundle of spinal nerve roots that arise from the lower end of the spinal cord and cancer of the spine or a tumour located on the spine which presses against a nerve can result in back pain. Infections of the spine or other infections such as pelvic inflammatory disease in women, bladder, or kidney infections may also lead to back pain.

Symptoms

Pain in the spine is the most common symptom of back pain. Other symptoms can be tenderness, numbness, inflammation, and pain in legs or hands. The nerves of the back could be affected by structural problems in the spine such as a bulge in the disc or herniation or disc rupture. This can press against a vital nerve which controls muscles in arms and legs, causing pain.

Treatment

• Back pain can usually be managed with over-the-counter (OTC) painkillers and by applying a hot compress or an ice pack to the area to relieve pain.
• Resting also helps.
• A change in lifestyle especially by improving body posture while using the computer at work, will be effective.

If the first line of treatment doesn’t work, doctors would prescribe

1. NSAID Medication: These are non steroidal anti-inflammatory drugs such as Codeine or hydrocodone which are prescribed for short periods
2. Physical therapy: This therapy uses the application of heat, ice, ultrasound and electrical stimulation to the back muscles and soft tissues to help alleviate pain. A physical therapist would suggest flexibility and strength exercises for the back and abdominal muscles. They would also suggest ways to improve posture and hence reduce back pain.
3. Cortisone injections: In severe cases, back pain sufferers would be given cortisone injections in the epidural space, which is the space around the spinal cord, to reduce pain by reducing inflammation.
4. Surgery: This is useful for treating herniated discs, ruptured discs or a bulge. Tumours are also removed surgically to treat back pain.

Rheumatoid arthritis is a chronic inflammatory arthritis with a prevalence of 0.5-1% in India. It is characterized by joint pain and swelling associated with morning stiffness lasting for more than 30 minutes. It generally has a slow onset - over weeks to months, though the onset can be acute also. Most common joints involved are small joints of hands and feet. Larger joints like knee and shoulder can also be involved. The incidence of RA increases with age. It is twice more common in females than in males. Early treatment is necessary to bring down the inflammation, avoid joint deformities and prevent other complications ( lung, heart, vasculitis). 

CAUSE: 

Predisposition to RA is multifactorial. It has a genetic component (family history of RA increases the risk). Environmental factors like smoking also play a role. 

SYMPTOMS: 

Initial symptoms start with fatigue, malaise, generalised bodyaches, low-grade fever. The onset is generally slow and eventually patient develops joint pain and swelling. Though the joint involvement is symmetrical in most cases, asymmetric onset is common (involving joints predominantly on one side). 

DIAGNOSIS: 

Diagnosis is made by a physician after detailed history, clinical examination and supportive lab tests. Rheumatoid factor and anti-CCP antibody are positive in 75-80% patients with RA. They have raised inflammatory markers (ESR, CRP) during active inflammation. 

TREATMENT:

RA treatment options are wide and quite effective. It starts with patient education regarding nature of the disease and the risk of complications. The need of early aggressive therapy should be emphasized. The patient should put in efforts for physiotherapy which play a very important role in muscle strength and joint mobility. Pharmacotherapy options are wide and include disease-modifying antirheumatic drugs ( DMARDS). These can be conventional DMARDS like methotrexate ( usually the first line drug), sulfasalazine, hydroxychloroquine, leflunomide. Failure to adequately respond to these drugs should lead your Rheumatologist to consider Biologic DMARDS ( TNF antagonists, Rituximab, Abatacept, Tocilizumab). Your Rheumatologist is the best person to guide you about dose, indications, monitoring and side effects of the drugs used in RA. Treatment duration depends on patient's response but is generally long ( 5-10 years or lifelong). 

COMPLICATIONS BEYOND JOINTS: 

RA patients can have rheumatoid nodules in skin, lungs, heart and other sites. These patients are at risk of accelerated bone loss, so calcium and vitamin D intake should be optimized. Eye complications include dryness, redness ( scleritis and episcleritis) and certain eye threatening complications. Lung involvement can be seen in various forms ( fluid in lungs, nodules, interstitial lung disease). 

These patients are at high risk of atherosclerosis ( heart and blood vessel disease). They also have a tendency to have frequent infections. 

NEED OF THE HOUR: 

All patients with joint pains should be seen early by Rheumatologist for diagnosis and treatment. With so many treatment options, no patient should suffer from joint deformities and other complications associated with long standing, untreated RA. LEAD A HEALTHY LIFE! 

Fibromyalgia is a condition characterised by chronic widespread body pains and increased responsiveness to pressure. Women are at a higher risk of suffering from this disorder than men. Fibromyalgia can be treated with physiotherapy, pharmacotherapy and combined efforts of physician and the patient.

