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R H E U M A T O L O G Y
Main article Dear readers, This edition of joints is about rheumatoid arthritis (RA). If we separate the various forms of arthritis into those accompanied by inflammation and those which are not, we have RA as the typical example of ‘inflammatory’ and osteoarthritis as the typical ‘non-inflammatory’ arthritis.
N E W S L E T T E R
R H E U M AT O I D A R T H R I T I S Rheumatoid Arthritis.
swelling pain and stiffness, but it is
as microorganisms), it overzealously
Rheumatoid Arthritis (RA) has a
possible for other parts of the body
attacks our own body. In RA this
central position in rheumatology.
to be affected, even though they are
results in inflammation of the joints
It is probably the most classical
unrelated to joints.
clinically (this means redness, swelling, pain and loss of function)
arthritis, expressing the specialty of rheumatology perfectly. This is be-
RA is an autoimmune disease.
and, as a rule, many joints are
cause joints are affected to a greater
Putting it simply, instead of our body
affected at the same time and in a
or lesser extent with inflammation,
only fighting foreign invaders (such
symmetrical way. (For example both wrists, the small joints of both hands,
Joints commonly affected by Rheumatoid Arthritis
the toes of both feet etc). Who is affected? As in other autoimmune diseases
Discussing RA is long overdue since it is the best known and most widely discussed arthritis amongst patients and rheumatologists alike.
(like thyroid disease or lupus), Shoulders
The problem can start in childhood or in old age, but the more characteristic age for the onset of RA is in women in their 40s and 50s. Relatives of peo-
The main article outlines the condition. ‘Psychology’ analyses the support of friends and family and the physiotherapy section deals with wax therapy as well as exercises for special groups. Finally, in the patients’ column we welcome Ms Sandra Canadello, chairperson of the European committee of people with rheumatic diseases.
Dr J Joseph
ple with RA tend to have a higher Wrists Knuckles and Middle finger joints
Most people with RA will not have a
How does RA affect people? joints swell and become red, painful and stiff more so in the mornings
difficulty in using their hands or
Less commonly Elbows, hips and neck
Principles of Physical Activities and exercise programmes for targeted groups of people Page 5
and after immobility. The person has
Balls of feet
walking. Continues to page 2
SANDRA CANADELLO An interview with the chairperson of the European Commitee of people with rheumatic Page 7 diseases
the disease is not strictly hereditary.
It has already been mentioned that
chance of developing the disease, but
close relative with the disease.
8 World Arthritis Day
women are more commonly affected.
Wax Therapy its role in the management of rheumatoid hands. Page 8
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Continued from page 1
How does one diagnose RA?
them, regarding the disease character-
Continuous inflammation especially
As in most diseases the diagnosis to a
istics, the various treatment options
In general, 20% of people with RA
if left untreated can cause damage to
large extent comes from the history
and the future. Then one needs care-
will always have very mild disease.
the joints. This damage causes more
described by the patient, in associa-
ful assessment of the severity of the
5% will have severe arthritis with
loss of function and the problem
tion with the clinical examination.
disease and to choose the appropriate
difficulty responding to any
continues. In a small proportion of
Specialized blood tests come to com-
drug for treatment.
treatment but 75% will have times
people one may have significant
plement the history and examination,
deformity of the joints giving the
but by themselves blood tests can not
The drug treatment is specialized and
with appropriate treatment they tend
characteristic picture of RA.
diagnose or exclude RA.
used early it tends to avoid severe
to live a normal life.
of flare and times of remission but
damage to joints, pain, stiffness and However, other parts of the body can
loss of function in the everyday life
be affected as well. Rheumatoid is a
The management of RA needs a
of the patient.
multisystem disease. It can affect
multidisciplinary approach which
skin, eyes, nervous system, heart,
means that the rheumatologist needs
One can avoid lost work days and
lungs, kidney, blood, lymph nodes
to cooperate with other health
lost time of someone’s life and in
and almost any part of the body. For
professionals as required, in order to
general timely intervention with the
that reason careful assessment and
face the person as a whole and not
right treatment has changed the old
follow up by a rheumatologist are
just deal with every painful area of
picture of RA which was a patient
necessary and rheumatologists must
the body separately.
