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Given the overwhelming glut of information, patients need to be armed with knowledge in order to be good patients and consumers. This is where evidence-based medicine comes into play. Evidence-based medicine is used as the foundation for the current training and practice of medical doctors, physical therapists, pharmacists, and nurses. It is the norm in the Western world. According to Sackett, et al (1996),

Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systemic research.”

There are multiple sources of evidence ranging from opinions of authorities to the ultimate source of evidence – the randomized control trial (RCT). The RCT is the “gold standard” of medical research. In a RCT, patients are randomly assigned to either receive a treatment or placeboGovernment regulations require the extensive use of these designs for the approval of medical treatments. For drug approval, years of development and testing are required from testing on animals through three phases of clinical trials on humans…

read the entire article at http://rheumatoidarthritis.net/living/using-evidence-based-medicine-make-decisions-treating-ra/

six month cervicalToday was a six-month follow-up on anterior cervical discectomy and fusion surgery where two herniated discs were removed, vertebrae C5-C7 were fused, and bone spurs removed. Before seeing the surgeon, a CT scan was conducted. The scan showed significant bone growth between the vertebrae (circled in the image). The screws are visible in the scan. The surgeon was very pleased at the amount of bone growth, decreasing muscle pain, increasing muscle strength, and decreasing numbness and tingling in my fingers. Nerve regeneration may take 1-2 years and hopefully things will continue to get better over time. If Payton Manning can lead the Denver Broncos to the Super Bowl after a similar surgery for one disc, then there’s hope for me!

Vertebrae C1-C2 were also checked on the CT scan since rheumatoid arthritis commonly impacts those joints that are near the skull. On a MRI radiology report last spring, it was noted that there was mild degeneration in that region. The surgeon showed those joints on the CT scan and indicated that there was some inflammation and bone-spurring present but it didn’t appear to be problematic at this time. I was told to pay attention to any deep pain in that region.

This was a very good report to receive. In hindsight, getting this surgery was a good decision giving the deteriorating situation at the time.

My right elbow has been giving me troubles for over a year now and my rheumatologist referred me to an orthopedic surgeon who specializes in hands and elbows. An MRI revealed a 50% tear in a tendon. Other parts of the elbow exhibit pain. In fact, the left elbow also displays the same symptoms but to a lesser extent probably due to the fact that I am right handed. The orthopedic doctor knows about my struggles with RA and my history with soft tissue damage. In fact, he works in the same clinic with the surgeon who conducted three surgeries on my ankles.

A bevy of conservative treatments were prescribed starting with rest and immobilization with splints designed to prevent movement of the tendon. After that failed to help, a cortisone injection was done. The doctor also used the needle to aggravate the tissue in the joint in order to stimulate a healing process by increasing blood flow to the region. Needless to say, excruciating pain was experienced for the next 24 hours but after that, the steroid provided some relief…for about 1 month after which time the pain returned. Occupational therapy was then prescribed. Occupational therapists (OT) tend to focus on the arm from the elbow down to the hand and they engage in treatments similar to physical therapists. Treatments included heat and transcutaneous electrical nerve stimulation (TENS), gentle stretching exercises, and continued use of immobilization with splints. The goal was to move into more rigorous strength building exercises. But this goal was never met as the pain only became worse. After several months of OT, the therapist made the decision that things were getting worse and indicated that I need to return to the surgeon to determine next steps. At about this time, severe neck problems were popping up and the orthopedic surgeon and I both agreed that priority needed to be given to the neck. The past six months were devoted to recovering from neck surgery.

The elbow continued to cause problems and it came to the point where use was difficult and pain was constant so I returned to the orthopedic surgeon. He said that surgery to repair the torn tendon and its attachment point to the bone would be the next option. But before doing that, he wanted to try one more, last ditch strategy – a platelet-rich plasma injection or PRP. He admitted that the research was sketchy and that it was not an FDA or insurance approved treatment. I would be required to pay for it out of pocket and the cost will be about $300. His argument is that in spite of the lack of experimental research on its effectiveness, there is clinic evidence, it is relatively inexpensive, and it is not as invasive as surgery. He did give me a choice between PRP and surgery but his comments were, “If it were me, I would do this first before having surgery.”

In PRP, a patient’s blood is drawn, platelets are separated from other blood components, and the concentrated solution is injected into a joint that has tissue damage in an effort to jump-start a healing process.[1] The theory is that growth factors contained in the platelets are able to help damaged tissue heal. It has been applied to tendon areas like the Achilles and elbow where there is a lack of blood low and healing is difficult. This approach is quite popular with professional athletes but clinical trails show mixed results (Harmon & Rao, 2013).[2]

In medical practice, there is a range of possible qualities of treatments. Balshem et al (2010) categorizes the ranges from very low quality to high quality evidence.[3] The approval of drugs would rate as high quality evidence. At the lowest end of the evidence quality continuum would be treatments that have little or conflicting evidence. Platelet-rich plasma would rank at the lowest end. This is why the FDA and insurance companies won’t approve it. There is even less research about PRP and rheumatoid arthritis. A search of research studies specific to RA revealed one study conducted on pigs[4] and another conducted in 1989 on knees of RA patients.[5] Never provided sufficient evidence documenting the effectiveness of PRP for rheumatoid arthritis.

