What is an antalgic (painful) gait? Let the sensors have their say.

Falsehood flies, and the truth comes limping after it, so that when men come to be undeceived, it is too late; the jest is over, and the tale hath had his effect.

Jonathan Swift

One of the things we are taught as medical students and doctors is how to recognise various types of gait. This is an imperfect art, particularly for the less observant among us! I remember telling someone that his painful, slow gait was due to his hip arthritis only to see that after successful hip surgery his gait was still just as slow. It turned out that he also had early Parkinson’s disease, and I had missed the early signs of his neurological condition. And if you think you are immune to such lapses of judgement, perhaps you – like me – were fooled by Virgil’s limp in the film ‘Usual Suspects‘ (one of my favourite cinematic endings).

One of the most basic gaits to recognise is someone walking with a single painful hip joint. This is commonly called the ‘antalgic’ gait, and is characterised by someone spending less time putting their weight on the painful leg compared to the other leg.

When surgeons replace hip joints they hope to relieve pain – but they also need to restore a normal gait pattern. Although pain relief happens quickly in most patients, restoration of normal function is more gradual. The best way to study this scientifically is to apply movement sensors to the limbs – accelerometers or more sophisticated triple component inertial movement sensors (IMUs). A 1999 paper by Aminian et al examined this question in a group of patients who had hip surgery for arthritis in a single hip. It turned out that simply measuring gait speed didn’t show the improvements as clearly as the ‘assymetry of double stance’ time. This is the difference between the time you spend on the bad leg vs. the good leg – i.e a scientific measure of the ‘antalgic gait’.

Using sensors to detect improvements in gait after hip replacement

Sensor detection of changes in assymetric (antalgic) gait after hip replacement surgery

In the top left (pre-op) picture you can see a big spread from the identical line (diagonal) – and then as we move to the bottom right (9 months post-op) you can see that the difference between double-stance time on either leg has narrowed except in one patient (circled in the image below).

Sensor detects Gait in Hip Osteoarthritis after surgery

Sensor detection of changes in assymetric (antalgic) gait after hip replacement surgery: spot the one exception!

Now, as it happens, this poor chap still had pain in his hip. I guess you could have found that out a lot easier just by asking him, but the point is that we’ve found that out through a very objective test. Looking at the trace from the motion sensors, an analyst miles away with no video footage could ‘diagnose’ that he still had an antalgic gait. The same sort of analytics can pick out differences that are just not obvious even to the practised eye.

This is just a simple example taken from what is a rapidly expanding area of the scientific literature – how to accurately measure and define human movement. In this case, the use of movement sensors provided objective evidence of improvements we could have discerned by observing the patient’s gait or by asking them to complete a questionnaire. However, movement analysis can be used to perform much more complex assessments that should help the therapist understand why our patients haven’t quite returned to full function at work or at home. Physiotherapists, sports scientists and experts in biomechanics/computer analytics are leading the way. Watch this space!

Reference: Arminian K et al Med Biol Eng Comput 1999 37 686-691

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What is a disease flare in RA? A medical student’s perspective

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Introduction: This guest article was written by Anca Smyth, who is currently a fourth year medical student at Queen’s University Belfast. She wrote an essay during her ‘special study component’ three week attachment in Altnagelvin hospital and later submitted it to the Irish Society for Rheumatology. Anca not only won the prestigious Bernard Connor Prize at the 2016 conference, but she was invited to present her paper to the Society. So congratulations to Anca and best wishes for the future! – Philip Gardiner

“When it comes to our health most of us are guilty of thinking that we are invincible. Imagine waking up one morning with excruciating pain, having stiff, swollen joints and weakness which markedly interfere with your ability to carry out the normal activities of daily living. To a rheumatoid arthritis (RA) sufferer such debilitating symptoms may constitute ‘a significant disease flare’, an episodic exacerbation of this chronic, symmetrical, small joint inflammatory condition. Or does it?

Unlike the ACR/EULAR classification criteria for RA [1] which is based on objective measurements of serological parameters, acute phase reactants, numbers and sites of swollen or tender joints and symptom duration, there has been no standard definition of what constitutes a RA flare or how it can be objectively assessed and classified according to severity. Apart from measuring the efficacy and safety of novel pharmacological agents used in the treatment of RA by means of randomised controlled clinical trials, a valid definition and classification of a flare would prove to be an invaluable tool in guiding clinical care and monitoring disease outcome.

When a patient is experiencing a flare, a significant increase in the disease activity so that it requires a change of treatment [2], there is often discrepancy in the interpretation of the severity of signs and symptoms between the doctor and the patient [3]. This may lead to inappropriate treatment, patient dissatisfaction and non-adherence to therapeutic interventions [4, 5]. Such discordance is due to the heterogeneous nature of the patient experience during this acute episode, which not only affects objectively measured clinical parameters but also generates self-reported symptoms such as pain, weakness, sleeplessness or fatigue [6, 7]. From the patient’s perspective the experience of a flare is also about functional impairment, disability and social participation [8, 9] which interfere with the patient’s quality of life and psychological well-being.