sitting in a wheelchair in the doctor’s
have a significant knowledge of
waiting room. Appropriate treat-
general internal medicine while being
Firstly, the correct education and
ment, starting early gives the major-
on the lookout in case another part of
information are required not only for
ity of RA patients a normal or nearly
the body becomes affected.
the patient but also for those close to
8 World arthritis day 8 Osteoporosis cycle ride
8 World arthritis day 12th October
President of the Cyprus League against Rheumatism Marios Kouloumas
The Cyprus Antirheumatic society organized a world arthritis day event at the press association premises. The subject was positive attitude towards life and the message was ‘your power is your
Editor Dr J Joseph, MB BCh MRCP (UK), Consultant physician and rheumatologist, Aretaeion hospital, February 2009
mind’. Apart from messages from the minister of health, the chair of the society, the Cyprus European commissioner for health, the parliamentary chair person for health and the president of the rheumatologists of Cyprus, the society also had a special guest Ms Sandra Canadello the chairperson of the EULAR standing committee for people with rheumatic diseases in Europe. Workshops on the power of one’s thought as well as regarding ‘the person and the family’ were held by psychologist Spyroula Sirimi. The day closed with an account of Mrs. Iosifina Iosif-Stylianou who described her own experiences during and after the diagnosis of her rheumatic condition.
8 Osteoporosis cycle ride On 4th October 2008, the annual osteoporosis cycle ride was held by the Cyprus association against osteoporosis and musculoskeletal diseases. The event was under the auspices of the Mayor of Nicosia and 100 cyclists took part, passing through mainly the roads of old Nicosia, emphasizing the importance of prevention and proper management of the silent epidemic.
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Frequently asked questions about RA Dr Joseph
My blood tests are normal; how can I have RA? It is very important to remember that not all people with RA have the characteristic blood results (antibodies in their blood like the ‘rheumatoid factor’). There are at least 25% of people with RA that have so called ‘seronegative’ RA meaning that the antibodies in question are negative while they actually have the condition.
I know I have RA because I have the blood test which is positive In contrast to our previous point, one should remember that the diagnosis of RA is made by the rheumatologist using the history, the clinical examination and the support of some blood tests like the markers of inflammation and the rheumatoid factor. However having positive rheumatoid factor on a blood test is something that may occur in people without RA. It is not enough to have rheumatoid factor in the blood for the diagnosis to be made. The clinical picture, history, examination, xRay findings and disease progression need to fit rather than just having a positive blood test.
I have been taking drugs for a month now but I have seen no result This is a logical and frequent point made by people with RA. Most drugs that change the disease course (the so called disease modifying antirheumatic drugs) take two or even three months to work fully. The only way for someone to respond quickly during the first days and weeks is by taking cortisone treatment either into the joint by injection or by mouth, or by intramuscular injection. Antirheumatic drugs need time to work and a significant proportion of patients will need a second and sometimes a third drug or to replace one drug with another etc. The management of RA by the rheumatologist is not simply taking a tablet to be cured, but a long undertaking and has at its centre the close cooperation of patient and rheumatologist.
It has been suggested that I take cortisone but I know that I should never take this drug This is one of the biggest myths in rheumatology as well as in other specialties of medicine. In large doses without control, cortisone is
a very dangerous drug. But given in small doses for short periods of time, or with continuous and careful monitoring by doctors, then it is not as dangerous as leaving the disease untreated. In other words, if you weigh on the one hand the damage that the disease can cause and on the other the potential side effects of low dose cortisone, surely the damage from the disease weighs more.
