ANKYLOSING SPONDYLLITIS BY RAIN HEALTH CARE

Ankylosing spondylitis (AS) is a type of arthritis in which there is long-term inflammation of the joints of the spine. Typically the joints where the spine joins the pelvis are also affected. Occasionally other joints such as the shoulders or hips are involved. Eye and bowel problems may also occur.

It is also known as Bekhterev's disease

SYMPTOMS:

The symptoms of ankylosing spondylitis vary. It’s often characterized by mild to moderate flare-ups of inflammation that alternate with periods of almost no symptoms.

The most common symptom is back pain in the morning and at night. You may also experience pain in the large joints, such as the hips and shoulders. Other symptoms may include:

• early morning stiffness
• poor posture or stooped shoulders
• loss of appetite
• low-grade fever
• weight loss
• fatigue
• anemia or low iron
• reduced lung function

Because ankylosing spondylitis involves inflammation, other parts of your body can be affected as well. People with ankylosing spondylitis may also experience:

• inflammation of the bowels
• mild eye inflammation
• heart valve inflammation
• Achilles tendonitis

CAUSE:

Ankylosing spondylitis has no known specific cause, though genetic factors seem to be involved. In particular, people who have a gene called HLA-B27 are at a greatly increased risk of developing ankylosing spondylitis. However, only some people with the gene develop the condition.

RISK FACTORS:

•  Sex. Men are more likely to develop ankylosing spondylitis than are women.
•  Age. Onset generally occurs in late adolescence or early adulthood.
• Heredity. Most people who have ankylosing spondylitis have the HLA-B27 gene. But many people who have this gene never develop ankylosing spondylitis.

COMPLICATIONS:

In severe ankylosing spondylitis, new bone forms as part of the body's attempt to heal. This new bone gradually bridges the gap between vertebrae and eventually fuses sections of vertebrae. Those parts of your spine become stiff and inflexible. Fusion can also stiffen your rib cage, restricting your lung capacity and function.

Other complications might include:

• Eye inflammation (uveitis). One of the most common complications of ankylosing spondylitis, uveitis can cause rapid-onset eye pain, sensitivity to light and blurred vision. See your doctor right away if you develop these symptoms.
• Compression fractures. Some people's bones thin during the early stages of ankylosing spondylitis. Weakened vertebrae can crumble, increasing the severity of your stooped posture. Vertebral fractures can put pressure on and possibly injure the spinal cord and the nerves that pass through the spine.
• Heart problems. Ankylosing spondylitis can cause problems with your aorta, the largest artery in your body. The inflamed aorta can enlarge to the point that it distorts the shape of the aortic valve in the heart, which impairs its function.

DIAGNOSIS:

X-RAY

MRI

HLA-B27 

E.S.R

TREATMENT:

Medications

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, are often used to help manage pain and inflammation. They’re long-acting drugs and are generally safe with few complications.

Surgery

If you have severe damage or deformity to your knee or hip joints, joint replacement surgery may be necessary. Likewise, an osteotomy may be performed on people with poor posture caused by fused bones. During this procedure, a surgeon will cut and realign the bones in the spine.

ALTERNATIVE :

In addition to more traditional medical treatments, some natural remedies may help ease symptoms of ankylosing spondylitis. These treatments may be used alone. They may also be combined with other treatments. Talk with your doctor about which ones are safe to use together and best for you.

Exercise

Range-of-motion exercises, as well as strength training exercises, may help ease the symptoms of ankylosing spondylitis. Both of these exercises can strengthen joints and help them be more flexible. Your doctor may refer you to a physical therapist so you can learn how to do these exercises correctly and safely.

Stretching

Stretching can make your joints more flexible and improve strength. This can lead to less pain and better range of motion in your joints.

Posture training

Stiffness in the spine may encourage bad posture. Over time, bones in the spine can fuse together in slouching or slumping positions. You can reduce the risk for this by practicing good posture.

Because this may not come naturally after years of poor posture positions, you may need to encourage better posture with reminders to correct your posture regularly. You can also use support devices, such as chairs or seat cushions.

Heat and cold therapy

Heating pads or a warm shower can help ease pain and stiffness in the spine and other affected joints. Ice packs can reduce inflammation in painful or swollen joints.

