Monthly Archives: January 2017

Signs & Symptoms of Rheumatoid Arthritis

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Unlike osteoarthritis, which results from wear and tear on your joints, rheumatoid arthritis is an inflammatory condition. The exact cause of rheumatoid arthritis is unknown, but it’s believed to be the body’s immune system attacking the tissue that lines your joints (synovium).

Rheumatoid arthritis is two to three times more common in women than in men and generally strikes between the ages of 20 and 50. But rheumatoid arthritis can also affect young children and adults older than age 50.

There’s no cure for rheumatoid arthritis. But with proper treatment, a strategy for joint protection and changes in lifestyle, you can live a long, productive life with this condition.
Signs and symptoms

The signs and symptoms of rheumatoid arthritis may come and go over time. They include:

* Pain and swelling in your joints, especially in the smaller joints of your hands and feet
* Generalized aching or stiffness of the joints and muscles, especially after sleep or after periods of rest
* Loss of motion of the affected joints
* Loss of strength in muscles attached to the affected joints
* Fatigue, which can be severe during a flare-up
* Low-grade fever
* Deformity of your joints over time
* General sense of not feeling well (malaise)

Rheumatoid arthritis usually causes problems in several joints at the same time. Early in rheumatoid arthritis, the joints in your wrists, hands, feet and knees are the ones most often affected. As the disease progresses, your shoulders, elbows, hips, jaw and neck can become involved. It generally affects both sides of your body at the same time. The knuckles of both hands are one example.

Small lumps, called rheumatoid nodules, may form under your skin at pressure points and can occur at your elbows, hands, feet and Achilles tendons. Rheumatoid nodules may also occur elsewhere, including the back of your scalp, over your knee or even in your lungs. These nodules can range in size — from as small as a pea to as large as a walnut. Usually these lumps aren’t painful.

In contrast to osteoarthritis, which affects only your bones and joints, rheumatoid arthritis can cause inflammation of tear glands, salivary glands, the linings of your heart and lungs, your lungs themselves and, in rare cases, your blood vessels.

Although rheumatoid arthritis is often a chronic disease, it tends to vary in severity and may even come and go. Periods of increased disease activity — called flare-ups or flares — alternate with periods of relative remission, during which the swelling, pain, difficulty sleeping, and weakness fade or disappear.

Swelling or deformity may limit the flexibility of your joints. But even if you have a severe form of rheumatoid arthritis, you’ll probably retain flexibility in many joints.
Illustration comparing rheumatoid arthritis and osteoarthritis

Osteoarthritis, the most common form of arthritis, involves the wearing away of the cartilage that caps the bones in your joints. With rheumatoid arthritis, the synovial membrane that protects and lubricates joints becomes inflamed, causing pain and swelling. Joint erosion may follow.
More On This Topic

* Osteoarthritis

Causes

As with other forms of arthritis, rheumatoid arthritis involves inflammation of the joints. A membrane called the synovium lines each of your movable joints. When you have rheumatoid arthritis, white blood cells — whose usual job is to attack unwanted invaders, such as bacteria and viruses — move from your bloodstream into your synovium. Here, these blood cells appear to play an important role in causing the synovial membrane to become inflamed (synovitis).

This inflammation results in the release of proteins that, over months or years, cause thickening of the synovium. These proteins can also damage cartilage, bone, tendons and ligaments. Gradually, the joint loses its shape and alignment. Eventually, it may be destroyed.

Some researchers suspect that rheumatoid arthritis is triggered by an infection — possibly a virus or bacterium — in people with an inherited susceptibility. Although the disease itself is not inherited, certain genes that create an increased susceptibility are. People who have inherited these genes won’t necessarily develop rheumatoid arthritis. But they may have more of a tendency to do so than others. The severity of their disease may also depend on the genes inherited. Some researchers also believe that hormones may be involved in the development of rheumatoid arthritis.
Illustration showing inflammation of rheumatoid arthritis

Rheumatoid arthritis typically strikes joints, causing pain, swelling and deformity. As your synovial membranes become inflamed and thickened, fluid builds up and joints erode and degrade.
Risk factors

The exact causes of rheumatoid arthritis are unclear, but these factors may increase your risk:

* Getting older, because incidence of rheumatoid arthritis increases with age. However, incidence begins to decline in women over the age of 80.
* Being female.
* Being exposed to an infection, possibly a virus or bacterium, that may trigger rheumatoid arthritis in those with an inherited susceptibility.
* Inheriting specific genes that may make you more susceptible to rheumatoid arthritis.
* Smoking cigarettes over a long period of time.

When to seek medical advice

See your doctor if you have persistent discomfort and swelling in multiple joints on both sides of your body. Your doctor can work with you to develop a pain management and treatment plan. Also seek medical advice if you experience side effects from your arthritis medications. Side effects may include nausea, abdominal discomfort, black or tarry stools, changes in bowel habits, constipation and drowsiness.
Screening and diagnosis

If you have signs and symptoms of rheumatoid arthritis, your doctor will likely conduct a physical examination and request laboratory tests to determine if you have this form of arthritis. These tests may include:

*

Blood tests. A blood test that measures your erythrocyte sedimentation rate (ESR or sed rate) can indicate the presence of an inflammatory process in your body. People with rheumatoid arthritis tend to have elevated ESRs. The ESRs in those with osteoarthritis tend to be normal.

Another blood test looks for an antibody called rheumatoid factor. Most people with rheumatoid arthritis eventually have this abnormal antibody, although it may be absent early in the disease. It’s also possible to have the rheumatoid factor in your blood and not have rheumatoid arthritis.
* Imaging. Doctors may take X-rays of your joints to differentiate between osteoarthritis and rheumatoid arthritis. A sequence of X-rays obtained over time can show the progression of arthritis.

Complications

Rheumatoid arthritis causes stiffness and pain and may also cause fatigue. It can lead to difficulty with everyday tasks, such as turning a doorknob or holding a pen. Dealing with the pain and the unpredictability of rheumatoid arthritis can also cause symptoms of depression.

Rheumatoid arthritis may also increase your risk of developing osteoporosis, especially if you take corticosteroids. Some researchers believe that rheumatoid arthritis can increase your risk of heart disease. This may be because the inflammation that rheumatoid arthritis causes can also affect your arteries and heart muscle tissue.