There is also variation between RA sufferers regarding what constitutes a significant disease flare. Reasons for this include the fact that patients report the severity of a flare according to their baseline disease activity and previous experiences with the disease [10], thus what seems a severe flare to an early RA patient may be classified as a normal fluctuation of disease activity by someone who has been living with this disease for an extended period of time. Additional factors in defining a significant flare include the level of a patient’s tolerance to worsening of signs and symptoms, health beliefs and coping skills [11, 12].

Current methods of assessing RA patients include measuring the disease activity in 28 joints using the DAS28 score and evaluating physical disability by means of a Health Assessment Questionnaire (HAQ28) and patient’s global health status by employing a 10cm Visual Analogue Scale (VAS).  However, none of these approaches are without flaws. Two of the main determinants of the patient’s global health are pain and fatigue [13], subjective symptoms which cannot be measured accurately and which are influenced by many factors including mental health status and co-morbidities [14]. Considering the ACR/EULAR disease remission criteria of a score of 1 or less on the patient’s global assessment scale of 0-10 such targets may be difficult to achieve accounting for the fact that many RA patients suffer from depression [15] or chronic pain syndrome [16].

The HAQ tool, limited by its ‘ceiling effect’ due to lack of adequate sensitivity in detecting a worsening of disability towards its upper limits or assessing lower limb function [17] does not accurately evaluate the severity of a RA flare. The DAS 28 score, a weighted composite of the number of swollen joints, level of the inflammatory marker ESR (erythrocyte sedimentation rate) and patient global assessment score is currently employed in clinical practice to classify disease activity, guide therapeutic treatment and function as an outcome measure in the treat-to-target approach [18]. Limitations of this approach include a misleadingly low DAS28 score if the flare predominantly affects the patient’s feet, which are not included in the DAS28 joint count, or if it is concentrated on a single joint, causing debilitating pain and rendering the patient unable to work. Conversely, a high DAS28 score based on a large number of swollen joints in the absence of pain or elevated ESR may initiate an unnecessary escalation in therapeutic treatment [19]. Some studies have used the inverse of the improvement criteria based on the DAS28 score to assess the severity of a flare but such a correlation seems inappropriate [20].

Given the complexity of patient experiences and heterogeneity of assessment tools that affect the interpretation of a significant disease flare, there is no ‘one size fits all’ approach to monitoring a flare. In an era of demedicalisation, there is an emphasis on treating the individual in the community, with medical care providers offering evidence based patient education and counselling regarding management of flares or side-effects of medication in the form of leaflets, telephone consultation with various members of the multi-disciplinary team or telecare services for people to report and be advised on their flares [21]. Such a model of care not only promotes self-efficacy and helps achieve an internal locus of control but it also increases accessibility and reduces travelling time for patients in the rural communities.

Since RA is a chronic condition, the patient may be the expert in monitoring their condition and self-management of a flare by means of non-pharmacological (such as exercise, bed rests, applying ice or heat packs or via complementary and alternative therapies) or pharmacological interventions (by increasing the dose of glucocorticoids, analgesics or non steroidal anti-inflammatory medication alongside a fixed-dose of disease modifying anti-rheumatic drugs) seems to be the approach employed by most RA sufferers [22]. There are times, however, when self-management of a flare is ineffective and the patient decides to seek medical help. Although the threshold at which such a decision is made is unknown, the doctor must adopt a holistic approach in assessing the patient and based on shared-decision making determine an appropriate change in treatment.

In conclusion, the concept of a significant disease flare in RA is complex, non-standardised and its interpretation depends on interplay between a patient’s physical and psychological parameters, previous disease experience and health beliefs. Monitoring of this acute episode should occur in the community, with health professionals providing ongoing patient education and counselling and facilitating timely review by the clinician when the patient seeks medical help.”

References

[1]. Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO, Birnbaum NS, Burnester GR et al. 2010 Rheumatoid Arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis and Rheumatism 2010; 62(9): 2569-2581.

[2]. Alten R, Pohl C, Choy EH, Christensen R, Furst DE, Hewlett SE, Leong A, May JE, Sanderson TC, Strand V, Woodworth TG and Bingham CO. Developing a Construct to Evaluate Flares in Rheumatoid Arthritis: A Conceptual Report of the OMERACT RA Flare Definition Working Group

[3]. Studenic P, Radner H, Smolen JS and Aletaha D. Discrepancies Between Patients and Physicians in Their Perceptions of Rheumatoid Arthritis Disease Activity. Arthritis and Rheumatism 2012; 64(9): 2814-2823.

[4]. Van den Bemt BJF, van den Hoogen FHJ, Benraad B, Hekster YA, van Riel PLC, van Lankveld W. Adherence Rates and Associations with Nonadherence in Patients with Rheumatoid Arthritis Using Disease Modifying Antirheumatic Drugs. The journal of Rheumatology 2009; 36: 2164-2170.

[5]. Matteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Medical Care 2004; 42: 200-209.