Acupuncture

This alternative treatment may reduce pain and other symptoms of ankylosing spondylitis. It does so by activating natural pain-relieving hormones.

Massage therapy

In addition to being relaxing and invigorating, massage can help you maintain flexibility and improve range of motion. Be sure to tell your massage therapist that you have ankylosing spondylitis. They can be aware of tender points around your spine.

Many treatments for ankylosing spondylitis are also smart practices for a healthier life. Read more about the 10 natural remedies for ankylosing spondylitis.

Don't smoke

If you smoke, quit. Smoking is generally bad for your health, but it creates additional problems for people with ankylosing spondylitis, including further hampering breathing.

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OSTEOPOROSIS

Osteoporosis is a bone disease that occurs when the body loses too much bone, makes too little bone, or both. As a result, bones become weak and may break from a fall or, in serious cases, from sneezing or minor bumps. Osteoporosis means “porous bone.”

Osteon is bone and porous is a hole in Greek. Osteoporosis is a “ Systemic skeletal disorder “ characterized by “ Low bone mass “, microarchitectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. It leads to the abnormally porous bone that is compressible, like a sponge. The spine, hips, and wrists are common areas of bone fractures from osteoporosis. 

Prevalence:-  Osteoporosis is the most prevalent bone disease in the world. According to the International Osteoporosis Foundation, 1 in 3 women over 50 will experience osteoporotic fractures, as will 1 in 5 men. 
Female to male ratio 1: 6

Types of bone cells:- 
Two types:- 1) Osteoclasts 2) Osteoblasts
Bone Remodeling:- Five phases – 1) Activation 2) Resorption 3) Reversal 4) Formation 5) Quiescence (Resting phase) 

Types of osteoporosis:- 
 2 types:- a) Primary osteoporosis:
Type-1: Postmenopausal osteoporosis 
Type-2: Age-associated osteoporosis 
                b) Secondary osteoporosis Loss of bone is caused by an identifiable agent or disease process such as inflammatory disorder, bone marrow cellularity disorder, and corticosteroid use.

CAUSES:

SIGN & SYMPTOMS:

• Fractures caused by osteoporosis are often painful. Osteoporosis is often called the ‘Silent disease’ or ‘Silent thief’ as many people don’t recognize they have it until a fracture occurs. 
• Back pain: Episodic, acute, low thoracic/high lumbar pain 
• Compression fracture of the spine 
• Bone fractures 
• Decrease in height 
• Kyphosis 
• Dowager’s hump 
• Decreased activity tolerance 
•  Early satiety

RISK FACTORS:

1. Current cigarette smoking 
2. Low body weight (<127 pounds) 
3. Alcoholism 
4. Estrogen deficiency 
5. Prolonged amenorrhea (>1 year) 
6. Early menopause (<45 years) or bilateral ovariectomy 
7. Lifelong low calcium intake 
8. Recurrent falls 
9. Poor health/fragility 
10. Inadequate physical activity 
11. Family history of osteoporosis

INVESTIGATION:

Physical examination:- 

1. Osteoporosis 
2. Height loss 
3. Bodyweight 
4. Kyphosis 
5. Humped back 
6. Tooth loss 
7. Skinfold thickness 
8. Grip strength Vertebral fracture 
9.  Arm span-height difference 
10. Wall- occiput distance 
11. Rib-pelvis distance

Diagnosis:- 

1. Bone Mineral Density (BMD) test:- The most common test. Results are reported using T-scores.T-scores are relative to how much higher or lower your bone density is compared to that of a healthy adult.T-score:- It is the number of standard deviation (SD) above or below a reference value

Category T-score:
 Normal -1.0 or Above Osteopenia(Low bone mass) 
-1.0 to -2.5 Osteoporosis
 -2.5 or Less Severe osteoporosis 
-2.5 or Less with one or more fragility fracture 

Laboratory Tests:- 

1. Blood Calcium levels 
2. 24-hour urine calcium measurement 
3. Thyroid function tests 
4. Parathyroid hormone levels 
5. Testosterone levels in men 
6. 25-hydroxyvitamin D test to determine whether the body has enough vitamin D 
7. Biochemical marker tests 

TREATMENT:

Pharmacological option in osteoporosis:- 
Antiresorptive:- Act on osteoclasts and stabilize the bone 
Calcium 
Estrogen 
Calcitonin 
Bisphosphonates 
Selective estrogen receptor modulators 
Thiazide diuretics Formation:- Act on osteoblasts and increase bone formation 
 Vitamin D 
Anabolic steroids 
Parathyroid hormone 
Growth factors (investigation) 
Fluoride (investigation) 

Goals:- 

1) To educate proper posture. 