In the past, people with rheumatoid arthritis may have ended up confined to a wheelchair because damage to joints made it difficult or impossible to walk. That’s not as likely today because of better treatments and self-care methods.
More On This Topic

* Osteoporosis

Treatment

Treatments for arthritis have improved in recent years. Most treatments involve medications. But in some cases, surgical procedures may be necessary.

Medications
Medications for rheumatoid arthritis can relieve its symptoms and slow or halt its progression. They include:

* Nonsteroidal anti-inflammatory drugs (NSAIDs). This group of medications, which includes aspirin, helps relieve both pain and inflammation if you take the drugs regularly. NSAIDs that are available over-the-counter include aspirin, ibuprofen (Advil, Motrin, others) and naproxen sodium (Aleve). These are available at higher dosages, and other NSAIDs are available by prescription — such as ketoprofen, naproxen (Anaprox, Naprosyn), tolmetin (Tolectin), diclofenac (Voltaren), nabumetone (Relafen) and indomethacin (Indocin). Taking NSAIDs can lead to side effects such as indigestion and stomach bleeding. Other potential side effects may include damage to the liver and kidneys, ringing in your ears (tinnitus), fluid retention and high blood pressure. NSAIDs, except aspirin, may also increase your risk of cardiovascular events such as heart attack or stroke.
* COX-2 inhibitors. This class of NSAIDs may be less damaging to your stomach. Like other NSAIDs, COX-2 inhibitors — such as celecoxib (Celebrex) — suppress an enzyme called cyclooxygenase (COX) that’s active in joint inflammation. Other types of NSAIDs work against two versions of the COX enzyme that are present in your body: COX-1 and COX-2. However, there’s evidence that by suppressing COX-1, NSAIDs may cause stomach and other problems because COX-1 is the enzyme that protects your stomach lining. Unlike other NSAIDs, COX-2 inhibitors suppress only COX-2, the enzyme involved in inflammation. Side effects may include fluid retention and causing or exacerbating high blood pressure. Furthermore, this class of drugs has been linked to an increased risk of heart attack and stroke.
* Corticosteroids. These medications, such as prednisone and methylprednisolone (Medrol), reduce inflammation and pain, and slow joint damage. In the short term, corticosteroids can make you feel dramatically better. But when used for many months or years, they may become less effective and cause serious side effects. Side effects may include easy bruising, thinning of bones, cataracts, weight gain, a round face and diabetes. Doctors often prescribe a corticosteroid to relieve acute symptoms, with the goal of gradually tapering off the medication.
* Disease-modifying antirheumatic drugs (DMARDs). Physicians prescribe DMARDs to limit the amount of joint damage that occurs in rheumatoid arthritis. Taking these drugs at early stages in the development of rheumatoid arthritis is especially important in the effort to slow the disease and save the joints and other tissues from permanent damage. Because many of these drugs act slowly — it may take weeks to months before you notice any benefit — DMARDs typically are used with an NSAID or a corticosteroid. While the NSAID or corticosteroid handles your immediate symptoms and limits inflammation, the DMARD goes to work on the disease itself. Some commonly used DMARDs include hydroxychloroquine (Plaquenil), the gold compound auranofin (Ridaura), sulfasalazine (Azulfidine), minocycline (Dynacin, Minocin) and methotrexate (Rheumatrex). Other forms of DMARDs include immunosuppressants and tumor necrosis factor (TNF) blockers.
* Immunosuppressants. These medications act to tame your immune system, which is out of control in rheumatoid arthritis. In addition, some of these drugs attack and eliminate cells that are associated with the disease. Some of the commonly used immunosuppressants include leflunomide (Arava), azathioprine (Imuran), cyclosporine (Neoral, Sandimmune) and cyclophosphamide (Cytoxan). These medications can have potentially serious side effects such as increased susceptibility to infection.
* TNF blockers. These are a class of DMARDs known as biologic response modifiers. TNF is a cytokine, or cell protein, that acts as an inflammatory agent in rheumatoid arthritis. TNF blockers, or anti-TNF medications, target or block this cytokine and can help reduce pain, morning stiffness and tender or swollen joints — usually within one or two weeks after treatment begins. There is evidence that TNF blockers may halt progression of disease. These medications often are taken with methotrexate. TNF blockers approved for treatment of rheumatoid arthritis are etanercept (Enbrel), infliximab (Remicade) and adalimumab (Humira). Potential side effects include injection site irritation (adalimumab and etanercept), worsening congestive heart failure (infliximab), blood disorders, lymphoma, demyelinating diseases, and increased risk of infection. If you have an active infection, don’t take these medications.
* Interleukin-1 receptor antagonist (IL-1Ra). IL-1Ra is another type of biologic response modifier and is a recombinant form of the naturally occurring interleukin-1 receptor antagonist (IL-1Ra). Interleukin-1 (IL-1) is a cell protein that promotes inflammation and occurs in excess amounts in people who have rheumatoid arthritis or other types of inflammatory arthritis. If IL-1 is prevented from binding to its receptor, the inflammatory response decreases. The first IL-1Ra that has been approved by the Food and Drug Administration for use in people with moderate to severe rheumatoid arthritis who haven’t responded adequately to conventional DMARD therapy is anakinra (Kineret). It may be used alone or in combination with methotrexate. Anakinra is given as a daily self-administered injection under the skin. Some potential side effects include injection site reactions, decreased white blood cell counts, headache and an increase in upper respiratory infections. There may be a slightly higher rate of respiratory infections in people who have asthma or chronic obstructive pulmonary disease. If you have an active infection, don’t use anakinra.
* Abatacept (Orencia). Abatacept, a type of costimulation modulator approved in late 2005, reduces the inflammation and joint damage caused by rheumatoid arthritis by inactivating T cells — a type of white blood cell. People who haven’t been helped by TNF blockers might consider abatacept, which is administered monthly through a vein in your arm (intravenously). Side effects may include headache, nausea and mild infections, such as upper respiratory tract infections. Serious infections, such as pneumonia, can occur.
* Rituximab (Rituxan). Rituximab reduces the number of B cells in your body. B cells are involved in inflammation. Though originally approved for use in people with non-Hodgkin’s lymphoma, rituximab was approved for rheumatoid arthritis in early 2006. People who haven’t found relief using TNF blockers might consider using rituximab, which is usually given along with methotrexate. Rituximab is administered as an infusion into a vein in your arm. Side effects include flu-like signs and symptoms, such as fever, chills and nausea. Some people experience extreme reactions to the infusion, such as difficulty breathing and heart problems.
* Antidepressant drugs. Some people with arthritis also experience symptoms of depression. The most common antidepressants used for arthritis pain and nonrestorative sleep are amitriptyline, nortriptyline (Aventyl, Pamelor) and trazodone (Desyrel).