Some of the symptoms that characterize this disorder are:

1. Pain: Fibromyalgia is characterized by pain that has no apparent reason. It can affect different parts of the body and presents itself in different ways. Some people may experience a stabbing pain while others complain of a persistent dull ache. This pain may be affected by climate changes or stressful situations. There is reduced threshold to pain, because of certain chemical ( neurotransmitters) abnormalities in brain. Pain is generalized, felt above and below the waist, right and left-side of body, arms, legs, neck and back. 
2. Abnormal Sensitivity: Fibromyalgia patients are extremely sensitive to environmental changes that involve sight, sound and smell. For example, cigarette smoke can make a fibromyalgia patient extremely nauseous while loud music can give the person an instant headache. Lights that are brighter than normal can also make such a person feel uncomfortable. Patients have an abnormal sensitivity to pain, which leads to generalized aching of the body and tender points. 
3. Muscle & Joint Stiffness: Fibromyalgia patients often experience stiff muscles and joints without any form of strenuous activity or other reason. This may be localised to one group of muscles or affect the whole body. For some patients, this pain is worse in the morning or when sitting for extended periods of time. However, moving around does not provide any significant relief.
4. Chronic fatigue and exhaustion: There are two main reasons for a fibromyalgia patient to complain of tiredness. Firstly, the condition itself drains a person of energy even without overexerting themselves. Secondly, the pain and joint stiffness can hamper a person’s sleep and lead to sleep deprivation. Over time, this can become a vicious cycle of tiredness and insomnia. Chronic fatigue also affects a person’s immune system causing his or her energy levels to drop.
5. Cognitive impairments: Fibromyalgia patients also complain of a compromised short term memory. They often face difficulties recalling names of people they have recently met or other newly acquired information. These people may also have trouble concentrating on tasks for extended periods of time and experience mental sluggishness also known as fibro-fog.
6. Irritable bowel syndrome: Bowel disturbance is another common symptom of this disease. Passing stool may become difficult due to a combination of pain and muscle stiffness. With time, this problem can worsen unless addressed with laxatives. However, an over-dependence on laxatives can lead to further problems.
7. Somatic Symptoms: Apart from pain, patient experiences unrefreshing sleep and fatigue throughout the day. Other associated features can be depression, abdominal cramps, chest pain, tingling.
8. Lab Tests: Fibromyalgia is a clinical diagnosis. There are no definite laboratory tests. In fact, most conducted tests will turn out to be normal. 
9. Treatment: Foremost important is an education of patient and caregivers, regarding nature of the disease. The patient needs to indulge in recreational activities and undergo supervised physiotherapy. There are potent medicines to correct the chemical imbalance in the body thereby increasing the pain threshold and leading to better quality of life.

Juvenile rheumatoid arthritis also known as juvenile idiopathic arthritis is a commonly occurring arthritis in children under the age of 15. Some common problems that are faced by patients with this disease include stiffness, joint pain, and swelling. While the symptoms might persist for a few months for some patients, for others it might continue for the rest of their lives. Patients might face serious complications such as inflammation of the eye, problems related to growth etc. The treatment of this condition focuses on preventing the bones from getting damaged, pain control and improving the function of the body.

What are some of the common symptoms of juvenile arthritis?

1. Pain: A child suffering from juvenile rheumatoid arthritis might face extreme pain in the joints. They might limp after a nap or night sleep due to pain or stiff joints.

2. Swelling: Larger joints such as the knee might swell frequently. The swelling might occur in smaller joints too.

3. Stiffness: In addition to limping the child might appear rough and clumsy after waking from night sleep or a nap.

Other conditions could include rashes, swollen lymph nodes, frequent fever, headache, etc.

What are the causes of Juvenile Rheumatoid Arthritis?

Juvenile Rheumatoid Arthritis occurs when the immune system of the body attacks its own tissues and cells. It is still unclear as to why it happens, although, researchers believe that the environment and heredity have a role to play. Certain genetic mutations might make a child more vulnerable and susceptible to microbes that can trigger this condition.

What are the complications involved?

There could be several complications that might arise due to this condition. It is, therefore, wise to keep a close watch on the child. Seeking immediate medical attention can go a long way in mitigating the risk of these complications.

• Problems related to the eye: Juvenile Rheumatoid arthritis can damage the eye by causing an inflammation known as uveitis. If this condition is not treated, it might result in other conditions such as glaucoma, cataracts, blindness etc.

• Growth problems: Juvenile rheumatoid arthritis could result in growth problems. To treat this, a child would require a dose of corticosteroid.

How to diagnose juvenile arthritis?

It is not very easy to diagnose juvenile arthritis. Doctors often prescribe blood tests to get an idea of erythrocyte sedimentation rate, rheumatoid factor, C-reactive protein, anti-nuclear antibody, cyclic citrullinated peptide etc. A doctor might also prescribe imaging tests such as X-rays, MRI etc to detect congenital defects, fractures, tumors etc.

What are the treatment options available?

The overall treatment goal is to control symptoms, prevent joint damage, and maintain function. Oral steroids such as prednisone, deflazocort may be used in certain situations, but only for as short a time and at the lowest dose possible. Some of the medications that are prescribed for this condition include NSAID such as ibuprofen and naproxen, DMARD such as methotrexate and leflunomide, TNF blockers such as adalimumab and etanercept, immune suppressants such as rituximab. In addition to this, doctors would also prescribe exercises and therapies.