Back to main pageÌý
BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES Programme no. 4 - Rheumatology
RADIO 4
TUESDAY 22ND APRIL 2008
PRESENTER: MARK PORTER
CONTRIBUTORS: ANDREW BAMJI
JULIE ABRAHAMS
PRODUCER: PAULA MCGRATH
NOT CHECKED AS BROADCAST
ACTUALITY
I can't kneel on any surface, it would be like kneeling on broken glass. It's excruciating.
And does it hurt you if I press there?
No.
But if you kneel on it, it does. So it could just be the back of the kneecap that's causing the problem.
But it is like broken glass.
PORTER
In today's programme I will be going behind the scenes in a busy rheumatology clinic to find out more about the speciality. Rheumatology may have a comparatively low profile, but it has a very broad reach, encompassing conditions ranging from arthritis and gout, to connective tissue disorders like lupus and the tick borne infection Lyme disease.
The British Society for Rheumatology is having it's annual meeting this week to discuss recent advances in the field. I joined the society's president, Dr Andrew Bamji, at one of his busy outpatient clinics at Erith Hospital in Kent.
BAMJI
Rheumatology is the specialty of arthritis and other musculoskeletal conditions. So rheumatologists see patients with different types of arthritis but also people who have what you might call soft tissue lesions, such as shoulder pain, tennis elbows and so forth, neck pain, back pain.
PORTER
So what sort of conditions might we expect to see in a general outpatients clinic like this one?
BAMJI
New patients probably 70-80% have what you would call mechanical or soft tissue conditions and only sort of 20% will have inflammatory joint disease like rheumatoid arthritis. A lot of those mechanical problems can be dealt with on a one-stop basis, so the patients that we see in the follow-up clinic tend to be the patients with inflammatory joint disease where you're monitoring their progress, their drugs and so on.
FARREN
It affected all my neck, my shoulder, my arms and I literally couldn't turn my head, I couldn't lift my arm up, even just the weight of my arm it was painful and I had seven weeks off work.
PORTER
Beverley Farren has rheumatoid arthritis and a recent flare up has prompted a return to Erith Hospital to see what Dr Bamji can do to ease her discomfort.
FARREN
I work on the public counter for the DVLA and I was using the till all the time and it got to the stage I couldn't drive, I couldn't even lift a kettle up, it was really bad.
PORTER
So your GP treated that - increased the dose of your steroids effectively - anti-inflammatories.
FARREN
But that's all he could do and then I had a couple of emergency appointments with Dr Bamji.
PORTER
And what's the difference between rheumatoid arthritis and the more common osteoarthritis?
BAMJI
It's very difficult to describe osteoarthritis because we used to call it wear and tear arthritis. But basically osteoarthritis is a degeneration of the joints which isn't associated with some immune problem that causes active inflammation in the joints which we can look at clinically and see because the joint is red and hot and tender and swollen.
PORTER
If I came to see you with a joint problem what would make you think, as a clinician, from the story I was telling you and by looking at the joint that it was either osteo or a rheumatoid type problem?
BAMJI
The first thing is in the history, patients with inflammatory arthritis tend to be very stiff in the mornings, very often they feel very unwell and they actually can get quite depressed. The joints are clearly swollen, boggy, very often quite tender to the touch. The patients can be of any age - I've got children ranging up to people in their 80s who've developed inflammation in the joints. Whereas with osteoarthritis unless you've had an injury to a joint you're mainly dealing with a middle-aged, slightly older aged population because this is the sort of thing that comes along as you get older. And patients with osteoarthritis have painful joints but the pattern may be different - the types of joints affected may be different. For instance, if you have trouble in the joints at the tips of the fingers then that isn't going to be rheumatoid arthritis, if you have pain across the knuckles that is going to be rheumatoid arthritis and isn't going to be osteoarthritis.
PORTER
And why is it so important to differentiate between the two?
BAMJI
Well the treatment of inflammatory arthritis is now quite serious, I think that's probably the best way I could put it. In a sense we're starting to manage inflammatory arthritis in the same way as doctors have been managing cancer. We are using very, very powerful drugs that suppress the immune system, that reduce the inflammation. We're using them at a very much earlier stage in the disease because what we've learned is that if we use these potent drugs at an early stage we can actually stop the inflammation in its tracks, prevent progression of joint damage and therefore obviously all the right things like making people feel better but keeping them in work as well.
PORTER
And do we understand what's causing this inflammation in the first place?
