Real Talk with a Rheumatologist

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Today I was able to talk to an arthritis expert:
Dr. Rebecca Burns, a rheumatologist at the Columbus Veterans Association.
Rebecca shared great insight into the pain points and symptom-relief tactics surrounding various types of arthritis.

Dialogue has been edited for clarity.

I was reading about the importance of exercise for individuals with arthritis. I know a lack of usage can lead to muscle loss and a decrease in the range of mobility; However, I know it can be painful and even harmful if individuals over-use areas of their body affected by arthritis. How do you discuss getting enough—but not too much—exercise with patients?

“Great, so first of all it depends on the type of arthritis. So, if they have osteoarthritis, we know it’s good to keep using those joints and those muscles. For instance, if those patients…Let’s say they have knee arthritis and they go to a physical therapist for knee pain. The therapist will actually focus on strengthening the muscles around the joint which kinda takes some of the “bad forces” off of the knee, for instance, which can alleviate knee pain. So, we know that it’s important to strengthen muscles around the knee joint. We certainly don’t want these patients sitting around all day and then their muscles atrophy and they just become weak and debilitated. We also know that its healthier for the joints to get some exercise. Like anytime you’re exercising and putting some load or gravity on that knee joint, it actually squeezes the cartilage. It helps to nourish the joint. It makes them healthier. Again, we want to make sure they’re doing exercise and keeping those joints and muscles healthy. That being said, you know there are some patients who will overdo it. They may be deconditioned, and they go into it too much instead of working their way up. They pull muscles and tear things… They knock things loose, I guess you would say, and so that’s not good for them either. I typically tell patients if it’s hurting while you’re doing it that means you’re doing too much. You need to start slower and build your way up so you’re not causing more injury. But we usually do recommend a graduated exercise program for most of these patients, especially if they’re deconditioned to get back into it.”

Thinking specifically of arthritic cases that have affected the upper body (hands, elbows, shoulders, etc.), what are some techniques you give patients for regaining function that you’ve personally found to be successful?

“So, I mean the first thing, especially from my standpoint, is to try to get some of their pain under control. Again, if this is like osteoarthritis we’re talking about.. it might be an oral pain medication or there’s a lot of topical medications, creams and things like that.. There’s topical EDSs… So, we try to do that to alleviate some of their pain. If it’s something like rheumatoid arthritis, then we try to treat the disease with immunosuppressant medications. And anytime we’re decreasing the inflammation and pain, they’re better able to regain function. As far as building back up once we have the pain and inflammation under control there are a lot of exercises. Like for the hand, the squeeze balls and things like that are helpful and very effective. Paraffin wax baths can help. They can do some light weights and things like that on their own, and then physical therapy is very effective especially when you’re getting into the elbows and shoulder and things like that. Here it’s actually more occupational therapy that does it, but they do similar exercises to a physical therapist and it helps them regain a lot of function.”

And so I know through reading online that there’s a ton of discussion around using hot compresses versus cold compresses, and I keep seeing individuals talk about morning routine where—if they have it in their hand for example—they need to dip their hands in water. Can you talk about treating that stiffness in the morning with either hot or cold?

“Yeah, so that’s an interesting question and a lot of people ask that for injuries too. So I think that for most patients, if something like an acute injury or an acute type of swelling or an acute flare up, sometimes cold is effective. But in general for most of my patients, it’s heat that feels better. And I don’t even know if this is scientific or not, but I think this is just general experience in terms of what feels better. Most of my patients will say that it’s like the hot shower or hot bath—dipping their hands in hot water—that makes it feel better and gets their joints loosened up and working better than cold. In general for my patients, heat is better than cold unless it’s a case of an acutely injured joint or something like that.”

The CDC says that 1 in 5 adults with arthritis have symptoms of anxiety or depression. I know your job as a rheumatologist is to diagnose and treat arthritis, not mental health concerns, but are there any forms of treatment you suggest or tips you give to clients who are struggling with anxiety, depression, or poor body image in addition to their arthritis?

“Yeah, so I think it definitely coexists. Here at the VA [Veteran’s Association], it seems like more than 1 in 5 adults have anxiety or depression just at baseline. So I think that we’re really impacted by that. For some patients, if its mild or it’s just encouragement, if they come in with rheumatoid arthritis its just encouragement at first ‘We have good medications for this. We can help you get better. In a few month’s you’ll probably be doing better so there’s hope.’ With osteo it’s a little tougher because there’s not good cure for it. With rheumatoid there’s no cure either, but we have good treatments for it. I’m quite often addressing things, like asking them how they feel mentally or asking them if they’re suicidal. We do have a very close relationship with mental health. Most of our patients are seeing someone for mental health it seems like, and I’ve been the one to send them sometimes. These patients go for counseling or anti-depressant medication. There’s also pain relief with anti-depressant medication. Things like Cymbalta or Savella. These are medications that treat things like anxiety and depression, but they’ve also been shown to treat pain form arthritis. So there’s some connection there too. Sometimes we’re treating both there with the medication.”

I keep reading about this connection between rheumatoid arthritis and oral health. Can you expand upon this? Is this connection just with Rheumatoid Arthritis?

“So that was actually a really interesting question. I had to actually look into that a little bit in order to properly answer that. I’m u able to find anything aside from rheumatoid arthritis, although I’m sure there probably is a connection with some other autoimmune diseases. I think a lot of this was coming out when I was in my fellowship—maybe like 10 years ago or something. I’ve heard only about rheumatoid arthritis, but I suppose—the mechanisms—it makes sense that it could also be some other autoimmune diseases. For one thing, it’s hard for these patients to have good oral hygiene if they can’t work their hands very well, which is why they could have periodontal disease. A lot of our patients with rheumatoid arthritis are on immunosuppressant medication which can cause poor dental health and increase bacteria. Increase infections. A lot of our patients co-existing Sjogren’s Syndrome.

Yes, so those patients have extremely dry mouth and saliva contains a lot of enzymes that are antibacterial. So those patients lack saliva, they lack the enzymes. So they’ll get a lot of dental carries, things like that—periodontal disease. So I guess that is obviously another immunosuppressant state, so it’s not just RA, it’s Sjogren’s as well. Some other things, at least from my learning and understanding, a lot of the pro inflammatory cells and cytokinds and things that are present in joints of people with RA are also present in the mouth. I don’t know if anyone knows for sure, but that would by my answer to that question anyway.”

Great, then is there any current tips or tricks that you know of—I know you’re not a dental expert but are there any products out there or forms of treatment that you would advise to patients to make sure they keep up their oral health?

“Yeah, so first off if they have any dryness at all we recommend artificial salivas. Bioteene is one of the ones patients will get over the counter or dentists will give to them. Those come in gels or mouthwashes and things like that. Other than that it’s just common sense stuff. Make sure you’re brushing at least twice a day, if not more. Make sure you’re doing a really thorough job. Mouthwashes. Make sure you’re going to the dentist very frequently. Tell them that you’re having these issues so that they can really screen you for dental carries and things like that.”

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