2) Teach safe ways of moving and lifting. 

3) To prevent a decline in bone mass and prevent fractures. 

4) To increase the strength in bones. 

5) To maintain or improve balance. 

6) To improve flexibility. 

7) To help decrease the stress placed on the bones by tight muscles. 

8) To improve overall mobility. 

9) To control pain and gradually returning back to regular activities. 

Physical therapy:-

1. Physical therapy intervention for individuals with osteoporosis, or even osteopenia, 
2. should include: Maintain posture, Strengthening exercise, Weight-bearing exercise, Balance exercise, Flexibility exercise.

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                                                                                     RAIN HEALTH CARE

                                                                                                 H.C. INDRAJIT BISWAS

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CERVICAL SPONDYLOSIS

Cervical spondylosis is a general term for age-related wear and tear affecting the spinal disks in your neck. As the disks dehydrate and shrink, signs of osteoarthritis develop, including bony projections along the edges of bones (bone spurs).

Cervical spondylosis is very common and worsens with age. More than 85 percent of people older than age 60 are affected by cervical spondylosis.

Most people experience no symptoms from these problems. When symptoms do occur, nonsurgical treatments often are effective.

Other names are arthritis of the neck, cervical osteoarthritis, or degenerative osteoarthritis.

Causes

The bones and protective cartilage in your neck are prone to wear and tear which can lead to cervical spondylosis. Possible causes of the condition include:

Bone spurs

These overgrowths of bone are the result of the body trying to grow extra bone to make the spine stronger.

However, the extra bone can press on delicate areas of the spine, such as the spinal cord and nerves, resulting in pain.

Dehydrated spinal discs

Your spinal bones have discs between them, which are thick, padlike cushions that absorb the shock of lifting, twisting, and other activities. The gel-like material inside these discs can dry out over time. This causes your bones (spinal vertebrae) to rub together more, which can be painful.

This process can begin to happen in your 30s.

Herniated discs

Spinal discs can develop cracks, which allows leakage of the internal cushioning material. This material can press on the spinal cord and nerves, resulting in symptoms such as arm numbness as well as pain that radiates down an arm. Learn more about herniated discs.

Injury

If you’ve had an injury to your neck (during a fall or car accident, for example), this can accelerate the aging process.

Ligament stiffness

The tough cords that connect your spinal bones to each other can become even stiffer over time, which affects your neck movement and makes the neck feel tight.

Overuse

Some occupations or hobbies involve repetitive movements or heavy lifting (such as construction work). This can put extra pressure on the spine, resulting in early wear and tear.

Risk factors

Risk factors for cervical spondylosis include:

• Age: Cervical spondylosis is a normal part of aging.
• Occupation: Jobs that involve repetitive neck motions, awkward positioning or a lot of overhead work put extra stress on your neck.
• Neck injuries: Previous neck injuries appear to increase the risk of cervical spondylosis.
• Genetic factors: Some individuals in certain families will experience more of these changes over time, while others will not.
• Smoking: Smoking has been linked to increased neck pain.

Symptoms

• Neck stiffness and pain.
• Headache that may originate in the neck.
• Pain in the shoulder or arms.
• Inability to fully turn the head or bend the neck, sometimes interfering with driving.
• Grinding noise or sensation when the neck is turned.