BAMJI
If we had a programme of about five hours I could probably have a stab at explaining the inflammatory cascade. It's pretty complicated and we don't fully understand it. But the bottom line is that something goes wrong with the immune system and something goes wrong with the way the white blood cells both produce antibodies and then what those antibodies do. Antibodies are proteins in the blood that traditionally we understand will, for instance, combat infection, if you get a cold you produce antibodies to the virus and those antibodies kill off the viruses. If something goes wrong with the immune system then those antibodies can be produced in the wrong way at the wrong times and sometimes they'll stick together and produce large molecules that are seen by the rest of the immune system as being something foreign. And then the rest of the immune system kicks in to eat them up, causing inflammation and that actually sets the arthritis off because that will often happen in and around joints.
ACTUALITY
It's not better, it's worse, when I wake up in the morning it's painful you know, it sort of like - it's hard for me to bend and this finger, if I try and do something or try to bend it's really painful
Okay, which one is it? The middle one?
The middle one.
Try and bend it for me, let me just feel that. Does it hurt if I press it there?
Yeah.
Which is worse - if I press there or if I press there?
No, if you do it the other way.
This one is worse. So that's over the tendon in the palm of your hand, so I just wonder whether in fact there's a bit of inflammation in that.
BAMJI
Nowadays we will get on and treat very early. You can treat the pain with painkillers or what we call anti-inflammatory drugs. However, we don't start with that anymore. Once we've made a firm diagnosis we put the patient straight on to a series of drugs called disease modifying drugs. Some of these are quite potent, the names that will come up in clinic are hydroxychloriquine, which is an anti-malaria treatment originally; sulphursalazine; methotrexate. In the old days we used to use gold injections but I think most people have given those up because the others are much better. Methotrexate's a drug that's used for cancer. When we started using it in rheumatoid arthritis used it in very small doses, very cautiously and it's taken us quite a while to realise we don't need to be that cautious on the one hand and on the other hand if we use big doses early we may actually suppress the disease better than if you dribble it in slowly. In much the same way as cancer responds when you hit people with lots of chemotherapy.
PORTER
And these are drugs that are working by somehow modulating the immune response?
BAMJI
That's right. We don't entirely know how some of them work, we assume that they do something to this white blood cell producing the antibodies, producing the reaction to those antibodies cascade. Some of the drugs and certainly some of the newer drugs affect some of the inflammatory chemicals that are produced in the blood when you get this sort of arthritis and these are the chemicals that actually make you feel unwell. Some of them are called interleukins, there's another chemical - tuminocrosis factor. And we can actually interfere with the production or the expression of those substances and that will switch the arthritis off as well.
PORTER
Well that is the theory anyway. Unfortunately not everyone can tolerate these disease modifying drugs. Sheila Heywood has rheumatoid arthritis and has tried most of them.
ACTUALITY
Did we at some stage ever give you a tablet called methotrexate?
Yes you did.
And?
It done my liver I believe, something to my liver and you took me off.
And sulphursalazine upset you as well. And then we gave you some gold, as a desperate measure and that upset you as well.
And that did something to me as well.
Yeah, you actually - methotrexate made you ill as well as upsetting you.
That's right yeah.
PORTER
Another group of drugs that's commonly used in these sorts of problems and has an effect on the immune system are steroids of course and many people will have heard of those. Are they disease modifying drugs?
BAMJI
Steroids probably are disease modifying drugs but they're very, very powerful anti-inflammation drugs. So it's a combination of the two. I actually use quite a lot of steroids and one of the ways that one can use them is actually to prove the problem is a problem of inflammation. If you put someone on steroids and their symptoms disappear instantly - well within two days - you can be pretty sure the problem is an inflammatory problem. Some patients, however, never get off them again and of course there are significant side effects from steroids and we don't therefore, certainly in younger patients, want to leave people on steroids longer than we have to. So I might give it as a test and if it works then say fine, we'll now move on to the disease modifying drugs.
ACTUALITY
Right, what I was going to ask you, I've been on steroids now 10 years, they don't seem like they're doing anything anymore can I come off of them? My skin's getting thinner and thinner.
You've got all the side effects of steroids.
Oh yes absolutely.
How much steroid are you on?
Seven and a half.
Right. You've been on it so long you're not going to be able to stop it at once. The question I would ask immediately is, is it doing something that you simply don't know what - that it's doing something and the only way we're going to find out is to start reducing it and see if you flare up horribly and if you flare up horribly then what we'll have to do is to say well okay, yeah you've got some side effects but we'll have to balance the side effects against the benefits. If we can get it down a bit terrific, try five.