[6]. van Tuyl LHD and Boers M. Patient’s Global Assessment of Disease Activity: What Are We Measuring? Arthritis and Rheumatism 2012; 64(9): 2811–2813.

[7]. Kalyoncu U, Dougados M, Daures JP, Gossec L. Reporting of patient-reported outcomes in recent trials in rheumatoid arthritis: a systematic literature review. Annals of the Rheumatic Diseases 2009; 68: 183–190.

[8]. Benka J, Nagyova I, Rosenberger J, Marcejova Z, Lazurova I, van der Klink JL, Groothoff JW and van DijkJP. Social participation in early and established rheumatoid arthritis patients. Disability and Rehabilitation 2015; 19: 1-8.
[9]. Sverker A, Ostlund G, Thyberg I, Valtersson E and Bjork M. Dilemmas of participation in everyday life in early rheumatoid arthritis: a qualitative interview study. Disability and Rehabilitation 2015; 37(14): 1251-1259.
[10]. Seror R, Tubach F, Baron G, Guillemin F, Ravaud P. Measure of function in rheumatoid arthritis: individualised or classical scales? Annals of the Rheumatic Diseases. 2010; 69(1): 97–101.

[11]. Rohekar G and Pope J. Test-Retest Reliability of Patient Global Assessment and Physician Global Assessment in Rheumatoid Arthritis. The Journal of Rheumatology 2015; 36(10): 2178-2182.

[12]. Sanderson TC, Hewlett SE, Flurey C, Dures E, Richards P and Kirwan JR. The impact triad (severity, importance, self-management) as a method of enhancing measurement of personal life impact of rheumatoid diseases. The Journal of Rheumatology 2011; 38: 191-194.

[13]. Bartlett SJ, Bykerk VP, Cooksey R, Choy EH, Alten R, Christensen R, Furst DE et al.  Feasibility and Domain Validation of Rheumatoid Arthritis Flare Core Domain Set: Report of the OMERACT 2014 RA Flare Group Plenary. The Journal of Rheumatology 2015; 42(11): 2185-2189.

[14]. Barton JL, Imboden J, Graf J, Glidden D, Yelin EH and Shillinger D. Patient-Physician Discordance in Assessments of Global Disease Severity in Rheumatoid Arthritis. Arthritis Care and Research 2010; 62(6): 857–864.

[15]. Khan NA, Spencer HJ, Abda E, Aggarwal A, Alten R and Ancuta C. Determinants of discordance in patients’ and physicians’ rating of rheumatoid arthritis disease activity. Arthritis Care Research 2012; 64: 206–14.

[16]. Wolfe F, Michaud K. Severe rheumatoid arthritis (RA), worse outcomes, comorbid illness, and sociodemographic disadvantage characterize RA patients with fibromyalgia. J Rheumatol 2004; 31: 695–700.

[17]. Gardiner PV, Sykes HR, Hassey GA and Walker DJ. An evaluation of the health assessment questionnaire in long term longitudinal follow-up of disability in Rheumatoid Arthritis. British Journal of Rheumatology 1993; 32: 724-728.
[18]. Ward MM, Guthrie LC and Alba MI. Clinically important changes in individual and composite measures of rheumatoid arthritis activity: thresholds applicable in clinical trials. Annals of the Rheumatic Diseases 2013; 1: 205079.
[19]. Pincus T, Yazici Y and Sokka T. Quantitative measures of rheumatic diseases for clinical research versus standard clinical care: differences, advances and limitations. Best Practice and Research Clinical Rheumatology 2007; 21(4): 601-628.

[20]. Leeb BF, Sautner J, Leeb BA, Fassl C, Rintelen B. Lack of agreement between patients’ and physicians’ perspectives of rheumatoid arthritis disease activity changes. Scandinavian Journal of Rheumatology 2006; 35: 441-446.

[21]. National Institute for Health and Care Excellence. Commissioning for people with rheumatoid arthritis. NICE commissioning guides [CMG51], 2013.

[22]. Hewlett S, Sanderson T, May J, Alten R, Bingham CO, Cross M, March L, Pohl C, Woodworth T and Bartlett SJ. ‘I’m hurting, I want to kill myself’: rheumatoid arthritis flare is more than a joint count- an international patient perspective on flare where medical help is sought. Rheumatology 2012; 51:69-76.

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Catching the Wave… Motivating people to get active and exercise

It has been said that ‘inactivity is the new smoking’, and there is no doubt about the medical problems caused by lack of physical activity. This is a growing problem, and one that is particularly difficult for many people with musculoskeletal diseases to deal with.

Historically, there used to be a feeling among doctors that exercise helped inflammation. Once upon a time, people with Ankylosing Spondylitis were put in plaster of paris spinal casts and patients with Rheumatoid arthritis were made to rest in bed for weeks upon weeks. Although the modern Rheumatologist would regard these practices are seriously misguided, it could be argued that our failure to actively promote exercise is also a failure to follow the evidence. If it affects both general and musculoskeletal health we should really be doing more to promote change.