Diagnosis

Your doctor will likely start with a physical exam that includes:

• Checking the range of motion in your neck
• Testing your reflexes and muscle strength to find out if there's pressure on your spinal nerves or spinal cord
• Watching you walk to see if spinal compression is affecting your gait

Imaging tests

Imaging tests can provide detailed information to guide diagnosis and treatment. Your doctor might recommend:

• Neck X-ray: An X-ray can show abnormalities, such as bone spurs, that indicate cervical spondylosis. Neck X-ray can also rule out rare and more serious causes for neck pain and stiffness, such as tumors, infections or fractures.
• CT scan: A CT scan can provide more detailed imaging, particularly of bones.
• MRI: MRI can help pinpoint areas where nerves might be pinched.
• Myelography: A tracer dye is injected into the spinal canal to provide more detailed X-ray or CT imaging.

Nerve function tests

Your doctor might recommend tests to determine if nerve signals are traveling properly to your muscles. Nerve function tests include:

• Electromyography: This test measures the electrical activity in your nerves as they transmit messages to your muscles when the muscles are contracting and at rest.
• Nerve conduction study: Electrodes are attached to your skin above the nerve to be studied. A small shock is passed through the nerve to measure the strength and speed of nerve signals.

Treatment

Treatment for cervical spondylosis depends on the severity of your signs and symptoms. The goal of treatment is to relieve pain, help you maintain your usual activities as much as possible, and prevent permanent injury to the spinal cord and nerves.

Medications

If over-the-counter pain relievers aren't enough, your doctor might prescribe:

• Nonsteroidal anti-inflammatory drugs: While some types of NSAIDs are available over the counter, you may need prescription-strength versions to relieve the pain and inflammation associated with cervical spondylosis.
• Corticosteroids: A short course of oral prednisone might help ease the pain. If your pain is severe, steroid injections may be helpful.
• Muscle relaxants: Certain drugs, such as cyclobenzaprine, can help relieve muscle spasms in the neck.
• Anti-seizure medications: Some epilepsy medications, such as gabapentin (Neurontin, Horizant) and pregabalin (Lyrica), can dull the pain of damaged nerves.
• Antidepressants: Certain antidepressant medications have been found to help ease neck pain from cervical spondylosis.

Therapy

A physical therapist can teach you exercises to help stretch and strengthen the muscles in your neck and shoulders. Some people with cervical spondylosis benefit from the use of traction, which can help provide more space within the spine if nerve roots are being pinched.

Surgery

If conservative treatment fails or if your neurological signs and symptoms — such as weakness in your arms or legs — worsen, you might need surgery to create more room for your spinal cord and nerve roots.

The surgery might involve:

• Removing a herniated disk or bone spurs
• Removing part of a vertebra
• Fusing a segment of the neck using bone graft and hardware

Lifestyle and home remedies

Mild cervical spondylosis might respond to:

• Regular exercise: Maintaining activity will help speed recovery, even if you have to temporarily modify some of your exercises because of neck pain. People who walk daily are less likely to experience neck and low back pain.
• Over-the-counter pain relievers: Ibuprofen (Advil, Motrin IB, others), naproxen sodium (Aleve) or acetaminophen (Tylenol, others) is often enough to control the pain associated with cervical spondylosis.
• Heat or ice: Applying heat or ice to your neck can ease sore neck muscles.
• Soft neck brace: The brace allows your neck muscles to rest. However, a neck brace should be worn for only short periods of time because it can eventually weaken neck muscles.

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GOUT

                                  GOUT

Gout is a common type of arthritis that causes intense pain, swelling, and stiffness in a joint. It usually affects the joints in the big toe.

SYMPTOMS:

The signs and symptoms of gout almost always occur suddenly, and often at night. They include:

• Intense joint pain: Gout usually affects the large joint of your big toe, but it can occur in any joint. Other commonly affected joints include the ankles, knees, elbows, wrists, and fingers. The pain is likely to be most severe within the first four to 12 hours after it begins.
• Lingering discomfort: After the most severe pain subsides, some joint discomfort may last from a few days to a few weeks. Later attacks are likely to last longer and affect more joints.
• Inflammation and redness: The affected joint or joints become swollen, tender, warm and red.
• Limited range of motion: As gout progresses, you may not be able to move your joints normally.

  Types

There are various stages through which gout progresses, and these are sometimes referred to as different types of gout.