Try five, okay.
If after a month you're okay then try five one day, two and a half the next day.
Right okay, for a month?
For a month.
Yeah okay.
If you can't manage put it back to the one where you could. I suspect ...
... really hurting so much now and I'm just thinking is it doing anything.
Well I suspect it may hurt more.
BAMJI
Steroids given by mouth will suppress the body's own steroid production from the adrenal glands. That means that if you've been on steroids for a long time and you get stressed - whether this is from an infection or anything else - then your own adrenals may not give you that cortisone rush that you need to keep you well. So we're very anxious not to give people long term steroids and suppress their adrenal glands if we can help it. The other things that they will do, and anybody has read about, is that they can make you put on weight, they can make you get fat in the face, they will certainly thin the skin, particularly in older people on long term use, they can hasten the development of cataracts and change the pressures inside the eyes. So - and they can put up your blood pressure and they can provoke diabetes. So there are lots of things they can do. As I say it's a question of benefit versus risk.
PORTER
One of the other ways that steroids are often used is locally, into the troublesome joint, if the person has a prominent joint that's given them most of their trouble, do they have similar side effects?
BAMJI
Giving steroids by injection into joints is not really a problem, they don't produce side effects for two reasons: one is you're largely concentrating the steroids in a local area, you're not actually giving a very large dose to the rest of the body; the second thing is that actually they're cleared from the rest of the body very quickly. And of course as a one shot it's not going to suppress your adrenal glands. So injection, no, I think we could safely say that the side effects are not really significant.
PORTER
And can we use injections as repeated treatments?
BAMJI
People worry about whether giving repeated injections is going to cause joint damage. The latest research actually suggests that it isn't. But on the other hand if repeated injections aren't keeping a joint under control then maybe one shouldn't be doing it, one should be looking at other ways of dealing with that joint.
PORTER
The next patient to arrive at the clinic is Margaret Davies. The combination of advancing years and arthritic joints mean she has been brought in by her husband in a wheelchair - but it's her back that's bothering her most today.
ACTUALITY
Mrs Davies, how are you?
Horrible.
Okay why?
Well it keeps moving from one place to another, this is the rheumatoid arthritis, and it's now in my legs. And I can't even lay down without them hurting.
Right, where is it hurting in your legs?
My back and my bottom.
Could you bear to go and have another x-ray today, just so that I can have a look at it?
Today?
Yeah. Well like now and then you can come back with this little slip of paper that tells me you've had it done and I can look at it.
Okay.
Shall we do that?
PORTER
Mrs Davies is back within half an hour and, thanks to digital "film less" technology, Dr Bamji can pull up the X-rays on his desktop PC.
BAMJI
Looking at this without knowing who we were looking at, as opposed to it being Mrs Davies, who we do know, we would say that she's an older person and there's a lot of disc wear and tear and loss of joint space.
PORTER
The loss of joint space - these are thinning of the sort of protective discs that sit between ..
BAMJI
Thinning of the discs, exactly so. And when you get this amount of narrowing it can compromise the space between the vertebrae, between the vertebrae where the nerves come out - one each side. And looking at this I think that probably is quite compromised down at the bottom. So I think if we're going to further investigate the symptoms that Mrs Davies has got, which are pains in the legs and that, we're probably going to have to scan her to look at the diameter of the spinal canal at that point. But we can also see that she has got some wedging of the discs and a slight twist in the spine rotationally, so there is a scoliosis superimposed on this. The reason you get this pain that increases as you walk is because the nerves are being pinched and the blood supply to the nerves particularly is being pinched. Now the way to investigate that properly is to do a full scan of your spine - an MRI scan - and that will enable us - that means going into a tunnel, a dark and very noisy tunnel.
ACTUALITY
I can't stand going in anywhere where I'm enclosed.
Right hang on a minute, there's more to it than that because if you said to me under no circumstances am I going in the tunnel, I can fix for you to have a scan at an open scanner but we have to pay extra for that, we have to authorise it individually. That's not a problem, it can be done but let's try the physio first.
PORTER
Next up is Jason Smith with a recurrent shoulder problem.
ACTUALITY
Jason, how's tricks?
Fine, thank you doctor, yes.
How's the shoulder?
Certainly that injection helped. Starting to wear off, I believe. Yeah so I'm noticing it - I am noticing it a bit.
Enough for me to do it again or not really at the moment?
Yes I think so but then I would say that, yes because it helped with the jib.
