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Rheumatologist’s aims is to save his patients from surgery


Doctors in this segment shed light on their specialties to give you awareness about your common problems and misconceptions. An Allergist will be here next month to enlighten the readers about his forte. Write to us if you want your queries answered.

a rheumatologist at Shifa International Hospital Islamabad, in an interview with Haleema Azmat
SN: Rheumatology seems to be a new concept in Pakistan. Is it a sub-specialty of orthopedics?

Actually the concept is new world over. And definitely in Pakistan too as experts are very few in this field. But things are improving gradually as trained physicians are coming from abroad and we are having local training as well. Orthopedics is a completely different field and is more on the surgery side through which physical and mechanical issues of joints can be corrected. Rheumatologists on the other hand are physicians who do not perform surgery. They take care of joint and muscle problems especially in the initial stages or that before surgery. So one of our aims is to save a patient from surgery.

SN: What are the common muscle and joint problems in Pakistan?
The most common is osteoarthritis or degenerative arthritis in which with age or weight gain, joints start to wear and tear. But there are other common problems here which otherwise seem to be rare in other parts of the world. For example, rheumatoid arthritis (ganthiya) occurs in different shapes and forms here. Then there is inflammatory arthritis and connective tissue disorder that is common among women. Inflammatory conditions of joints and muscles that involve other internal organs like kidney, brain and lungs and also affect the blood pressure are also common in the country. All these combine to become a bigger problem.

SN: Are they common in both genders?
Inflammatory conditions are more common among women. But of course they occur in men too.

SN: How prevalent are these problems in the country?
The disease burden is unknown as research based practice is not common here. The estimates given are quite unrealistic because there is no record. But it is definitely high.

SN: Do bone and joint problems occur at a specific age?
Degenerative arthritis is common in advanced age. Moreover, obesity is a growing problem here so we see joint problems in young patients too. Inflammatory conditions on the other hand, can occur at any age. It is seen in children and middle aged individuals as well. Children however, also have different kinds of problems.

SN: What problems do children have?
Inflammatory arthritis also known as juvenile idiopathic arthritis or juvenile rheumatoid arthritis is common among children. It is inflammation of the joints and in layman term is referred to as “water in the joints.” Though rare, congenital problems are also seen here. But due to lack of diagnosis and treatment facilities unfortunately we cannot help these patients much. Whatever treatment is available is expensive.

SN: Does menopause in any way affect the joints and muscles?
It does to an extent but some of them are just myths. Menopause actually occurs in the age when a woman usually undergoes degenerative problems. So people tend to relate it to menopause. However, menopause does not cause these problems. In postmenopausal women osteoporosis is another common problem which causes bones to become brittle and wear out.  It is directly linked to menopause. This condition is either under diagnosed or over diagnosed. Even young female patients are prescribed same medicines and tests although they may not suffer from the problem. Osteoporosis is about bone quality while osteoarthritis is a joint function issue.

SN: You said currently there are few rheumatologists in the country, where should patients go to then for joint and muscle problems?
Earlier patients consulted orthopedic surgeons for bone or joint problems. And trend is the same now. Things are however, changing gradually. There are certain conditions which of course are not for the rheumatologist to consult. And orthopedic surgeon is the best choice. Inflammatory conditions like osteoporosis, early arthritis or osteoarthritis in which a patient does not require joint replacement should be consulted by a rheumatologist. We do cross-referrals and send patients we consider may need help from the other specialty.

SN: Do you think patients get misdiagnosed or mishandled in such scenarios?
Well, other than rheumatology such scenarios occur in every health field. But yes there is a lot of misdiagnosis especially in connective tissue disorder. Patients are not aware and even doctors do not have much idea. When such patients come to us unfortunately, they have already developed complications and reversal becomes difficult. Problems are misdiagnosed, under diagnosed and over diagnosed too. Sometimes patients are undergoing treatment for a disease they do not even have.

SN: Why do these conditions occur in the first place?
Degeneration is part of aging plus the way you do your work and lifestyle have an impact. Smoking and sugary drinks can also affect joints and muscles. Inflammatory conditions, like rheumatoid arthritis (ganthiya) are autoimmune diseases and one usually does not have much control over it. But there are factors that can aggravate them. For example, smokers have a high chance of having rheumatoid arthritis. Moreover, family history has a role too. If an individual is following a healthy lifestyle then chances of its occurrence are less. But sometimes even that does not count.

SN: Can you identify other wrong practices in our culture that promote joint and muscle problems?
Weight gain is a big issue which people do not bother much about. Joint and muscle problems increase because of excess weight. Moreover, while doing routine work like sitting for prolonged periods for instance while cooking or using the toilet, standing for prolonged periods, lack of exercise and weight lifting in the wrong manner can cause problems. Joints are mechanical. You need to take care of them. How you lift weight has an impact on your joints. People generally do not have any concept about this and even doctors do not know what to advise patients regarding incorrect postures. We need to first focus on the prevention side; treatment comes later.