Before the birth of modern Rheumatology, Physical Rehabilitation skills were very much part of the training of a doctor who treated patients with arthritis. Modern training leads us to regard ‘silos’ of physical rehabilitation, medical therapy and surgical therapy as mutually exclusive. We do refer to our physiotherapy colleagues, but is it possible that some patients need a more committed approach from their doctor to get them started? It is clear that a doctor’s advice about smoking is still reasonably effective. And for some patients who just need more general physical activity, perhaps we need to be finding ways for our patients to get involved in local Tai Chi classes, Pool exercise sessions and other ‘Gym Voucher’ schemes to help get people started. The 3 month ‘Gym Voucher’ incentive scheme funded by Public Health in this area is particularly imaginative and effective. The local gym instructors funded to lead these programmes can be a great asset.

From many years of experience in giving advice it has gradually dawned on me that for many people, major behavioural change is not easy. We’ve all seen the person who has just had a heart attack or developed cancer throw their 50cig./day habit in the bin without a second thought. Or the person who has been told by the orthopaedic surgeon that if they don’t lose X amount of weight they won’t get their knee replacement. For some patient it might be getting a dog and starting to walk regularly again. I like to think of this as ‘catching the right wave’ – waiting for a strong motivational push to get them going.

Catching the right wave

Catching the right wave

 

Clearly Staged Graduated programmes can be very effective. ‘Couch to 5k’ is a great example of this. When we are dealing with people with arthritis we need to be sensitive to the fact that their pain and stiffness will not help them to get started.

couch to 5k

Using technology to motivate. There are now several studies which have shown that simple pedometer devices can be used to help motivate adherence to increased physical activity. These studies usually employ some sort of ‘target’, sometimes using social sharing of our achievements as a further motivator. There are many successful apps such as ‘Runtastic‘ that are helping athletes to improve: perhaps we need more help at the less active end of the scale!

Doctors in Sweden are all trained in the art of issuing an Exercise Prescription. The ‘Doctor’s Handbook’ from Hong Kong (in English) is an excellent booklet which should be required reading for every medical student and doctor.

One useful mnemonic to use when writing an exercise prescription is FITT-VP

—Frequency – sessions per day or week
—Intensity – rate of energy expenditure or force during resistance exercise
—Time (Duration)
—Types of Exercise (Aerobic, Muscle-Strengthening, Stretching, Neuromuscular activity
—Volume – total amount
Progression (advancement)

I would be interested to hear what you think. What motivators work for you? Perhaps you feel that this is not something rheumatologists have time to talk about. Should we just leave it to the physiotherapists? There is no doubt that the latter will give expert advice and this is very necessary with complex rehabilitation programmes, but simple generic advice should be within our remit.

 

 

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Recommended links from ACR14 Blogging Bootcamp

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These are a few of my favourite blogs… Most of these examples were mentioned in my ‘Blogging Bootcamp’ talk at the ACR 2014 meeting in Boston but sadly there was no time to go into any detail. I hope you enjoy exploring some of these blogs which I think illustrate why rheumatologists should consider blogging. I am sure I have left out many masterpieces, and if you have any other recommendations for the rheumatology ‘Blogging Hall of Fame’, please let me know! Apologies to all those that I’ve left out. I am not aware of any female rheumatology bloggers out there and actively blogging, but if there are please let us know. Paul Sufka’s blog

Ronan Kavanagh’s blog

Carlo Caballero’s Meta Blog

Irwin Lim’s Blog

Other Rheumatology Blogs

Other recommended medical blogs

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Blogging References for ACR 2014 Social Media Bootcamp

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Francis Berenbaum The social (media) side to rheumatology Nature Reviews Rheumatology 2014(10):314–318 This is an excellent general introduction to social media for rheumatologists

Brian S McGowan, Molly Wasko, Bryan Steven Vartabedian, Robert S Miller, Desirae D Freiherr, Maziar Abdolrasulnia. Understanding the Factors That Influence the Adoption and Meaningful Use of Social Media by Physicians to Share Medical Information J Med Internet Res. 2012 Sep 24;14(5):e117

Cheston, Christine C.; Flickinger, Tabor E.; Chisolm, Margaret S. Social Media Use in Medical Education: A Systematic Review Acad Med 2013:88;893-90

S. Ryan Greysen, MD, MHS, MA; David Johnson, MA; Terry Kind, MD, MPH; Katherine C. Chretien, MD; Cary P. Gross, MD, MPH; Aaron Young, PhD; and Humayun J.  Chaudhry, DO, MS, SM Online Professionalism Investigations by State Medical Boards: First, Do No Harm Ann Intern Med. 2013;158(2):124-130

Bahner DP1, Adkins EJ, Hughes D, Barrie M, Boulger CT, Royall NA. Integrated medical school ultrasound: development of an ultrasound vertical curriculum. Crit Ultrasound J. 2013 Jul 2;5(1):6. doi: 10.1186/2036-7902-5-6

Bahner DP1, Adkins E, Patel N, Donley C, Nagel R, Kman NE. How we use social media to supplement a novel curriculum in medical education. Med Teach. 2012;34(6):439-44

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Social Media Guidelines

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A quick list to Social Media Guidelines for Medics: take your pick!