I am taking long term antirheumatic drugs. Surely they will do some damage to my body There are no drugs in medicine without side effects. The important point about the antirheumatic drugs is that they are watched carefully by the rheumatologist and in particular they are monitored frequently using blood tests. The blood test makes sure that in almost all cases there is no danger of severe side effects. When we have abnormal blood results then we can reduce or discontinue the treatment appropriately. The vast majority of people taking antirheumatic drugs do not have any significant side effects.
I have been well for many months now. Why should I continue taking the drugs? This emphasizes why the diagnosis of RA has to be made by specialists. Once the antirheumatic drug is started and because its role is to avoid or reduce the damage to joints, then its use is long term. The aim is for someone to live a normal life if possible without remembering that they have the disease but just because someone is well doesn’t mean they can stop their drugs. This is because in people who really have RA, stopping the drugs tends to result in a worse flare of the condition and antirheumatic drugs tend not to work as well when they are restarted.
What else should I pay attention to apart from my joints? A recent and very important observation in rheumatology is that people with RA have increased chances of cardiovascular events like heart attacks and strokes. Therefore one should be very careful with risk factors like smoking, high blood pressure, high cholesterol, diabetes and not taking adequate exercise.
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Psychology “Those around me do not understand me” Often people with a diagnosis of RA complain that people around them do not understand their pain, weakness and their difficulty to accommodate activities they used to take part in before. They might feel that their family have a lot of expectations and demands. Answer by Viki Mbalomenou
Why does this happen and how can one change this situation? When patients feel that way it is very likely that they do not pay attention to certain important points. Perhaps the patient feels it is self evident to those around them, what the particular disease is all about and what effects it is having on them. Patients with RA could have tiredness, a feeling of weakness, they may not feel able to complete simple everyday tasks, they may have reduced chances of finding work and it may disorganize their family life. They often have feelings of anxiety or depression and a feeling of worthlessness. Those around them though, may not have the complete picture of the disease. They may not even know that a patient can be affected psychologically. So they maintain the same attitude towards the patient, asking for the same things they used to before. It is also possible that the patients themselves do not have the complete picture of their condition. This may mean that they complain continuously about tiredness, anxiety, anger and disappointment and they may associate all these with other situations or other people. Those around them cannot connect these feelings and understand them and therefore in the end, they doubt that the symptoms really exist. For example someone may feel tiredness and they may associate this with their job; those around them may doubt that this is true because the type of work they do does not involve much exertion. Therefore their demands towards the patient remain unchanged. Another important point is that some patients think it is self evident that those around them can immediately realize what they need in terms of help, support or understanding. But this can lead to a lot of misunderstanding. On the one hand relatives may try to show their support in their own way and on the other hand patients may consider support as something completely different (for example, someone else taking over the housework). In that way the patient thinks others do not care and those around them feel disappointed (“what else can I do?”) Finally, some patients choose not to tell those close to them about their disease for various reasons. They continue all their activities with the same rhythm trying to hide their symptoms. In this case, how can the family change their attitude towards them when they don’t know anything about the illness? Disagreement and misunderstanding continue to multiply and the symptoms escalate.
So what could a patient do? 8 They can be educated better about what the disease is all about. In this way, they can have an active role in dealing with their condition as well as helping themselves and making their life easier.
8 They may ask their family to talk to the doctor to be better informed
8 8 8 8 8
about their disease; they can educate their family using leaflets and make sure they inform other important people in their lives, for example their boss. They can consider what they need from those around them in terms of help or support and actively ask for it! They should allow themselves to ask for help. They should allow themselves to relax and rest (both are necessary, especially at times of increased symptoms.) They can seek help from a psychotherapist so as to learn stress and anxiety management methods and they can learn relaxation techniques. In this way they can reduce the intensity of their pain. Many times a disease is a chance for someone to look after themselves (especially people who are not used to doing that previously!)
The family on the other hand: 8 Should independently ask for information regarding the disease. 8 Should help the patient express their feelings (anger, disappointment, anxiety etc).
8 Should seek practical solutions with the patient to make their life easier 8 Should listen to the patient; that implies listening and giving help that is requested not just offering help that they consider appropriate.