SN: How does a healthy diet and exercise impact the joints and muscles?
They have a big role especially in degenerative arthritis. If you are otherwise healthy, there are less chances of having inflammatory conditions compared to someone following an unhealthy diet and is inactive. There is no specific diet for maintaining the health of joints. A healthy balanced diet is good enough. Exercise should be done at least every other day for 30-45 minutes. Some people say they work at home all day which is a substitute for exercise. But that does not count as exercise. That is fatigue.

SN: What role does calcium have in maintaining joint and muscle health?
It definitely has a role but only to an extent. If an individual’s diet is balanced they do not have to take calcium supplements. Calcium has been over promoted. Generally people do not need that much calcium. Excess of calcium has its own problems.

SN: How can a bone and joint problem be differentiated?
Joint problem is usually a painful condition. Bone problems like osteoporosis are usually not painful. Some doctors say that while treating osteoporosis, joints will also become alright. This is a wrong concept. There are rare painful conditions of the bone. Patients usually do not know that their bones are weak unless one gets fractured. So patient education is an important aspect that should be considered by the physicians.

SN: What is patha khich jana (muscle pulling)?
The locomotive system of the body like muscles and joints can be compared to any other machine. Joints can strain or sprain. Wrong posture while picking up something or lying etcetera can cause the muscle to pull.  Sometimes it is due to repetitive movements or trauma. For example, you continuously work on the computer whole day and after some time you realize that your shoulder or back is paining.  The pain can occur anywhere for that matter. Normally it is self-limiting. But one needs to identify what is causing the problem. Treatment is definitely needed but you also need to stop the thing causing the problem.

SN: Can inappropriate footwear cause problems?
Definitely, especially for women who wear heels. Back and knee pain and deformity of the big toe (in which the bone turns inwards) can occur with inappropriate footwear.

SN: Many people nowadays complain of stiff neck and shoulder muscles. Is it because of mental or physical stress?
It can be because of both. Degeneration of the neck’s vertebral column can be a cause. But those who have stress and depression also complain of persistent headache and neck spasm. It needs to be identified as treatment for both is different.

SN: Is massage helpful?
Yes but not aggressive. Massage should be gentle. Untrained people like pehalwans apply such pressures that they sometimes tend to aggravate the problem.

SN: Visiting a pehlwan for jor charhana (joint reduction) is common trend here. Your take on this?
Traditional medicine of course has its role to an extent. And there was a time when there were trained people who managed it. But unfortunately, there are many untrained people in this field now. And patients come to us after being mishandled after a massage or acupuncture treatment.

SN: What is fibromyalgia?
Fibromyalgia is a common rheumatic condition characterized by muscular or musculoskeletal pain with stiffness and localized tenderness at specific points on the body. It however has controversies associated to it. Some physicians say the condition does not exist and it is just a mental health issue. But it is so common and its pattern is so similar that I think it is definitely a disease. And because it is difficult for patients to understand, I tell them apko dardon ki bemari hai (you have pain problem). But there is more to this condition than just pain. It is a whole spectrum. Patients have low moods, stress, fatigue, insomnia, restless sleep, and stomach and memory problems.

SN: Can muscle and joint problems become severe enough to cause fatality?
It can have both direct and indirect link. Uncontrolled inflammatory conditions put an individual at high risk of having a heart attack. Then people who have less mobility because of joint and muscle pain will have weight gain and high blood pressure therefore have more chances of developing diabetes and complications associated to it. Inflammatory conditions have a direct link too. Uncontrolled connective tissue disorders affect the kidneys, brain and can lead to death.

SN: Steroid injections are commonly used for treating joint pain; how is it useful?
If you do it for a good reason then it is indeed useful because it is recommended only when the patient is either not getting pain relief through medicines or the other option has more side effects than these injections. So careful selection of the patient is necessary.  It is not a good practice to prescribe injections for every other patient in pain. They work best in acutely inflamed swollen warm joints and frozen shoulder. They are also a good option for osteoarthritis patients who want to avoid surgery. It is symptomatic treatment and not a permanent solution. Some degenerative arthritis patients do not get any relief after getting a shot of steroid. But some get relief for a year or so after which it can be repeated.

SN: What happens in frozen shoulder?
Every shoulder pain is not frozen shoulder. The tissue surrounding the shoulder is called the joint capsule. It gets inflamed which causes restricted movement. Because of pain the movement gets even more restricted and patients stop moving the joint. The joint then gets stuck and freezes. Sometimes it is not frozen shoulder. It is ligament tear and in certain cases the patient may need surgery. This needs to be differentiated through an X-ray and ultrasound as physiotherapy and injections become ineffective in such cases.

SN: Is there anything left that you would like to add at the end?
Exercise, maintain a healthy diet and lose weight to keep your muscles and joints healthy as this will have overall health benefits.

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