Asymptomatic hyperuricemia

It is possible for a person to have elevated uric acid levels without any outward symptoms. At this stage, treatment is not required, though urate crystals may deposit in tissue and cause slight damage.

People with asymptomatic hyperuricemia may be advised to take steps to address any possible factors contributing to uric acid build-up.

Acute gout

This stage occurs when the urate crystals that have been deposited suddenly cause acute inflammation and intense pain. This sudden attack is referred to as a “flare” and will normally subside within 3 to 10 days. Flares can sometimes be triggered by stressful events, alcohol, and drugs, as well as cold weather.

Interval or intercritical gout

This stage is the period between attacks of acute gout. Subsequent flares may not occur for months or years, though if not treated, over time, they can last longer and occur more frequently. During this interval, further urate crystals are being deposited in tissue.

Chronic tophaceous gout

Chronic tophaceous gout is the most debilitating type of gout. Permanent damage may have occurred in the joints and the kidneys. The patient can suffer from chronic arthritis and develop tophi, big lumps of urate crystals, in cooler areas of the body such as the joints of the fingers.

It takes a long time without treatment to reach the stage of chronic tophaceous gout – around 10 years. It is very unlikely that a patient receiving proper treatment would progress to this stage.

Pseudogout

One condition that is easily confused with gout is pseudogout. The symptoms of pseudogout are very similar to those of gout, although the flare-ups are usually less severe.

The major difference between gout and pseudogout is that the joints are irritated by calcium pyrophosphate crystals rather than urate crystals. Pseudogout requires different treatment for gout.

Risk factors

There are a number of factors that can increase the likelihood of hyperuricemia, and therefore gout:

Age and gender: Men produce more uric acid than women, though women’s levels of uric acid approach those of men after the menopause.

Genetics: A family history of gout increases the likelihood of the condition developing.

Lifestyle choices: Alcohol consumption interferes with the removal of uric acid from the body. Eating a high-purine diet also increases the amount of uric acid in the body.

Lead exposure: Chronic lead exposure has been linked to some cases of gout.

Medications: Certain medications can increase the levels of uric acid in the body; these include some diuretics and drugs containing salicylate.

Weight: Being overweight increases the risk of gout as there is more turnover of body tissue, which means more production of uric acid as a metabolic waste product. Higher levels of body fat also increase levels of systemic inflammation as fat cells produce pro-inflammatory cytokines.

Recent trauma or surgery: Increases risk.

Other health problems: Renal insufficiency and other kidney problems can reduce the body’s ability to efficiently remove waste products, leading to elevated uric acid levels. Other conditions associated with gout include high blood pressure and diabetes.

Causes

• Gout occurs when urate crystals accumulate in your joint, causing the inflammation and intense pain of a gout attack. Urate crystals can form when you have high levels of uric acid in your blood.
• Your body produces uric acid when it breaks down purines — substances that are found naturally in your body.
• Purines are also found in certain foods, such as steak, organ meats, and seafood. Other foods also promote higher levels of uric acid, such as alcoholic beverages, especially beer, and drinks sweetened with fruit sugar (fructose).
• Normally, uric acid dissolves in your blood and passes through your kidneys into your urine. But sometimes either your body produces too much uric acid or your kidneys excrete too little uric acid. When this happens, uric acid can build up, forming sharp, needlelike urate crystals in a joint or surrounding tissue that cause pain, inflammation, and swelling.

Complications

People with gout can develop more-severe conditions, such as:

• Recurrent gout: Some people may never experience gout signs and symptoms again. Others may experience gout several times each year. Medications may help prevent gout attacks in people with recurrent gout. If left untreated, gout can cause erosion and destruction of a joint.
• Advanced gout: Untreated gout may cause deposits of urate crystals to form under the skin in nodules called tophi (TOE-fie). Tophi can develop in several areas such as your fingers, hands, feet, elbows or Achilles tendons along the backs of your ankles. Tophi usually aren't painful, but they can become swollen and tender during gout attacks.
• Kidney stones: Urate crystals may collect in the urinary tract of people with gout, causing kidney stones. Medications can help reduce the risk of kidney stones.