8 Should ask for help and support from a psychotherapist in dealing with their feelings, so they can be of more use to the patient. It is important that when there is love and good-will within a family, ways are found in order to communicate effectively and make everybody’s life easier.
Born in Greece, Viki Mbalomenou has a degree from the University of Thraki as a social worker, and three-years’ postgraduate training in systemic psychotherapy of individuals, couples, families and groups. She has completed a postgraduate programme on advising in substance dependence. (Course in association with the psychiatry department of San Diego university of California). She held advisory posts in Thessaloniki and Kavala. Since 2005 she has been in charge of advice and family therapy in the 'Ayia Skepi' treatment programme. In parallel, she worked as family therapist at the centre for family direction of the welfare department and works privately in systemic psychotherapy of individuals, couples, families and groups.
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Physiotherapy PRINCIPLES OF PHYSICAL ACTIVITIES And exercise programmes for targeted groups of people Lena Antoniadou
Physical activity offers one of the greatest opportunities for people to extend years of active independent life and reduce functional limitations. Promoting this in carefully planned regular exercise programs is one of the most effective ways for middle aged and older adults, including those with disabilities, to prevent or slow down chronic disease, promote independence and increase quality of life.
KEY COMPONENTS OF PHYSICAL ACTIVITY PROGRAMMES A well rounded physical activity programme should include endurance, strength, balance and flexibility. These activities should be tailored to the individualâ€™s specific needs and interests to ensure maximal enjoyment and optimize adherence to the physical activity regime. Group based physical activity is an excellent way to start a physical activity programme. It provides several advantages, including enhanced adherence through social interaction with others and mutual commitment to physical activity among friends, opportunities for instruction in proper technique and with qualified supervision.
bands is safe, cheap, progressive and versatile to be used from different starting positions to suit patients with special needs and promote natural and functional movements. While both upper and lower body muscles should be included in a strengthening regimen, muscles of the lower body (ankles, hips, leg extensors and flexors) are particularly important for mobility and independence.
8 Flexibility activities facilitate greater range of motion around a joint and can increase the length of the muscle beyond that which is customarily used in normal activity. These exercises are specifically important for targeted groups with disabilities and
8 Endurance activities refer to continuous movement that involves large muscle groups and is sustained for a minimum of 10 min. e.g. biking, swimming or walking.
8 Strength activities refer to increasing muscle strength by moving or lifting some type of resistance at a level that requires some physical effort. Resistance with elastic chronic problems like arthritis. Stretching should include appropriate static and dynamic techniques. In dynamic stretching, the muscle is moved through the full range of motion of a joint, for example, arm circles. A static stretch is when the muscle is lengthened across the joint and held for a period of 10-30 seconds.
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Continues from page 5
8Balance activities Balance is the ability to maintain control of the body over the base of support so as to avoid falling. While improvements in muscular strength and endurance can lead to improvements in balance, specific balance activities can have additional benefits especially for groups of older adults
aerobic exercise programmes, participating in a variety of activities specific to the problems and avoiding high intensity vigorous exercise. Musculoskeletal overuse injuries should be avoided and the advice of the physical therapist on starting positions, posture and the use of resistance is of high importance. Preventing fall related injuries is also an important focus.
SUMMARY Scientific evidence indicates that regular physical activity can bring dramatic health benefits to people of all ages and abilities, and that this benefit extends over the entire life course. Physical activity offers one of the greatest opportunities for people to extend years of active independent life and reduce functional limitations. Regular participation in physical activity is one of the most effective ways for older adults, including those with disabilities, to help prevent chronic disease, promote independence, and increase quality of life in old age. A multidimensional activity programme that includes endurance, strength, balance and flexibility training is generally considered to be optimal for older adults. Activities should be tailored to the individual to ensure maximal enjoyment with the goal of optimising adherence. Although most sedentary individuals should be encouraged to begin with low-intensity physical activity moderate physical activity yields a better risk-to benefit ratio and should be the goal for older adults. The combination of effective and targeted physical exercise with the social support, positive reinforcement and safety in the supervision by a professional is what is required. The small increase in acute risk for injury must be weighted against the with diminished eye sight and groups with osteoporosis where falls can lead to fractures. There are two types of balance: static balance which is the ability to maintain balance without moving and dynamic balance which is the ability to move without loosing balance or falling.