Given the lack of evidence, I remain quite skeptical about PRP but am willing to give it a shot (pun intended) in order to avoid surgery.

[1] http://orthoinfo.aaos.org/topic.cfm?topic=A00648

[2] http://www.ncbi.nlm.nih.gov/pubmed/24319241

[3] http://www.jclinepi.com/article/S0895-4356(10)00332-X/abstract

[4] http://onlinelibrary.wiley.com/doi/10.1002/art.30547/full

[5] http://link.springer.com/article/10.1007/BF00270285#page-1

The American College of Rheumatology (ACR) diagnostic criteria incorporate four main areas – joint involvement, RA related blood tests, general inflammation blood tests, and duration of symptoms.1According the ACR,

Joint involvement refers to any swollen or tender joint on examination, which may be confirmed by imaging evidence of synovitis.”2

Physical examination is the starting point for identifying joint involvement. But confirmation by actually looking inside the joint with imaging techniques remains a critical part of confirmation.The synovium is a sac-like lining around certain joints. It provides nutrients and lubrication for joint soft tissues. During the disease processes involved with RA, the synovium swells and thickens, becoming permeated with inflammatory cells and chemicals. Ultimately, cartilage and bone tissue erodes leading to the classic joint damage associated with RA.3 The synovial fluid can be taken from a joint and analyzed for chemicals and cells associated with RA.4 This can be done via needle biopsy or surgery. During an ankle surgery I had several years ago, the orthopedic surgeon sent a sample of tissue to a laboratory for analysis – the results came back positive for RA related synovitis. Medical imaging procedures can be used in as a noninvasive technique for examining a joint.

Read the rest of the article at http://rheumatoidarthritis.net/living/medical-imaging-diagnosing-ra/

Corticosteroids or glucocorticoids are powerful anti-inflammatory drugs commonly used to treat a variety of medical conditions. They are not to be confused with anabolic steroids that are notoriously abused by athletes.1 Anabolic steroids are associated with muscle mass gain and corticosteroids are connected with metabolism and immunity.

Most every RA patient has probably taken oral steroids in the form of pills or a dose pack that tapers down the dose over a period of time. Oral steroids are effective at providing quick reduction of RAsymptoms although long-term use is generally discouraged and even short-term use is being questioned.2 When taking an oral steroid, the drug goes throughout the entire body systemically. But there are other forms of steroids that are directly injected into a specific area of the body in an effort to treat RA related symptoms. Since being diagnosed with RA, I’ve had one steroid injection into my right knee, four into my left hip, one into my neck, and one into my right elbow.

Read the rest of the post at http://rheumatoidarthritis.net/living/steroid-injections-treating-ra-symptoms/

Rheumatoid arthritis is one of many autoimmune diseases (AD). In a normal immune response, white blood cells identify foreign invaders like bacteria and viruses. They produce antibodies against these invaders so other cells can destroy them. In an autoimmune response, your white blood cells have difficulty distinguishing between foreign invaders and your own healthy cells – in essence, your body attacks itself.1

It is estimated that upwards of 22 million Americans suffer with an autoimmune disease and more than 80 ADs have been identified.2 Some of the most common autoimmune diseases include rheumatoid arthritis, type I diabetes, multiple sclerosis, systemic lupus erythematosus, inflammatory bowel diseases, and psoriasis.3 The financial impact of these diseases is in the billions. Autoimmunity tends to more common in women and the ratio of women to men with RA is about 2.5 to 1.4 It is common for people to suffer with multiple autoimmune diseases.

Given the dramatic impact of autoimmune diseases on society and the interrelatedness of autoimmune diseases,5 it is important that awareness efforts be pursued. The American Autoimmune and Related Diseases Association, or AARDA, is the only non-profit organization devoted solely to raising awareness of autoimmune diseases.

Read the rest at http://rheumatoidarthritis.net/living/american-autoimmune-related-diseases-association-aarda/

I’ve been on seven – count them – seven different biologic medicines since being diagnosed with rheumatoid arthritis. I started with several anti-TNF biologics and then moved to several others even bouncing back to try another anti-TNF before eventually trying Rituxan. I’ve self-injected with auto-inject pens, self-injected with needles, and seems like I’ve had every type of infusion possible. This is probably something of a record although similar stories emerge on discussion boards from time to time. With some of the biologics, I would respond for a period of time and then it would stop working. With others, there was never a response. With yet others, there would be some adverse side-effect causing cessation. This is not all to unusual as it is widely know in the rheumatology community that upwards of 30% of RA patients do not positively respond to anti-TNF biologic medicines.

Read the rest at … http://rheumatoidarthritis.net/living/switching-ra-medicines-dont-wait-long-try-many/

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