If you are new to Social Media I hope you’ll be made to feel welcome among the rheumatology band of bloggers! Using Social media can be rewarding for physicians and health professionals, but occasionally we can make mistakes! When mistakes are made in social media they are much more public than you might think, and unfortunately when this happens someone may spot it and take great delight in spreading it. If that does happen, take care how you respond. If you respond with courtesy and humility others are more likely to take your side in the debate. On the other hand if you see something that a colleague is doing that you think is ‘sailing close to the wind’ send them a private message and politely warn them of your concerns.
Useful Blog articles:
Social Media highway code RCGP (UK)
The Code (please see full text link for more detailed advice)

1. Be aware of the image you present online and manage this proactively
2. Recognise that the personal and professional can’t always be separated
3. Engage with the public but be cautious of giving personal advice
4. Respect the privacy of all patients, especially the vulnerable
5. Show your human side, but maintain professional boundaries
6. Contribute your expertise, insights and experience
7. Treat others with consideration, politeness and respect
8. Remember that other people may be watching you
9. Support your colleagues and intervene when necessary
10. Test out innovative ideas, learn from mistakes – and have fun!

Australian and NZ Medical Associations Social Media and the Medical Profession

This is an excellent document, and gives some great examples of borderline cases that might have caught us out.

Example 1:

You are working in a rural hospital and make a comment on a social networking site about an adverse outcome for one of your patients. You are careful not to name the patient or the hospital. However, you mentioned the name of the hospital you are working at in a post last week. A cousin of the patient searches the internet for the hospital’s name in order to find its contact phone number. In the search results, the patient’s cousin is presented with your posting mentioning the hospital. The cousin then sees the subsequent posting regarding the adverse outcome involving the
patient

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The Farmer, the Camel and the Cow with a Bad attitude.

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farmer sickleFarmers in Ireland are bred tough. They don’t come in to see their Rheumatologist with a bit of muscular pain. They don’t come in with a few Heberden’s nodes. When they do arthritis, they do it properly.

The typical encounter with a farmer would be a chap who hobbles in ruefully, asking politely ‘Sorry to bother you doctor, but is there anything you can do for my knees?’. I usually rub my beard sagely and say –  ‘Hmm, let’s have a look at your hips, then’. Chances are that his knees are fine but his hips are shot to pieces. By the time they stumble into clinic you can guarantee that their hip joints are done for. It never ceases to amaze me that someone can develop severe osteoarthritis (OA) of the hips without ever having experienced pain in the hips or groin. And by the way, I still don’t know why OA of the hips is an occupational hazard for farmers. You see people from other heavy occupations who don’t seem to have the same problem. Perhaps it is something to do with the heavy work most of them did on the farm as young teenagers.

Another common example is the farmer with a seemingly straightforward shoulder capsulitis or tendon rupture. When you get down to the story, however, you find – for instance – that he has been dragged halfway up the field hanging on to the back of a tractor driven away by his 12 year old son who had found the accelerator instead of the brake. Perhaps the most memorable ‘rheumatological case’ was a farmer who hobbled painfully into clinic leaning precariously on two walking sticks with the worst knee joints I’ve ever seen. The valgus deformity on each side was at least 45 degrees and the knees had rubbed together with such violence that he had developed huge suppurating rheumatoid nodules.With each step he had to swing from one side to the other using his stick a bit like a pole vault. When I got him up onto the couch his legs seemed to be connected to the thigh by no more than half an ACL. How this man had continued working on the farm for the previous 5 years I will never know. To my amazement, he recovered well after his knees were replaced and he is probably still working on his farm to this day.

camelAnyway, I digress and really must return to the subject of my story. I could barely contain my excitement when a farmer come in to clinic and showed off his impressive knee swellings. I immediately recognised this as the little known ‘Bactrian camel’ sign. The ‘double hump’ is a dead giveaway. Given the usual yarns, I was not surprised when he told me the story of how this all started with being kicked on the shin by a mischievous young cow. It’s never something mundane like an ingrown toenail. For a farmer this is a regular hazard – but his story was tame compared to one of my patients recently who had barely escaped with his life after having been trampled over by half a dozen stampeding cows. Anyway, our farmer had developed a cellulitis in his ankle which was eventually treated in the local hospital. I say eventually because it is highly unlikely that a farmer would go to see the doctor when there was only a little redness around a scratch. He recounted how the swellings had started after the kick and now they were getting a bit painful. When he took his trousers off I was taken aback. The swelling on top of his right kneecap was like a six inch ‘bap’, and just below that he had a second fluctuant swelling above the tibial tuberosity. Both the pre-patellar and infra-patellar bursae were swollen and clearly displayed in all their glory. The profile was unmistakably that of a double hump-backed or Bantian camel. I wish I had taken a photograph for posterity. A large amount of clear fluid was aspirated from each swelling and steroid injected, to the patient’s evident relief.