much more substantial benefits associated with long tern physical activity, Sustaining a physically active life style is an excellent way for older adults with chronic conditions or disabilities to maintain their physical function and improve their overall health. All older adults with
chronic conditions or disabilities should be encouraged to work within an
While there are some risks associated with participation in regular physical activity, the risks associated with a sedentary life style far exceed them. Low intensity exercises have obviously a lower risk of injury and muscle soreness. However the consensus is that moderate physical activity has a better risk- benefit ratio and moderate intensity physical activity should be the goal for older adults. A knowledgeable physical therapist can provide the level of intensity and mode of physical activity following a careful assessment. Before starting or increasing the level of physical activity, older adults and groups with special problems should have a strategy for risk management and prevention of activity related injuries. The most important strategy is to start with low intensity physical activity and increase the intensity gradually including a warm up and cool down component. Increasing muscular strength around weight-bearing joints, particularly the knee, also reduces the risk of musculoskeletal injury. Other strategies include active stretching during the warm-up and cool-down portions of
individualised physical activity program under the supervision of an experienced therapist.
Lena Antoniadou is a physiotherapist working in the private sector with special interest in musculoskeletal problems. She trained at Guyâ€™s Hospital, London and is a member of the chartered society of physiotherapy of England and the Cyprus association of physiotherapy. For the last 10 years she has been teaching exercise classes based on the Alexander technique and the Pilates method. She is also a Theraband trainer and teaches exercise courses.
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Patient’s column SANDRA CANADELLO
WHAT MESSAGE DO YOU HAVE FOR PEOPLE WITH ARTHRITIS?
An interview with the chairperson of the European Commitee of the people with rheumatic diseases My name is Sandra and I'm 35 years old. I am responsible for the Chairmanship of the EULAR Standing Committee of People with Arthritis and Rheumatism in Europe (PARE) since 2005. The Standing Committee is composed of 32 user support organisations coming from all over Europe and also Israel. The committee also cooperates with disease specific European user support organisations like the Ankylosing Spondylitis International Federation, Lupus Europe, FESCA and ENFA.
HOW DID YOU GET INVOLVED? I started to get involved with my national patient organisation in 2001. I had been diagnosed with RA in 1998 and the need for further information on the disease and how to manage it, led me to start working with the Portuguese league and to participate in activities nationally and at European level. In time these activities led to a closer involvement with the PARE network and to my election into the PARE Manifesto Board. In 2005 I was asked to take responsibility for the chairmanship of the Standing Committee.
WHAT IS THE ROLE OF PARE? The action developed by the PARE network in the European political arena, counting on a close collaboration with the scientific part of EULAR provided a greater awareness of rheumatic diseases by EU decision-makers and stakeholders. EULAR asked policy makers in the European Union to become fully aware of the burden rheumatic diseases pose to society and the needs of people with arthritis, as well as to guarantee access to adequate care for all Europeans with rheumatic diseases. Lately, a project presented by EULAR to the European Union was positively received and is to address the lack of comparable and available data on musculoskeletal conditions in Europe. This European Musculoskeletal Atlas will be developed and implemented with the support of the EU Public Health Programme.
It is unfortunate that today people continue to associate rheumatoid arthritis with old age. Rheumatism does not discriminate on grounds of age or gender, and it can regrettably occur in children of tender age. Awareness campaigns about Rheumatic Diseases are essential to achieve an understanding of what these diseases imply and the obstacles people have to overcome to live well with them. Employers and stakeholders need to understand that people with arthritis can contribute to societal development. Active inclusion policies are required to guarantee effective integration into society - work and leisure alike. People with rheumatic diseases need to be actively involved in decision-making processes which have direct impact on their lives, namely in medical, social and personal issues associated with rheumatic diseases. The involvement of patients and their support groups as key stakeholders in all relevant processes is essential. I urge all people with arthritis not to let matters that affect them directly in the guard of people who do not experience the effective impact of these diseases. Do not let go of your rights as a citizen.