Surgical or other procedures
Although a combination of medication and self-care is the first course of action for rheumatoid arthritis, other methods are available for severe cases:

* Prosorba column. This blood-filtering technique removes certain antibodies that contribute to pain and inflammation in your joints and muscles and is usually performed once a week for 12 weeks as an outpatient procedure. Some of the side effects include fatigue and a brief increase in joint pain and swelling for the first few days after the treatment. The Prosorba column treatment isn’t recommended if you’re taking angiotensin-converting enzyme (ACE) inhibitors or if you have heart problems, high blood pressure or blood-clotting problems.
* Joint replacement surgery. For many people with rheumatoid arthritis, medicines and therapies can’t prevent joint destruction. When joints are severely damaged, joint replacement surgery can often help restore joint function, reduce pain or correct a deformity. You may need to have an entire joint replaced with a metal or plastic prosthesis. Surgery may also involve tightening tendons that are too loose, loosening tendons that are too tight, fusing bones to reduce pain or removing part of a diseased bone to improve mobility. Your doctor may also remove the inflamed joint lining (synovectomy).

More On This Topic

* Steroid use: Balancing the risks and benefits
* Are COX-2 drugs safe for you? An interview with a Mayo Clinic specialist
* Knee replacement: Surgery can relieve pain

Self-care

Treating rheumatoid arthritis typically involves using a combination of medical treatments and self-care strategies. The following self-care procedures are important elements for managing the disease:

*

Exercise regularly. Different types of exercise achieve different goals. Check with your doctor or physical therapist first and then begin a regular exercise program for your specific needs. If you can walk, walking is a good starter exercise. If you can’t walk, try a stationary bicycle with little or no resistance or do hand or arm exercises. A chair exercise program may be helpful. Aquatic exercise is another option, and many health clubs with pools offer such classes.

It’s good to move each joint in its full range of motion every day. As you move, maintain a slow, steady rhythm. Don’t jerk or bounce. Also, remember to breathe. Holding your breath can temporarily deprive your muscles of oxygen and tire them. It’s also important to maintain good posture while you exercise. Avoid exercising tender, injured or severely inflamed joints. If you feel new joint pain, stop. New pain that lasts more than two hours after you exercise probably means you’ve overdone it. If pain persists for more than a few days, call your doctor.
* Control your weight. Excess weight puts added stress on joints in your back, hips, knees and feet — the places where arthritis pain is commonly felt. Excess weight can also make joint surgery more difficult and risky.
* Eat a healthy diet. A healthy diet emphasizing fruit, vegetables and whole grains can help you control your weight and maintain your overall health, allowing you to deal better with your arthritis. However, there’s no special diet that can be used to treat arthritis. It hasn’t been proved that eating any particular food will make your joint pain or inflammation better or worse.
* Apply heat. Heat will help ease your pain, relax tense, painful muscles and increase the regional flow of blood. One of the easiest and most effective ways to apply heat is to take a hot shower or bath for 15 minutes. Other options include using a hot pack, an electric heat pad set on its lowest setting or a radiant heat lamp with a 250-watt reflector heat bulb to warm specific muscles and joints. If your skin has poor sensation or if you have poor circulation, don’t use heat treatment.
* Apply cold for occasional flare-ups. Cold may dull the sensation of pain. Cold also has a numbing effect and decreases muscle spasms. Don’t use cold treatments if you have poor circulation or numbness. Techniques may include using cold packs, soaking the affected joints in cold water and ice massage.
* Practice relaxation techniques. Hypnosis, guided imagery, deep breathing and muscle relaxation can all be used to control pain.
* Take your medications as recommended. By taking medications regularly instead of waiting for pain to build, you will lessen the overall intensity of your discomfort.

Coping skills

The degree to which rheumatoid arthritis affects your daily activities depends in part on how well you cope with the disease. Physical and occupational therapists can help you devise strategies to cope with specific limitations you may experience as the result of weakness or pain. Here are some general suggestions to help you cope:

* Keep a positive attitude. With your doctor, make a plan for managing your arthritis. This will help you feel in charge of your disease. Studies show that people who take control of their treatment and actively manage their arthritis experience less pain and make fewer visits to the doctor.
* Use assistive devices. A painful knee may need a brace for support. You might also want to use a cane to take some of the stress off the joint as you walk. Use the cane in the hand opposite the affected joint. If your hands are affected, various helpful tools and gadgets are available to help you maintain an active lifestyle. Contact your pharmacy or doctor for information on ordering items that may help you the most.
* Know your limits. Rest when you’re tired. Arthritis can make you prone to fatigue and muscle weakness. A rest or short nap that doesn’t interfere with nighttime sleep may help.
* Avoid grasping actions that strain your finger joints. Instead of using a clutch purse, for example, select one with a shoulder strap. Use hot water to loosen a jar lid and pressure from your palm to open it, or use a jar opener. Don’t twist or use your joints forcefully.
* Spread the weight of an object over several joints. For instance, use both hands to lift a heavy pan.
* Take a break. Periodically relax and stretch.
* Maintain good posture. Poor posture causes uneven weight distribution and may strain ligaments and muscles. The easiest way to improve your posture is by walking. Some people find that swimming also helps improve their posture.
* Use your strongest muscles and favor large joints. Don’t push open a heavy glass door. Lean into it. To pick up an object, bend your knees and squat while keeping your back straight.