As an educational aside, it is well known that infected bursitis often occurs in association with cellulitis, and a good long course of antibiotics is called for. However, this is not the first time I have seen ‘post-infective’ bursitis persisting long after the infection has cleared up. There isn’t a strong evidence base when treating bursitis, but in my experience a small dose of steroid can do the trick quite effectively. Some experts counsel weeks of inactivity, but in my experience if you tell a farmer to rest it is likely that you will be wasting your breath.

The old Irish farmer belongs to a stoical and dependable tradition, in touch with the land and in command of their over-worked but hardy frames. But are they a dying breed? I now see so many of them working on well into their 80s because their children have moved away seeking greener pastures and easier lifestyles. As a rheumatologist who sometimes tends to their ‘war wounds’, I salute them.

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Were Irish ‘Sweating houses’ used to treat Arthritis?

I’m not much of a student of history, but I’m intrigued by glimpses into the way medicine was practised a few centuries ago. I guess there would be a few people who would be amused to hear that physicians in Ireland were widely known as ‘leeches‘ – presumably because of their expertise in the ancient Galenic practice of blood letting rather than their avaricious nature! The ancient physician went about on horseback carrying around a ‘fer bolg’ or medicine bag, full of herbal remedies.

Among the few remaining physical traces of the physician’s work are the stone ‘sweating houses’ known in Gaelic as Tigh ‘n alluis [Teenollish]. These small one-man huts were built with small entrance portals that people would have had to crawl through. They were dotted around Ireland, often in quite remote rural areas. Quite a few of them are still to be found in remote fields, but I don’t think any have been used for quite some time!

imageA fire would be lit in the hearth inside the sweating house  – using a cart-load of turf – and allowed to burn out leaving the stones hot for the sweating session the following day.

 

A great fire of turf was kindled inside till the house became heated like an oven; after which the embers were swept out; and vapour was produced by throwing water on the hot stones. Then the person, wrapping himself in a blanket, crept in and sat on a bench of sods, after which the door was closed up. He remained there an hour or so till he was in a profuse sweat; and then creeping out, plunge right into the cold water, after emerging from which he was well rubbed till he became warm. After several baths at intervals of some days he usually got cured of Rheumatism

So apparently this sort of treatment was prescribed for people with rheumatism. Sadly we don’t know if there was a secret therapeutic ingredient (although there has been plenty of speculation). I can’t imagine that many of my patients would agree to trudge up the hill, undress and crawl through a tiny entrance into a very rough sauna before struggling out and jumping in the local pond! My ancestors were clearly made of hardy stuff!

sauna_cabinI got to thinking about whether or not there had been some studies that have looked at sauna treatment for rheumatoid arthritis or AS. I know that there is a strong tradition of spa therapy (Balneotherapy) for arthritis and there may be weak evidence of benefit – but what about dry heat? A small pilot study into the potential benefits of an ‘infrared sauna’ for treating RA and AS was published in 2008 by Oosterveld et al. They used an infrared sauna cabin similar to the one pictured and found that although patients felt less pain and stiffness during the sauna, the benefits in pain and stiffness were not sustained. Of course, the study did not include the post-sauna dip into an ice cold Irish peat bog puddle – which could well have been the secret ingredient! I note, with approval, the authors’ use of stiffness as an outcome and their use of the little used EPM-ROM scale for quantifying range of movement. Sadly, there was no sustained improvement in pain or stiffness or range of movement.

So, do you think that the ancient Irish physicians were right about the benefits of the sweating house – or can you prove them wrong?

Philip Gardiner

Wannabe Irish Leech-Doctor
(in search of a sweating house and some good hungry leeches!)


Further reading: A Social History of Ancient Ireland http://www.libraryireland.com/SocialHistoryAncientIreland/II-XIV-4.php

Isomäki H (1988) The sauna and rheumatic diseases. Ann Clin
Res 20:271–275
Nurmikko T, Hietaharju A (1992) Effect of exposure to sauna heat
on neuropathic and rheumatoid pain. Pain 49:43–51

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The Robber of Memories: Memory loss in Art and Medicine

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…and he recalled that the Magdelena, father of waters, one of the great rivers of the world, was only an illusion of memory’
Gabriel Garcia Marquez ‘Love in a time of cholera’

Probably the most embarrassing experience I will never remember
My first personal experience of a significant memory lapse took place when as a medical student I took part in a study of oral Midazolam. I didn’t feel any different for a few hours after taking the drug and decided that I would make my own way home. An hour later I started to feel very sleepy, and everything for a few hours after that became a blur, a black hole in my memory. I was later told that I had walked into a packed meeting 20 minutes late, sat down in the front row beside the speaker’s wife and had promptly fallen asleep for the rest of the meeting! No matter how hard I tried, I could not piece together one thing the speaker had said or indeed how I had made my way home. Even though this was a trivial event, it was strangely frustrating and my mind kept churning the events over and over for weeks to try and get it back. I felt as if I had been robbed of something precious. It made me wonder what it must be like for people who begin to lose their memory, especially the most treasured memories of their loved ones.