Sandra Canadello was born in Portugal in 1973. She obtained the ‘Diploma in Translation’ by the Institute of Linguists, London. Currently, she is working as a self-employed translator. She has a diagnosis of Rheumatoid Arthritis since 1998. Since 1999 she has been an active Member of the Liga Portuguesa contra as Doencas Reumaticas (LPCDR) Portuguese League Against Rheumatic Diseases). Since 2001 she has been involved in the European work for people with rheumatic diseases and was Vice Chair of PARE Manifesto 2004 – 2006. She was international Relations Coordinator of the LPCDR 2003 – 2007 and since 2005 Chairs the Standing Committee of People with Arthritis/Rheumatism in Europe (PARE) of EULAR (European League against Rheumatism).
Which of the following personalities does NOT have Rheumatoid Arthritis?
Pierr August Renoir Painter
Michael Jackson Singer
Thomas Jefferson US President 1801
Theodore Roosevelt US President 1901
Edith Piaf Singer
Christiaan Barnard Surgeon
James Madison US President 1809
Katherine Hepburn Actress
Answer: Michael Jackson. He has Lupus. Contact details: Dr J Joseph, MB BCh MRCP (UK), Consultant physician and rheumatologist, Aretaeion hospital, 55-57 Andreas Avraamides Str. Strovolos 2024, Nicosia, Cyprus. Tel: 22200328, Fax: 22512373, e-mail: email@example.com Sponsors:
Design by: M.A.D. Copyright: Dr J Joseph, 2009
Leading the way to a healthier world
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Wax Therapy its role in the management of rheumatoid hands. Another form of heat applied to the hands of patients with Rheumatoid Arthritis (RA) is melted paraffin wax baths (PWBs) heated between 42°C and 50°C. These temperatures are slightly higher than would be tolerated if the body part were placed in hot water. The physiological properties wax makes PWBs an effective way of heating superficial tissues. Research trials have reported that 3 to 4 weeks of PWBs applications were accompanied by significant improvements in hand function (range of motion, pain on nonresisted motion and grip and pinch function) in patients with RA when followed by exercise and therefore can be recommended for beneficial short-term effects on hands in RA.
Application: the body part is inspected for any contraindications (lack of thermal sensitivity, open wounds, impaired circulation, acute dermatitis, devitalised skin, damaged or infected tissues) and washed. In the dip and wrap method, the part is first immersed in the warm wax. It is then withdrawn and the wax allowed to set. The procedure is repeated, normally 4 to 6 times, to develop a ‘wax glove’. The whole is then wrapped in plastic or waxed paper and an insulating layer of material such as a towel. Because the most useful effect of a PWB is relief
of morning stiffness due to the gel phenomenon, it should be applied by clients in their own homes. However, applications of wax at home are cumbersome and fraught with danger, and unless the wax is heated in a double boiler, it can cause a fire. A simple, safer alternative is to apply mineral oil to the hands, wear rubber dishwashing gloves, and soak hands in hot water from the tap for 5 to 10 minutes.
Your back has 256 muscles,
Antonis Zacharopoulos is a private physiotherapy practitioner and former head physiotherapist of APOEL men’s football team. He specialized in the field of musculoskeletal and sports physiotherapy working in UK NHS teaching hospitals and pursued postgraduate studies at University College London where he was awarded M.Sc. in physiotherapy.
TARGETED RELIEF FOR PAIN.
150 ligaments and 33 vertebrae, but it only takes one of them to make it ache.
Nurofen to target the pain.
Te l : 2 2 3 4 7 4 4 0