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Back Pain – SI Joint Dysfunction

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Sacroiliac joint pain

Sacroiliac (SI) joint pain has gained a lot of attention in the last ten years as an underappreciated cause of back pain with some studies indicating it is responsible for 15% to 40% of low back pain. The increased attention is due to the increasing knowledge of the SI joints intimate role in pelvic stability.  I hope more physicians consider SI joint pain in their differential after reading this article.

Pathophysiology

SI joint dysfunction due to inflammation within the joint itself is called sacroilitis. Pain from within the SI joint is common in rheumatoid patients and spondyloarthropathies.

The other cause of SI joint dysfunction stems from instability of the SI joint.  Many experts feel that SI joint pain is a component of a larger problem of pelvic instability (1). Pelvic instability has traditionally been underappreciated as a cause of low back pain, buttock pain, groin pain, and leg pain. Physical therapists and doctors of osteopathic medicine have been teaching these concepts for years but only relatively recently has this dissemination of knowledge trended towards mainstream thinking among medical doctors.

The SI joint complex (the SI joint and its associated ligaments) is the major support structure of the pelvic ring and is the strongest ligament complex in the body.  The complex consists of interosseous sacroiliac ligaments, iliolumbar ligaments, posterior sacroiliac ligaments, and the sacrotuberous and sacrospinous ligaments. The SI joints are two of the three joints involved in the stability of the pelvic ring.  The pelvic ring is the meeting place of the force vectors from the upper body and the lower extremities.  The third joint in the pelvic ring is the pubis symphysis. Pelvic instability causes pelvic rotation which can also cause twisting of the pubis symphysis.  Coupling this with its anterior location appears to provide an explanation as to why patients with SI joint instability can also experience anterior groin pain. Anecdotal evidence for this is seen when patients undergo a successful SI joint intra-articular injection relieving all of their posterior back, buttock, and leg symptoms but the patient still has groin pain. Groin pain is almost never eliminated by SI joint injections unless pelvic symmetry is corrected.

If the SI joints are unstable, it can lead to significant pain and discomfort over the SI joints as well as numerous referred areas.  If an individual affected by SI joint pain has pain only over his or her SI joint, he/she  should be considered lucky. Most often SI joint instability causes unnatural strain on the entire low back and pelvic region causing a sometimes confusing clinical picture. Pain referral patterns of SI joint pain are often confused with L5 or S1 radiculitis or radiculopathies.

Referral patterns of SI joint dysfunction (2)

SI joint dysfunction often presents with a confusing clinical presentation.

1.       Buttock pain 94%

2.       Lower lumbar pain 74%,

3.       Lower extremity pain 50%, with 28% of these lower extremity pains going distal to the knee

4.       Pain goes all the way into the foot 13%. Younger patients are more likely to refer pain distal to the knee.

5.       Groin pain 14%.

Most patients with SI joint instability also experience pain over the buttock region due to secondary muscle spasm of the gluteus muscles and piriformis complex.  Lower extremity symptoms are explained by the piriformis muscles natural tendency to spasm or tighten over the sciatic nerve whenever the SI joint is out of alignment.  This spasm of gluteus and piriformis muscles can cause a mechanical crowding or impingement of the sciatic nerve as it exits just below the SI joint (see figure 1. note the intimate association of the piriformis muscle, SI joint, and sciatic nerve).  Patients often complain of buttock pain and radiation of pain down to the knee and even down to the foot. Not all back pain and leg pains are due to a pinched a nerve from an intervertebral disk herniation.  SI joint dysfunction very closely mimics S1 or L5 radiculitis’ or radiculopathies because of the above described sciatic nerve irritation or impingement.

Groin pain and abdominal pain are not uncommon with SI joint instability.  Often times the groin pain is mistaken as a urologic problem like pudendal neuralgia, prostatitis,  genitofemoral neuralgia, or sterile epididymitis(1). This is likely either due to unnatural tension on the nerves and ligaments around the pubis symphysis or actual impingement of the pudendal nerve which lies between the sacrospinous ligament and sacrotuberous ligament. The distance between these two ligaments abruptly narrows when the Ilium and sacrum are out of alignment i.e. SI joint instability.

The typical history of SI joint dysfunction consists of lateral or bilateral low back pain almost always below the pelvic rim. Pain can also radiate into the hip, groin, pelvis, leg, and foot.  The most common location of pain is in the buttock with pain extending down to the knee. Females are much more affected than males though the ratio is unclear.  The mechanism of injury is a continuum from completely atraumatic events to more obvious trauma like motor vehicle accidents, childbirth, or falls. A little over one-third of failed back surgery patients suffer from SI joint dysfunction. In my practice, I often see patients who lose a substantial amount of weight and then develop SI joint dysfunction.  The etiology of this is unclear. Women who have had multiple births also seem to have a higher incidence of SI joint dysfunction.  The symptoms may be acute or may present as a remote or cumulative injury with chronic waxing and waning of symptoms with slow progression over time.  Patients often experience some degree of temporary relief with manipulation.  Patients must change positions frequently to avoid pain.  This is called “Theater Party Cocktail Syndrome”. Patient’s legs can also feel like they’re going to give out, but with objective testing of motor strength, no dysfunction is found. This is called a “Slipping Crutch syndrome”. Patients usually have a difficult time sleeping and getting out of bed in the morning can be excruciatingly painful. Continued movement after waking up tends to improve the pain.

There are many provocative physical exam maneuvers used to help establish the diagnosis of SI joint dysfunction. Going through each one of these provocative maneuvers is beyond the scope of this article.  It is important to note that the predictive value of provocative SI joint maneuvers in determining SI joint dysfunction is only 60%(4).  The conclusion of a recent study by Slipman et al(5), was that physical exam techniques can at best enter SI joint dysfunction into the differential diagnosis of a patient’s low back pain.  Of the alleged signs of sacroiliac joint pain, maximum pain below L5 coupled with pointing to the PSIS or local tenderness just medial to the PSIS (sacral sulcus) has the highest positive predictive value (PPD) at 60%(4).