A memorable Film informs an improbable clinical encounter

One of the most striking descriptions of memory loss in art has to be Christopher Nolan’s Memento. In the film the main character tries to compensate for his dramatic and specific deficit in short term memory by tattooing all over his body aide-memoire notes to himself as part of an obsessive and desperate search for the truth. I have encountered many patients with general memory loss in clinical practice but I did wonder if this dramatic failure of short term memory was just a fictional construct or if it could really happen. My question was recently answered when I came across someone with exactly the same deficit, brought on by a bout of encephalitis. She had suddenly become unable to form new memories whilst her past memories remained unaffected and her higher mental function was mostly intact. She continued to work out her puzzles but she  could not retain any new information for more than a couple of minutes. She just could not understand why she couldn’t go home or why people weren’t telling her what was going on. The frustration and anger that this caused was already beginning to distort her normally placid and cheerful character. Apart from ‘locked in syndrome’, I can’t imagine too many conditions more terrible to develop. The ability to remember (and forget) is definitely something we take for granted.

Probably the most memorable book I will always struggle to remember clearly
This leads me in a roundabout way to some of the books I have read this summer. The first was the Gabriel Garcia Marquez classic ‘100 years of Solitude’ which begins with the memorable line “Many years later, as he faced the firing squad, Colonel Aureliano Buendía was to remember that distant afternoon when his father took him to discover ice.” The novel revolves around the Buendia family and the people of Macondo, who have been afflicted by a plague of insomnia whose side effect is a loss of  memory.  We read how the people in this imaginary village had to resort to labelling everyday objects and even write instructions on how to use them.  In the words of Jacob Silverman, “Garci­a Marquez, who has described himself as a professional of the memory, that awareness (i.e. of slippage of memory) must be especially piquant, both because his work is so predicated on notions of memory, history, and ancestry, and because neurological conditions run in his family.” There are many references to memory in his works, and when reading ‘100 years of Solitude’ I almost felt as if I was being transported into a world where I myself was losing my grip on reality and getting lost in an impossible jumble of characters. The thread of history gets tied into so many knots that it takes an effort to unravel it (including regular reference to the family tree, for instance). In spite of the use of magical realism, some of the insights from these books are now being reflected or confirmed by research. For instance, we now know how important sleep is in developing and shaping our memories. Garcia Marquez’ books are also strongly influenced by the author’s experiences and travels in the area of Columbia near the Magdelena river.

Probably the least likely but most memorable travel itinerary in the world

This novel was the inspiration for another book I read this summer: ‘The Robber of Memories’ by Michael Jacobs. Jacobs is another writer with a life long obsession with memory, not to mention his childhood interest in tales of the Spanish exploration of South America. In his own words “The older I got the more I appreciated the role of travel as a stimulus to memories, and the way in which journeys even to new places were somehow always awakening memories of places seen in an ever-receding past”. This book is an intensely personal travelogue/meditation but should be of interest to those of us who want to gain an insight into the experiences of patients or relatives with memory loss or dementia.  ‘Escaping’ for some respite from his role of carer for his elderly mother with dementia, Jacobs embarked on a mission fraught with danger, following in the literary footsteps of his hero Garcia Marquez. Unusually, his journey was a quest to retrace his hero’s love affair with the Magdalena river, ignoring the threat of FARC guerilla attacks to make his way to the source of the river. The story begins with a meeting with the aged author, now himself in the lonely hinterland of early dementia. Garcia Marquez himself has had to let go of so many precious memories, but images of his beloved river had remained. His 81 year-old literary agent Balcells was quoted as saying of him:  ‘Gabo carries a constant glare of nostalgia in his eyes’. That description would have fitted my patient to a tee.

Mingled through the narrative Jacobs reminisces about his parents’ loss of memory and frets with anxiety and guilt about having left his mother. A dread of what might happen to him if he was to follow his parents into the fog of dementia seems to be an undercurrent throughout. He re-reads ‘100 years of Solitude’ and finds evidence that the author may have had a premonition of what was going to happen to him. He meets Marcela, whose mother has Alzheimer’s disease. She tells him about the tales of the disappeared, about the days when two or three unidentified bodies floated down the river every day. In itself, this is a powerful metaphor for the brutal ravages of dementia, separating sufferers from their loved ones in a way that reopens old wounds and prevents them from getting closure for their grief. She said that her mother could still recall some of the trauma but she couldn’t recall where or when they had happened. Jacobs quizzes the locals about the local myth about a ‘robber of memories’ who would visit you in your sleep. It is almost as if he was challenging the robber in his own backyard!

As we are led slowly up the river Jacobs reveals his plan to visit the village of Yarumal, where so many of its inhabitants are struck down early in life with Alzheimer’s disease. The seemingly fanciful idea of a whole community being struck by a ‘plague’ of memory loss is actually based in the strange but real world of the Magdalena. He meets and talks to Fransciso Lopero, a leading researcher who has made the sudy of this unique tribe his life work. Genetic discoveries here have allowed susceptible people in this town to be identified so that in future  potential treatments or vaccines can be tested in this group before they develop clinical symptoms of Alzheimer’s disease.