Okay, let's have a look at your shoulder. Stand up for me a minute. Okey doke. Now let me just turn it that way, tell me if that hurts?
No.
So going externally rotated it doesn't. Keep your elbow tucked into your side and push my hand away. That hurt?
A little.
A little. So that's a suggestion that the muscle is still irritable. And now lift your arm out from your side and push up against my hand and that hurts.
Yes.
I'm sure the problem's the same, it's a problem with the muscles, as it comes round the back of your shoulder.
Right.
The question is if it's still not right should we inject it again and keep our fingers crossed or should we actually scan it and let's see if there's any damage in the tendon.
Right okay. But that's your call isn't it? The injection helps me from now.
How long ago is it we did it?
December I think.
I'm not absolutely sure that's long enough, I think I'd go for a scan first because if there are signs of tendon damage we could make it worse by giving you another injection at this point. So if we fix a scan for you and then depending on what the scan shows we can either do it again if it doesn't look too bad or I get my surgical colleague who specialises in shoulders to have a look at it.
Right okay, yeah.
Okay?
Yeah.
Good. The waiting list is probably about six weeks at the moment, so it's actually not too bad.
Shorter than I was expecting.
Yeah well - which is good for my patients.
Would it be like an MRI scan?
It's an MRI scan, yeah. You haven't got any metal anywhere funny, have you, that's going to pop out under the magnet?
No.
Right. Persistent left rotator cuff symptoms.
BAMJI
The reason that x-ray has its limitations is that it's very good at looking at bones but it's very bad at looking at soft tissues, you can't actually see the muscles, the tendons, the nerves and things that you can see on either an ultrasound examination or an MRI.
PORTER
And by ultrasound I mean that's a similar sort of technology that we'd use to look at an unborn baby for instance?
BAMJI
Exactly so. And there are new machines which are unfortunately too expensive for my department to afford which you can actually use in the clinic.
PORTER
And those scanners, both of them, will they actually pick up inflammation - if something's intact, if it's structurally normal will you actually be able to see whether it's inflamed or not?
BAMJI
MRIs and ultrasound are capable of picking up inflammation even in very small joints. So when traditionally we used, for instance, to look at inflammatory arthritis, like rheumatoid arthritis, we could only tell that there was joint damage by seeing that there were changes on the x-rays. Those changes on the x-rays means that the inflammation has eaten through the cartilage that lines the joints into the bone. With MRI and ultrasound we can now see damage to the cartilage before we've got damage in the bone. Now in terms of picking up damage that means that we're bringing forward the point at which we can see the damage by six to nine months and that of course means we can treat the patient before the damage has become irreversible, so that is actually terribly important. As far as a shoulder's concerned, how do I manage a patient with a tendon injury to a shoulder? Well probably, first of all, I'll give them an injection but thereafter if the injection hasn't worked we really do need to know something about the tendon because the question is do we do a second injection, is that appropriate, is that just inflammation, do we actually want to look more carefully at the way in which the tendon relates to the little joint at the tip of the shoulder because there are three joints in the shoulder and the one on the tip of the shoulder, called acromioclavicular joint can actually act like a saw - little sharp points sticking into the tendon and wearing it away like a rope over the edge of a rough area. Has the tendon actually torn? Because what we do will depend on what we see. Am I going to inject it again, am I going to send them to physiotherapy, am I going to send them to the surgeons?
PORTER
Just down the corridor from the rheumatology clinic is another important member of the team - senior physiotherapist Julie Abrahams. Referrals from Andrew Bamji make up around a third of her department's workload.
ABRAHAMS
When you're well you need to keep the joints free range of movement and to maintain muscle power and of course you need to think of general fitness as well. So it is important that patients with arthritis keep moving.
PORTER
And what does the muscle power add to the joint, does it help to keep it more stable?
ABRAHAMS
It does keep the joint more stable and it helps to promote your function.
PORTER
So if you're not using the joint actually losing the muscle power can make the strains on the joint worse, which makes the joint worse so you get more pain, so you do less and ...
ABRAHAMS
Yeah it becomes a vicious circle.
PORTER
And practically what's actually involved? People come here from the clinic, they come and see you, they have a problem with their knee, for instance, or any other joint what are you likely to do with them?
ABRAHAMS
First of all they have an assessment, so we look at the whole condition, we ask a history and then we do a physical examination where we look at the structure of the joint, the stability, the muscle power, the range of movement and any other issues regarding that problem. And then we make a treatment programme that we apply to the patient and the patient's needs and wants.
PORTER
And do they have to come here to have that - they have their initial assessment here and you show them but can they do these things at home?