Diagnosis

The gold standard for making a diagnosis of SI joint dysfunction is a fluoroscopically guided SI joint injection. Fluoroscopy is needed to accurately and consistently inject the sacroiliac joint.  Only 12% of patients had intra-articular SI joint injections when fluoroscopy was not utilized (3).  Also important is to anesthetize the entire SI joint complex.  In my experience as an interventional pain physician, this cannot be consistently done by palpation alone, especially in obese patients.  It is humbling to see anatomy change under fluoroscopic guidance. What you perceive with palpation is sometimes markedly different than the actual location of the structure that you palpate.  Also vitally important is that these diagnostic injections are followed up with another physical exam while the patient is in the recovery room. Sending a patient home, having them follow up in several weeks, and then determining if this “diagnostic” injection was successful has consistently been shown to be an inaccurate way of establishing a pathoanatomic diagnosis.

Treatments

There is no one specific treatment for SI joint dysfunction which helps all patients.  The treatment varies if the dysfunction is intra-articular (inflammatory), or if it’s a lack of stability. Conservative treatment should first be tried including the manipulation by a qualified physical therapist or osteopathic physician to restore normal motion and balance,  home self-correction exercises,  a walking program (avoid heavy axial loading maneuvers), and core strengthening exercises (Pilates, Yoga, or guided physical therapy). Some patients also benefit from a quality SI joint support belt.  If conservative therapy is not helpful then I recommend a diagnostic SI joint complex injection.  The injection should include the SI joint ( intra-articularly) and the supporting ligaments with pain relief lasting for the duration of the local anesthetic and achieving greater than 75% pain relief. If there is any question about the positivity of this diagnostic test,  it should be repeated.

Radiofrequency Denervation

If the diagnosis has been established by an intra-articular SI joint injection and pain relief using conservative therapy affords no long-term pain relief, then consideration for other treatments can be made.  Radiofrequency denervation of an SI joint carries about a 65% success rate for patients who have failed other conservative therapies and only mild instability around the joint. The procedure involves the neurotomy of the lateral branch nerves that lay over the sacrum and innervate the posterior SI joint. The advantage of SI joint radiofrequency is that it is a very safe procedure with almost no documented morbidity.

Prolotherapy

Another treatment for SI joint pain is Prolotherapy.  Prolotherapy works by stimulating an inflammatory cascade which leads to fibroblastic activity thereby strengthening the entheses of ligaments and tendons. Prolotherapy on SI joints usually requires very strong Prolotherapy solutions.  In my experience, hypertonic Dextrose Prolotherapy only relieves 20 to 30% of most patients’ pain.  More aggressive prolotherapy usually reduces pain by 50% or greater in roughly 75% of patients. The greatest advantage of Prolotherapy is that it provides a level of permanent relief.

SI Joint Fusion

If the patient fails radiofrequency and prolotherapy, the last treatment option would be a consideration for an SI joint fusion.  The outcome data on SI joint fusions is not highly favorable.  However, there are new minimally invasive SI joint fusions that have recently been approved by the FDA that appear promising. Patients with very diffuse pelvic pain and leg pains are not good candidates for fusion surgery.

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Treatment Guide for a Herniated Disc

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As we begin to age, the probability of dealing with a health complication is relatively high. From cancer to heart attacks and extreme pain – it seems expected to contend with one of these impediments to normal life. For instance, back pain which is a common health concern among Americans has affected millions marked by discomfort and inability to live life the fullest.

Though back pain is a common complaint, it has various types, symptoms and treatment methods. Most cases of back pain are attributed to a herniated disc. Based on the report of FamilyDoctor.org, “Herniated discs are most common in the lumbar spine–the part of your backbone between the bottom of your ribs and your hips. Discs are the soft “cushions” between the bones of the spine.” When your disc is pushed against a nerve, it begins to bulge and become very uncomfortable. Often referred to as a “slipped disc,” the pressed nerve can elicit pain in the back and leg, as well as numbness. Generally, the more you move, the more painful it becomes. Even the slightest movement from coughing or sneezing can bring on an excruciating muscle spasm.

Treament Procedures For Herniated Discs

If you suffer from a herniated disc, there are several treatments that you can undergo. First and foremost, maintaining a regular exercise rudiment is helpful. Although you have to consult your doctor before making a concrete action, stretching can mitigate the pain. Indulging yourself in Yoga or Pilates can help since the procedure improves your flexibility and blood circulation. You may also need to take in prescribed medicines or take a shot in your back bone.

Non-responsive? If so, spinal decompression therapy could help. Popularly known as one of the most effective and non-invasive treatments, spinal decompression therapy targets herniated discs, Sciatica as well as pinched nerves. It consists of lying on a table and being connected to a harness that is then hooked to a computer. The computer sends the signal that puts pressure to the spine stretching the discs apart to enable blood and oxygen to flow back into the spine. This is often referred to as a “vacuum effect,” since the pressure creates suction.

Though many would assume that spinal decompression therapy hurts, the treatment is 100% painless. For most patients, the effect is positive since it eases pain and relieves muscle spasm. The therapy triggers the disc to stretch and become flexible which marks the start of the healing stage. Much cheaper than spinal decompression surgery, this treatment requires the patient to undergo 4-5 sessions per week for a minimum of twenty sessions. By the end of the process, the majority feel as if they have either been cured or significantly helped.

The case of herniated discs is not an unusual problem for millions of people worldwide. It can be a frustrating experience since your mobility suffers. You no longer can take that daily walk or go swimming with friends – everyday becomes a sore day. With alternative treatments such as yoga or spinal decompression therapy, herniated discs no longer have to be your death sentence. Such treatments can significantly ease the pain, reduce the occurrence of symptoms and restore your confidence. Trust us, pain doesn’t have to be forever.

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Source by Blaise Breton

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Arthritis of the Hands and Wrists – Need for a Surgery

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Arthritis of the Hands and Wrists – Need for a Surgery

People whose hands and wrists are affected by arthritis are not always recommended by a surgery. They are usually treated with steroidal injections or non-steroidal anti-inflammatory drugs. A surgery is always the last resort as far as treatment for arthritis is concerned.

Only when the symptoms stop responding to the medications and injections and the severity of the symptoms become unbearable, would a doctor recommend a surgery. But finally, it is for the patient to decide whether or not to take up surgery as an option.

