Telemedicine for evaluation and treatment of pain is live and ready to go. In this video Siddharth Tambar MD discusses Tele Physical Therapy and how it works with Keith Travers from Fyzical Therapy & Balance Centers.
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In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses Telemedicine, physical therapy, arthritis, tendinitis.
Rheumatoid arthritis and osteoarthritis are very different types of arthritic conditions. This video will answer for you what is rheumatoid arthritis and what is osteoarthritis.
Rheumatoid arthritis and osteoarthritis can both be very significant, debilitating conditions that can cause significant pain and reduction in your physical ability. They’re different however. They’re different in what causes them. They’re different in how they’re expressed, the kind of symptoms that you have, and they’re different in how you treat them. It’s important to understand the difference because a correct diagnosis will get you on the path to a correct treatment program, which can then get you better in terms of your pain and get you back to doing the things that are important to you with the people that you care about. Rheumatoid arthritis is a type of inflammatory arthritis. What that means is that your immune system is being overly active and causing inflammation in the joints. How that works is your immune system, which is normally meant to defend your body against bacteria and viruses, in some cases can accidentally start to recognize your own body as foreign and then start causing inflammation by attacking those structures. In the case of rheumatoid arthritis your immune system recognizes your own joints and tendons and sometimes other organs as well. Basically attacks them, causes inflammation, which then causes pain, dysfunction, and destruction to the joints. Osteoarthritis on the other hand is a type of degenerative arthritis. What that means is that you have chronic instability in the joint which then leads to stress on the bone and the joint itself, which is what causes that degeneration to occur. You can get a mild component of inflammation in the joint but that’s not because the immune system is being overly active like you see in rheumatoid arthritis. Rather it’s because in osteoarthritis, you have chronic instability in the joint which leads to that chronic inflammation and stress on that structure. There are a number of other differences between these conditions as well. Such as Rheumatoid arthritis is a systemic condition while osteoarthritis is a local condition. That means is in rheumatoid arthritis you can also find other types of symptoms that are generally affecting the rest of the body. For example that condition can also present with fevers, weight loss, severe fatigue as well. In addition you can also have other organ systems that can be involved as well. Since it’s a condition where the immune system is overly active that overactivity can also affect other areas such as inflammation in the eyes, inflammation in the skin, amongst other areas as well. That’s not something you would expect to see in osteoarthritis. Stiffness is another interesting symptom that you can see in a lot of people that have arthritis in general. But it’s different in terms of how it presents in rheumatoid arthritis versus osteoarthritis. In general the stiffness that you see in osteoarthritis will last less than one hour. On the other hand the stiffness that you see in rheumatoid arthritis can last for several hours if not the whole day. That’s different because the systemic nature of rheumatoid arthritis leads to that overall feeling of stiffness that can be very profound and last for a very long period of time. Another interesting difference between these conditions is the effect of activity on the level of pain. In osteoarthritis, because the condition is caused by instability and stress on the joint, activity will make that condition feel worse. It’ll make the pain feel worse. On the other hand in rheumatoid arthritis activity generally actually will make the pain and the symptoms feel better. The reverse when it comes to rest. Rest in the setting of rheumatoid arthritis very much significantly makes that feel worse. While on the other hand in osteoarthritis rest and activity minimization generally makes the joint pain feel better. Swelling in the joint is another similar factor that you can see in all arthritis patients, but can be a bit different in rheumatoid arthritis versus osteoarthritis. In osteoarthritis you don’t always see swelling in the joints, sometimes you do. On the other hand in rheumatoid arthritis swelling is a hallmark and defining factor with how this condition presents. In addition because it’s severe inflammation the joint itself will actually feel warm. It can also look red in an inflamed state. You don’t see that level of inflammation in osteoarthritis. It tends to be a milder level of inflammation and swelling while in rheumatoid arthritis it’s significantly more inflamed and aggressive in that regard. Another important aspect to understand is that it’s possible to have a primary rheumatoid arthritis and then secondarily you also develop osteoarthritis. In that sort of condition the active inflammation may be under control, but you may have developed some chronic damage and some chronic secondary osteoarthritis. An appropriately trained musculoskeletal health and wellness physician will be able to differentiate between the two and should be able to get you on the right path for both the inflammatory component and for the wear and tear osteoarthritis component as well. Now that you understand the difference between rheumatoid arthritis and osteoarthritis, you can get yourself on the right track to treat your musculoskeletal condition in the right way, the ideal way, to get the best result possible. If you’d like to learn more about those treatment options, check out my additional content. If you found this information useful and interesting consider subscribing to my channel, subscribe to my email list. I hope this was helpful. Have a good day and live well, bye bye.