ABRAHAMS
Yes, I mean maintaining their own health and having responsibility for their own well being is quite an important part of our role. So we do promote our patients' self-care and self-maintenance and we point them in the right direction - we do give them exercises and we do expect them to do them at home. Then we maintain those exercises, monitor and progress. But we also give them other options too, for example, go to sports centres and exercise classes.
PORTER
Back with Andrew Bamji, Beverley Farren is troubled by pins and needles in her right hand. A common problem called carpal tunnel syndrome, which is even more frequent in people with rheumatoid arthritis like Beverley.
ACTUALITY
I keep getting tingling down those two fingers, from there and just slightly up there. But it goes into like a spasm, it seems like an electric shock in your arm.
Okay, but it's mainly the thumb and the index finger?
It's here and here.
And up the forearm. Okay. Now I'm going to do something and you tell me if it hurts. I think I did this before. Now that will hurt but tell me if anything happens to the pins and needles as I bend your wrist forwards like that.
It's started to go ...
It's starting to go in your thumb and finger. What I'm doing, doing that, is I'm compressing the median nerve, which runs through your wrist, because when we flex your wrist into the palm like that we're compressing the nerve against all the other tissues in there and holding it down. If that makes the pins and needles worse it suggests that the nerve is trapped at the wrist. Why then, do you say, am I getting pain up my arm? And the answer is it sometimes happens, is as good as I can get really. I think the problem is in the wrist. Now we can do two things: we can either prove the point by doing some electrical tests, but they're not always positive or we could try an injection and see if it switches off the symptoms.
Okay. It's gone all funny now.
But you see I haven't done anything to the rest of your arm, all I did was I played with your wrist and that makes me very suspicious that this is what we call retrograde symptoms, symptoms are going back from where they should be, normally they only go outwards but sometimes they go backwards. So what would I do if it was me? I think if it was giving me this much trouble, as you've described it to me, I would try an injection in your carpal tunnel. Happy with that?
Not happy with that but ... [Laughter]
You can always say no, you don't have to - just because I say that you have to have it done, no I don't say you have to have it done, I'm recommending that's what I'd do if it was me.
Yeah, it's getting quite uncomfortable at work. They've altered everything round at work and given me all sorts of gadgets and things to sort of take the pressure of it and everything but it still keeps going - when it goes like that it makes my hand go funny. So no it is getting quite irritating.
So we'll have a try at it. If that doesn't work - we give it six weeks - if it hasn't worked after six weeks let us know and then I'll fix some electrical tests up, all righty?
Yeah.
Good, I will go and get the stuff.
Okay.
BAMJI
Carpal tunnel syndrome is a problem where you develop pain, numbness, pins and needles in the palm of the hand. Thumb, index and middle finger, not usually more than half of the ring finger and never the little finger. It's always in the palm of the hand and the reason you get it is that the nerve that supplies that part of the hand, which is the median nerve, is caught in some way at the wrist. It has to pass through a tunnel, the tunnel's made up of a ring of bones, a ligament over the top and various muscles and other structures, tendons, that pass through that space. And if for some reason the space is reduced, whether that's due to the wrist being very small in a petite lady or the muscles being very strong in a bricklayer, or someone who's got inflammation in the tendons in the joints then the reduction in the space of the wrist may be significant enough to cause pressure on the nerve. Symptoms then come on, typically a patient will wake up at night with them, the worse it gets the more persistent the symptoms are, very often the pain and the pins and needles will then develop into numbness, sometimes you can see wasting in the ball of the thumb. So these are all signs that the nerve is trapped and we can do a very, very simple examination by pressing on the wrist and pushing the fingers up so that the wrist is bent forwards and if the symptoms then develop then that's QED.
ACTUALITY
Right, if you stick your hand up on the table for me, that's okay. Come just a bit closer to me. That's it. You don't have to watch - I never insist. So what we're going to do is use the smallest needle that we can use, no anaesthetic, because otherwise if you catch the nerve you can damage it. Little needle prick coming. Now if you feel a very sharp electric shock into your fingers you must let me know because I must move the needle. Just coming now. Alright?
That's fine.
No problem?
No.
And we shall inject. Now what you may find is because we're putting some fluid into a very small space that your fingers start to tingle. And if they do that doesn't matter because that will go off. Stick your finger on that, all finished.
That wasn't too bad.
And this is the most difficult part of the procedure is getting the backing off the plaster. Voila!
ENDS
Back to main page
|
ÌýPrint this page