The Need for a Surgery: Hands or wrists that are affected by arthritis can make the hands and fingers look deformed and unimpressive. But, a surgery is initially done not to improve the look, but to alleviate the joint pains and stiffness thus, improving the function.

The overall aim of the surgery is relief from pain and an increased overall function of the joints. Let us take a brief look at each of the different surgeries.

Carpal Tunnel Release: The median nerve is responsible for the movement of the thumb and for the transmission of the information from the thumb to the brain. When this nerve is squeezed, the thumb suffers the most with immense pain and numbness.

When the pain stops responding to other treatments, a surgery of the carpal tunnel would be necessary. The ligament of the carpal tunnel would have to be moved as it is responsible for applying the pressure on the media nerve.

A patient can go home soon after the surgery is done and the bandages would stay for two weeks. During this time, it is necessary to keep the fingers and thumb moving in order to avoid the scar tissue from jamming the joints.

Dupuytren’s Contracture Fasciotomy: A scar tissue in the palm and the fingers can cause the fingers to curl towards the palm. This is due to the formation of contractures. A surgery is required to cut these contractures and enable finger stretching.

This surgery would require the patient to stay overnight at the hospital and would take almost 12 weeks before one gets to use the hand fully.

Trigger Finger Release: In patients who suffer from arthritis, the finger sometimes would bend normally but wouldn’t return back into a normal position and will remain curled. The tendon that surrounds it would have to be operated upon in order to release the finger.

This involves a minor surgery and the recovery would take 15 days.

Tendon Repair: In patients who suffer from rheumatoid arthritis, there is a possibility that the hands’ tendons are ruptured. A tendons’ rupture can either lead to problems with finger straightening or bending.

The surgery would involve replacing the damaged tendons with healthy ones from the unaffected fingers. If the rupture is the resultant of a rough bone, then the bone has to be either smoothened or removed to prevent the problem from repeating.

The recovery period is nearly 3 months during which time the hand should be properly rested in order to heal.

Ganglion Removal: Synovial fluid is essential to avoid friction in the synovial joints during movement. Inpatients, who suffer from arthritis, there is every chance that the synovial fluid would leak from the joints allowing the formation of ganglion cysts, usually formed at the back of the wrist.

A surgery (in very rare cases) would be required to draw the leaking fluid in order to prevent the cyst formation.

Knuckle Joint Replacement: Rheumatoid arthritis can leave the hands severely deformed and decrease their functionality completely. In such severe cases, artificial knuckles would have to be implanted in order to restore the hand flexibility.

The recovery from this surgery takes a while and it can be sometime before the hand can be used normally once again.

Thumb Joint Surgery: Rheumatoid arthritis can severely damage the thumb joint and it is not easy replacing this joint. Instead, a surgery would stiffen the damaged joint thus, completely disabling the movement of the joint. Dis baling the joint would relieve a patient from pain.

In a few cases, the joint is removed and the space is either allowed to fill with naturally forming materials or an artificial joint may be used.

Wrist Joint Surgery: Wrists affected by rheumatoid arthritis cause severe pain and either a fusion surgery or a replacement surgery of the wrist would become essential.

Based on the severity of the symptoms, the surgery would either restrict the movement of the wrist (fusion) or the affected joint would be replaced. The latter surgical option is still not being used vividly.

A surgery for arthritis of the hands and wrists can be very useful for alleviating the pain associated with the affected joints. The only matter of concern with a surgery would be the recovery time, otherwise, there are not too many serious complications that arise.

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Source by mohammed

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Cold Laser Therapy For Arthritis Knee Pain Sufferers

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A common serious type of arthritis is rheumatoid arthritis, which initially manifests as sore or stiff joints in the knees, feet, elbows, and hands. Typically, the stiffness will start in the same joint on both sides of the body. Gradually the patient of arthritis feel a sense of fatigue and flu-like symptoms, accompanied by aches and pains as well as joint inflammation. Now if the pain is felt in any joint of the body following a repetitive action, this might be indicative of another type of arthritis called Osteoarthritis. Such as an individual who has been a professional athlete for years may someday feel some pain in his/her knee without any evident cause. Standard imaging tests like X-rays may uncover wear and tear in the cartilage of the knees, which weaken the joints and cause increasing pain.

Osteoarthritis commonly affects the joints of hips, back, neck, and fingers. Swollen or misshapen fingers joints are telltale signs of the disease. In severe cases, affected patients may find it difficult if not impossible to perform even simple activities such as walking, sitting down, or standing up. In such conditions, joint replacement surgery may be the only course of action. A common approach to treating severe arthritis in the knees is the cold laser therapy or use of knee braces, either off-the-shelf or custom-made. Off-the-shelf types of knee braces may not fit perfectly but are less expensive, whereas custom-made types are more expensive and are devised to fit both your knee and your specific condition.

While cold laser therapy or the prescription drugs may help alleviate pain, they are seldom able to eliminate it completely. New medications and remedies however, are now available to manage the painful symptoms of arthritis. In addition to standard and usual medications, physicians may prescribe creams and ointments for oral application. NSAIDs are often the prescription of specific choice for a majority of doctors.”diagnosis: a preface to an autopsy”
“To confess ignorance is often wiser than to beat about the bush with a hypothetical diagnosis.”
“Being a reporter is as much a diagnosis as a job description” Rheumatoid arthritic patients are usually given biologics or anti-rheumatic medications, which can be injected at regular intervals to improve the patient’s condition and to lessen the pain. Another technique that has been known to effectively reduce the progression of the disease is doing regular arthritis knee exercises, including swimming, cycling, and walking. Regular work out programs will help improve or restore joint function. These work outs need not be rigorous, as even simple steps can do wonders to the joints. Strenuous work outs that may further damage or aggravate the joints must be strictly avoided.

In extreme severe cases, knee surgery and chemotherapy may be necessary. Alternative methods of treatment such as acupuncture and magnetic pulse therapy have also become popular these days, owing to the many users who attest to their efficiency.

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Source by ihtesham

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Back Pain Caused by Allergies

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Back Pain problems are developed in many different ways. If your back pain is caused by an allergy, then it is more difficult to deal with. This is a very common problem. If left untreated it can cause very severe back problems.