I see quite a few inflammatory arthritis patients as part of my practice. That includes patients with inflammatory back pain. Of course many of my patients also have degenerative arthritis related lower back pain. This video is meant to help people understand the difference between inflammatory and degenerative arthritis related back pain, diagnostic differences, and treatment differences.
One of the most common musculoskeletal issues that we see in our society is back pain. I want to discuss how to differentiate between inflammatory back pain and degenerative back pain. It’s important for a number of reasons. Back pain is a humongous problem in our society. Roughly 75% of people in Western societies will have some version of back pain at some point in their life. It’s important to differentiate between inflammatory versus degenerative back pain because the etiologies are very different, the treatments are very different, and even the prognosis can be different as well. From a cost standpoint, if we can make a correct diagnosis and get an individual on the right treatment path and algorithm, we have a better chance of bending the cost curve, rather than spending time on the wrong treatments.
There are very distinct diagnoses that cause inflammatory back pain versus degenerative back pain. The classic diagnoses for inflammatory back pain include ankylosing spondylitis, inflammatory bowel disease related sacroiliitis lower back pain as well as psoriatic arthritis. There’s a number of other conditions, but those are really your core three inflammatory back pain conditions. The cause of inflammatory back pain is related to autoimmune conditions meaning the individual’s immune system is miscommunicating, recognizing it’s own joints and other organs frequently as foreign and basically attacking them. This then leads to inflammation which then results in pain and damage, restriction of range of motion and eventually functional disability.
The prevalence of inflammatory back pain is still relatively less common, essentially ankylosing spondylitis makes up less then one percent of the population. Inflammatory bowel disease related back pain, again, less than one percent. Psoriatic arthritis is a bit more common, psoriatic arthritis affecting the lower back is less common however. So all told, around two percent of the population could have inflammatory back pain.
The presentation is really key here. The presentation for inflammatory back pain is pain that is very definitively worst first thing in the morning, worse with rest, and generally better with low impact physical activity. So a classic description would be someone with significant stiffness first thing in the morning, lasting for more than one hour. That’s fairly classic for inflammatory back pain. It will also be pain that will wake them up at nighttime or wake them up very early in the morning with pain.
Examination findings in an early stage might be limited, but the classic findings would be tenderness over the sacroiliac joints. Also there is a maneuver called a FABER’s test where essentially you externally rotate the hip and it creates pain in the sacroiliac joint area. There’s also the Schober’s test where you can actually get a sense for range of motion in the sacrum and sacroiliac joints to see if there is any restriction. Typically you see that as this condition progresses, not so much early on.
The diagnoses for degenerative back pain are the ones people are more familiar with. This includes facet joint osteoarthritis, strain of the soft tissues including ligaments or muscles in the lower back, a pinched nerve in the lower back from foraminal stenosis and spinal stenosis. These are all very interrelated conditions that can occur primarily after a prior injury or chronic stress that then leads to chronic instability, due to weakness of some of the soft tissue structures, which then eventually leads to a progressive degenerative process including stressing the facet joints, the nerves and some of the other soft tissue structures. The cause is very clearly instability or trauma that progresses. The lifetime prevalence of degenerative back pain is up 70 to 75% of our population at some point of their lifetime.