Diagnosis

Tests to help diagnose gout may include:

• Joint fluid test: Your doctor may use a needle to draw fluid from your affected joint. Urate crystals may be visible when the fluid is examined under a microscope.
• Blood test: Your doctor may recommend a blood test to measure the levels of uric acid and creatinine in your blood. Blood test results can be misleading, though. Some people have high uric acid levels but never experience gout. And some people have signs and symptoms of gout but don't have unusual levels of uric acid in their blood.
• X-ray imaging: Joint X-rays can be helpful to rule out other causes of joint inflammation.
• Ultrasound: Musculoskeletal ultrasound can detect urate crystals in a joint or in a tophus. This technique is more widely used in Europe than in the United States.
• Dual-energy CT scan: This type of imaging can detect the presence of urate crystals in a joint, even when it is not acutely inflamed. This test is not used routinely in clinical practice due to the expense and is not widely available.

Treatment

Treatment for gout usually involves medications. What medications you and your doctor choose will be based on your current health and your own preferences.

Gout medications can be used to treat acute attacks and prevent future attacks. Medications can also reduce your risk of complications from gout, such as the development of tophi from urate crystal deposits.

Medications to treat gout attacks

Drugs used to treat acute attacks and prevent future attacks include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAIDs include over-the-counter options such as-
  
  
•  ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve), 
• as well as more-powerful prescription NSAIDs such as indomethacin (Indocin) or celecoxib (Celebrex).
• Colchicine: Your doctor may recommend colchicine (Colcrys, Mitigare), a type of pain reliever that effectively reduces gout pain. The drug's effectiveness may be offset, however, by side effects such as nausea, vomiting, and diarrhea, especially if taken in large doses.
  After an acute gout attack resolves, your doctor may prescribe a low daily dose of colchicine to prevent future attacks.
• Corticosteroids: Corticosteroid medications, such as the drug prednisone, may control gout inflammation and pain. Corticosteroids may be in pill form, or they can be injected into your joint.
  Corticosteroids are generally used only in people with gout who can't take either NSAIDs or colchicine. Side effects of corticosteroids may include mood changes, increased blood sugar levels, and elevated blood pressure.

Medications to prevent gout complications

If you experience several gout attacks each year, or if your gout attacks are less frequent but particularly painful, your doctor may recommend medication to reduce your risk of gout-related complications. If you already have evidence of damage from gout on joint X-rays, or you have tophi, chronic kidney disease or kidney stones, medications to lower your body's level of uric acid may be recommended. Options include:

• Medications that block uric acid production: Drugs called 
  Side effects of allopurinol include a rash and low blood counts. Febuxostat side effects include rash, nausea, reduced liver function and an increased risk of heart-related death.

xanthine oxidase inhibitors (XOIs), including allopurinol (Aloprim, Lopurin, Zyloprim) and febuxostat (Uloric), limit the amount of uric acid your body makes. This may lower your blood's uric acid level and reduce your risk of gout.

• Medication that improves uric acid removal: These drugs, called uricosurics, include probenecid (Probalan) and lesinurad (Zurampic). Uricosuric drugs improve your kidneys' ability to remove uric acid from your body. This may lower your uric acid levels and reduce your risk of gout, but the level of uric acid in your urine is increased. Side effects include a rash, stomach pain, and kidney stones. Lesinurad can be taken only along with an XOI.

Prevention:

During symptom-free periods, these dietary guidelines may help protect against future gout attacks:

• Drink plenty of fluids: Stay well-hydrated, including plenty of water. Limit how many sweetened beverages you drink, especially those sweetened with high-fructose corn syrup.
• Limit or avoid alcohol: Talk with your doctor about whether any amount or type of alcohol is safe for you. Recent evidence suggests that beer may be particularly likely to increase the risk of gout symptoms, especially in men.
• Get your protein from low-fat dairy products: Low-fat dairy products may actually have a protective effect against gout, so these are your best-bet protein sources.
• Limit your intake of meat, fish, and poultry: A small amount may be tolerable, but pay close attention to what types — and how much — seem to cause problems for you.
• Maintain desirable body weight: Choose portions that allow you to maintain a healthy weight. Losing weight may decrease uric acid levels in your body. But avoid fasting or rapid weight loss, since doing so may temporarily raise uric acid levels.

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