Finding The Cause

To find out what is causing the allergic reaction is an important step for a person dealing with back pain caused by allergies. The worst time of year for allergies is springtime. To help determine what you can be allergic to, you can have a doctor do a few tests.

These are various allergies that you could have:

House dust, house dust mites, animal dander, yeasts, bee/wasp stings, and certain drugs and foods can also cause allergic reactions. Eggs, milk, shellfish, nuts, dried fruits, and certain food dyes can cause food allergies.

Lower Back Pain And How To Deal With It

What is going to happen next is that there are steps that need to be taken to tell what is the best treatment for the person who has the intolerance to the allergens. There are some very effective options, but it will depend if the back pain is acute or chronic.

What happens with sudden acute low back pain, is it comes on all of a sudden and you don’t know where it came from. Chronic lower back pain is the recurring type and can last for a couple months to even longer in some cases.

Typically, drugs are the first step in the treatment plan. There are prescription and non-prescription drugs that are available for people who are suffering back pain caused by allergies. Depending on how serious and how long a person has been suffering will determine what drug to take.

You could take anything from Advil to NSAID’s (non-steroidal anti-inflammatory drugs). These are commonly used to help alleviate all types of back pain.

Now when you get to the prescription drugs there are risks in taking some of them. You can have possible side effects, drug interactions with other medications you may be taking, so be careful.

Always read the labels of the medication you are taking even the ones prescribed by a doctor. This will ensure that you have as little cause for an allergic reaction as possible.

To increase your nutrition, you can also take supplements and vitamins. It is important to have a good diet as well.

There is treatment for people who are dealing with back pain caused by allergies. Talk to your doctor and you will get proper treatment for the condition that you are suffering from. Take care of yourself so that the back pain does not become permanent.

Don’t suffer anymore from back pain. Just think how good it would feel to be back pain-free. You can get your FREE report now. Discover information on arthritis low back pain and lots more.

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How To Identify Lower Back Pain Symptoms?

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The first step to kill any kind of pain and particularly back pain is to understand its true cause. What could be the possible reason of your lower back pain symptoms is the pain mild or severe? Since how long are you facing the pain? These questions could help you introspect into getting some critical answers with the help of which your back pain could be cured at an early stage itself.

Some Very Important Things To Remember

In the present times, four out of five adults face Back pain symptoms and most commonly lower back pain symptoms. Lower back pain can be mild or severe. It is important to understand that most of the times these pains are periodical and may not last continuously for days. They keep re-occurring over a period. In most of the cases, lower back pain occurs due to damage or over exertion of certain ligaments in the spine. Therefore, it is important to observe these pains to determine their true nature. The most commonly faced problem by the doctors is that they fail to determine the true cause of this pain and provide an effective curative solution. One must understand that back pain being of a complex nature, the doctor may choose to observe and study these pains carefully and over a period before prescribing strong medication. However, you are your best judge. Therefore, your observations also play a vital role and could help your physician in back pain diagnosis. Some of the common symptoms to lower back pain are:

1. Persistent aching or stiffness in the hips or waist area
2. Pain encountered after long hours of sitting or standing.
3. Pain encountered during back movements. For e.g. while bending, walking, or performing any kind of sport.
4. Pain during while getting up from the bed in the mornings.
5. Pain while moving hands. For e.g. while shaking hands.

The above points are the most common symptoms and the most ignored symptoms of back pain. Ignorance of these back pain symptoms in most of the cases is the common reason of chronic pain. Lower back pain symptoms if attacked at an early stage can be cured with proper medical attention, care and the right back pain diagnosis. One the other hand, one must also understand that there is no need to get panicky as soon as you encounter back pain. With advancement in the scientific field, there are a number of treatments available, which can cure back pain. It is just important to be optimistic.

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Source by Apurva Shree

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Herniated Disc – A True Pain in the Back!

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So you have back pain, and you have been diagnosed with herniated disc. What is most important to get you back on the road to recovery as soon as possible?

Although back pain can occur for many different reasons, one of the most common occurrences of serious back pain comes from a herniated disc. In between the vertebrae of our spine there exists small pockets of fluid which helps the vertebrae to move independently of each other. When one of these discs becomes bulged or perhaps even ruptures, it is commonly known as a herniated disc. Not only can it cause severe pain for the person that is suffering, it can be a life altering event which may have long-term implications. Once you have one of these herniated discs, what can be done to help the situation?

Your doctor may tell you that there is a chance you may need to have surgery if your herniated disc doesn’t improve over time. Don’t let that discourage you, because the fact of the matter is, there are a number of different treatments that can take place if you have a herniated disc. A lot of it has to do with your own personal condition and how it is affecting you. It may also be a matter of the position of the disc in your spine that would determine the best course of treatment. For most individuals, however, the severe pain that comes whenever the disc is first ruptured typically goes away to a certain extent after a week or two. With just rest and taking it easy for a little bit, you may be able to actually overcome a majority of the symptoms within a couple of months. For those that are truly suffering from the pain of a slipped disc, however, a couple of months can almost feel like a lifetime.

There may be some things that can be done in order to speed along the process and to make sure that your healing time is as reduced as possible. More than likely, your doctor is going to give you some medication that will help to mask the pain that you are feeling. Unfortunately, this doesn’t do much to help with the problem, it simply makes it easier for you to be able to endure it. Other forms of therapy such as hot and cold compresses, electrical stimulation and traction may also be recommended in order to help with the difficulty. The traction does help with stretching your back and relieving the pressure so that you can start recovering and eliminating a lot of the pain. If you happen to have a rented traction device, it is wise to use if soon before retiring to sleep at night for the most benefit.

There are also some other things that you can do such as specific stretching exercises or other forms of exercise which will greatly help to reduce the pain that you are now feeling. It will also help to shorten the length of time that you will be experiencing the difficulty. These important steps will put you back on the road to health in the shortest amount of time possible.

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Source by Verona Raymond

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Herniated Disc Causes and Relief

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What is a herniated disc?

You’ve probably heard people say they have a “slipped” or “ruptured” disc in the back. Sometimes they complain that their back “went out”. What they’re most likely describing is a herniated disc. This condition is a common source of back and leg pain.