Presentation is classically pain that is worse with certain activities depending on the condition. Different types of motion will make the pain worse and rest generally makes it better. So in general, degenerative back pain will be very definitively worse with activity and better first thing in the morning and with rest. Examination findings will vary, however, frequently provocative maneuvers can make things worse as well as significant tenderness and findings of subtle instability based on how you position an individual to see if it stresses the back or not.
In terms of some of the other objective findings, labs in inflammatory back pain can sometimes be abnormal, meaning sometimes your inflammatory parameters like sedimentation rate and C-reactive protein can be elevated. This is not true in all inflammatory back pain patients, but in some it can be found. The classic antibody, the HLA-B27 test, can be positive in some people. Again, not 100% and so the labs should not determine a diagnosis of inflammatory back pain, but they can help to confirm.
Of course in degenerative back pain, abnormal labs are really not an issue. If someone has a very high elevated inflammatory parameter and degenerative back pain, consider other potential etiologies as well. As an example, bone metastases if someone has cancer or a history of cancer, or infectious cause should be considered if a high level of inflammation is found on labs.
In contrast imaging is key here. In inflammatory back pain, the classic imaging used to be X-rays, in which someone who has progressive disease over years develops fusion of the spine. This does not occur early on. What you will see early on, however, is inflammation in the sacroiliac joints. This is really best seen under MRI where you can see bone marrow edema in the sacroiliac joints which is called sacroiliitis. There is a question in the medical literature of imaging negative inflammatory arthritis, which is a challenging diagnosis to make strictly based on symptoms and lack of other findings.
Degenerative back pain, of course, is very well understood in terms of what you will see on imaging. Whether that is arthritic changes in the facet joints or slight shifting of the vertebra indicative of chronic instability these can be seen on xray. Some other things you can see on MRI would include foraminal stenosis, where the nerves coming out of the spine are pinched. In addition, a really subtle finding, not always described by radiology would also be multifidus muscle atrophy in a degenerative spine, which is an indication of a slight pinched nerve in the lower back as well.
It’s important to note that inflammatory back pain patients are just as common, probably even more common, to also develop degenerative back pain issues as well. So frequently, in inflammatory back pain patients, you’ll find that they also have findings of degenerative disc disease or degenerative joint disease. It’s important to recognize that a person’s back pain, if they have something like ankylosing spondylitis, a component of it might be inflammatory, but a component may also be degenerative and should be treated appropriately as well.
First line treatment will be very similar with both of these conditions, namely very intensive and purposeful core strengthening, hip strengthening, working on range of motion, doing everything you can to help support the areas that are stressed, chronically inflamed, and unstable. In addition, utilizing certain over the counter supplements can be helpful as well. Glucosamine chondroitin in general can help 50% of people with degenerative. Omega-3 and tumeric/curcumin are low level anti-inflammatory supplements that are low risk, can help with pain in people with arthritis, and are also worthwhile trying. If the over-the-counter supplements can minimize the utilization of narcotics and chronic anti-inflammatory medications, that is worth trying as well. If that’s not adequate, then the escalation of treatment will differ between these two conditions.
For inflammatory back pain, treatment escalation typically utilizes some kind of medication like a biologic medication to help control the systemic inflammation that’s driving this condition. That is certainly worthwhile trying. If a person has really just very inflamed one sacroiliac joint, it can be worthwhile trying an injection, whether that’s an injection of a steroid or with alpha-2-macroglobulin, which is an autologous biologic from a person’s own blood.
Escalating treatment in degenerative back pain generally should be considered with injections if they’re failing conservative management. Rather than utilizing steroid injections, some other options would include, utilizing a person’s own blood and platelets, which can help to strengthen the soft tissue structures, treat the arthritic facet joints, and even reduce the inflammation and pain from a nerve if that has been pinched as well.
So the escalation of treatment is different depending on the etiology of the back pain. That is key because if you want to put an individual down the right path for treatment, you want to make sure you have the right diagnosis first and then appropriately escalate treatment in the correct way based on the actual etiology of the condition.