Discs are soft cushions found between the vertebrae that make up the spinal column (your backbone). In the middle of the spinal column is the spinal canal, a hollow space that contains the spinal cord. The nerves that supply the arms, leg, and torso come from the spinal cord. The nerves from the neck supply the arms and hands, and the nerves from the low back supply the butt and legs. The discs between the vertebrae allow the back to move freely and act like shock absorbers.

The disc is made up of two main sections. The outer part (the annulus) is made up of tough cartilage that is comprised of series of rings. The center of the disc is a jelly-like substance called the nucleus pulposus. A disc herniates or ruptures when part of the jelly center pushes through the outer wall of the disc into the spinal canal, and puts pressure on the nerves. A disc bulge is when the jelly substance pushes the outer wall but doesn’t completely go through the wall.

What do you feel?

Low back pain will affect four out of five people during their lifetime. The most common symptom of a herniated disc is “sciatica”. Sciatica is best described as a sharp, often shooting pain that begins in the buttocks and goes down the back of one leg. This is most often caused by pressure on the sciatic nerve that exits the spinal cord. Other symptoms include:

• Weakness in one leg or both legs
• Numbness and tingling in one leg (pins & needles)
• A burning pain centered in the low back
• Loss of bladder or bowel control (seek medical attention immediately)
• Back pain with gradually increasing leg pain.

(If you have weakness in both legs. Seek immediate attention.)

How do you know you have a herniated disc?

Your medical history is key to a proper diagnosis. A physical examination can usually determine which nerve roots are affected (and how seriously). A simple x-ray may show evidence of disc or degenerative spine changes. An MRI (magnetic resonance imaging) is usually the best option (most expensive) to determine which disc has herniated.

Why do discs herniate?

Discs are primarily composed of water. As we become older (after the age of 30), the water content decreases, so the discs begin to shrink and lose their shape. When the disc becomes smaller the space between the vertebrae decreases and become narrower. Also, as the disc loses water content the disc itself becomes less flexible.

While aging, excess weight, improper lifting and the decrease in water in the discs all contribute to the breaking down of discs, the primary cause of a herniation or bluge is uneven compression and torsion that’s placed on the discs.

This uneven pressure is caused by imbalances in muscles that pull the spine out of it’s normal position and then your body is forced to function in what I call a physical dysfunction. Every human being develops these dysfunctions over time and eventually they cause enough damage to create pain.

The best treatment options

When it comes to treating a herniated disc, there are traditional treatments such as ice/heat, ultrasound, electrical stimulation, cortisone injections, anti-inflammatory medications and even surgery. While these may deliver some relief, it will usually be temporary if at all.

But the major problem with these traditional treatments is that they can’t fix or heal a herniated disc as they do not address the actual cause of the problem. For example, even if you were to have a surgery and get some pain relief, the fact is the dysfunctions that caused the disc to herniated in the first place are still there and if not addressed, they will continue to place uneven pressure and strain on the discs and sooner or later you will likely have another problem with that disc, or others.

Without identifying and addressing the underlying cause of the problem, which is the physical dysfunctions caused by imbalances in muscles, you will likely continue to suffer with this condition and the continuous flare ups for years.

Unfortunately, most doctors, chiropractors and physical therapists don’t spend time or focus on identifying the physical dysfunctions that are responsible for the condition so most people end up jumping from one useless traditional treatment to the next and suffer for months or years unnecessarily.

If you have been diagnosed with a herniated disc, or are wondering if your back pain may be caused by a herniated disc, either way you must identify and address the physical dysfunctions that are causing your pain.

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Source by Dr. Robert Duvall, Dpt, Atc

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How to Tell if you have Rheumatoid Arthritis

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There are actually two major varieties of arthritis the osteoarthritis and rheumatoid arthritis both involve pain such as Knee Pain, swelling and stiffness in the joints. How do you know if you have osteoarthritis or rheumatoid arthritis? What differentiates rheumatoid arthritis is the inflammation of the smooth, moist synovial membrane which lines the interior of the joint. The membrane gets inflamed, sore and swollen. The hands and feet are the most affected joints.

Another difference is the fact that rheumatoid arthritis scarcely develops in the hips or spine which is most common on osteoarthritis. Nonetheless, the neck or cervical spine can be involved. This can result in severe outcomes. Rheumatoid arthritis can be activated by a viral infection or stress. It’s an autoimmune disease which means that the body’s immune system seemingly and incorrectly attacks its own tissue. This is what leads to the inflammation or arthritis knee pain.

Attacks typically come on abruptly. You wake up one morning with pain and stiffness in the small joints of the hands and feet. It’s possible you’ll experience pins and needles sensations, tiredness and have a general feeling of being ill. There can even be a low grade fever. The initial signs and symptoms are often quite mild though. The early morning stiffness lessens during the day. However, within a few days severe symptoms can appear.

There are numerous self-help methods which are utilize to treat arthritis. However , there is no known prevention or treatment. However, the signal to pay your doctor a visit is once the pain and rigidity in the joints turn out to be so severe that may limit movement and interfere with normal activities. For the reason that disease gets worse, it makes agonizing pain which you cannot disregard. Furthermore, the joints become inflammed and deformed; the muscles may begin wasting away and red painless lumps known as rheumatoid modules may appear under the skin. You may even experience chest pain and difficulty in breathing.

Your self-help measures ought to include regular, moderate exercise, getting enough rest on a firm mattress and maintaining your weight at a healthy level. Considering that arthritis tends to restrict mobility, swimming can be advantageous especially if you can do so in a heated pool. Making use of heat to the joints can give a calming relief. Diabetics and persons with poor circulation need to stay away from utilizing heat.

If you at some point need the help of your doctor, he will most likely advise specific blood-tests, x-rays and examination of joint fluid for diagnosis. The results of these tests give the doctor a measure in which to determine the severity of the disease. Once you’ve been diagnosed with the disease, you’ll likely need constant care from your physician, yet individual cases do differ. Surgical procedure is an alternative for a small number of patients. Despite the fact that there is absolutely no cure; control is essential and accessible for most patients.

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Source by Angel Rymes

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