Many seek for hope at the end of the rainbow: Jacobs sought hope at the source of the Magdelena. And after all, the best research is essentially an adventure into the unknown inspired by a passionate hope and anticipation of discovery. Sadly, Jacobs died from cancer earlier this year. At least he was spared a house call by the ‘robber of memories’.

Further reading
The town of Yarumal and Alzheimer’s disease: Telegraph article by Michael Jacobs
Telegraph Obituary for Michael Jacobs
BBC Article (2011) about Francisco Lopera and his research in Yarumal
Selected quotes and memories of ‘Gabo’ – Huffington Post

More about Alzheimer’s disease from the Alzheimer’s Society

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The Rheumatologist, The Student, and the ever so humble Hashtag

hashtagsMany doctors are still sceptical about whether or not using Twitter is a sensible use of their time. I have to confess that before I started using it I had regarded it as little more than a written form of gossiping. For some well established academics with narrow interests and a network of colleagues who shun social media it may indeed be an unhelpful distraction. For others it may seem frustrating that even if one day they happened across a nugget of insight it would disappear from their sight like catching a snowflake. Some early adopters have been put off by finding that even though they may know a hundred colleagues in their specialty, very few of them were using Twitter and even fewer were tweeting about the things that interest you most. But the humble Hashtag has changed all that. Hashtags on twitter are words beginning with the character # and are highlighted in blue. If you click on them you will see an up to date listing on that topic. For the enlightened (or optimistic) medic, hashtags are like Pubmed keywords on steroids. You aren’t limited to any official MESH list of headings and following topics of interest is simple enough for everyone to use. And it can allow us to really filter the stuff that we look at.

The most obvious impact of hashtags among Rheumatologists has been their use to mark out the tweets from conferences e.g. adding #Rheum2014 somewhere in a tweet about the BSR Rheumatology meeting in 2014. If everyone is using the ‘official’ hashtag for the conference, then you will see all the tweets from the conference. This will help you to gain an insight into the sessions you aren’t able to attend and you can also use it to meet up with and get to know other doctors attending the conference (through face to face ‘tweet-ups’). tweetup2At the end of the conference you can collect up the interesting tweets using tools such as ‘Storify‘. But you need to be aware that tweets do ‘fall over the waterfall’ after a week and a general search will not be able to retrieve earlier tweets. This doesn’t matter too much for conferences where the hashtag becomes redundant a day or two after the event, but it can be an issue for tweets that arrive at an inconvenient time. Although the stream of tweets are only catching a tiny amount of what goes on at a conference, experienced users can often summarise the key points from presentations in three or four tweets.

In Rheumatology, we use a number of hashtags to filter content for different audiences/groups. For instance #rheum is mostly used by patients and is a popular general tag. I use it when sharing general information that the public might be interested in. Ronan Kavanagh nominated #rheumedu for more specialist tweets particularly for information that a specialist health professional/trainee specialist might want to view/keep. Keeping one eye on #rheumedu will allow you to quickly find out who is tweeting the sort of material you are interested in and build up the list of people you want to follow.

Why bother with a twitter hashtag for medical students learning musculoskeletal medicine?

I recently suggested that we should use #mskstu for collecting information of use to medical students. I hope that we can help our students by keeping this hashtag to help them track down the very best freely available teaching tips and resources on musculoskeletal medicine. I suppose it could be argued that even if Twitter is useful for professionals, it might still be a bad idea to encourage medical students to start using it. Students do need to maintain a tight focus on what they are learning throughout the course and may have been set a lot of background reading by their university. However, over the past year or two I’ve noticed that a lot more students are using Twitter and reading blogs – and at least part of the time they are using these sources for their studies. There are some great resources out there for students & if they want to use their initiative to learn in this way then I think we should encourage them. Hashtags are also useful for arranging online twitter ‘chats’, particularly if you want to engage with patient groups. You can combine a couple of hashtags in the same tweet e.g. #mskstu and #anatomy – but don’t overuse them!

Any app or program that you use to follow Twitter will have an option to search for a particular hashtag, usually listing results in a separate column. So if you have a column for #mskstu it will collect tweets using this hashtag. If you prefer a more visual presentation then Flipboard can be configured to have a section devoted to your favourite hashtag.


Storing the best tweets for posterity is currently not a straightforward task. One way to store your own personal tweets is to use IFTTT to set up a ‘recipe’ that automatically collects all of your tweets into Evernote. I’m still looking for a tool that would help to build up a teaching resource for students based on the #mskstu – something like ScoopIt can do for web pages, for instance. Your suggestions and ideas would be very welcome.

Other hashtag related resources you may find useful:

Twubs is a site that lets Twitter users form groups around popular hashtags. Hashtags are roughly categorised in a form of unofficial directory. This site could also be used to organise online chats.

Tagdef has columns of information about trending hashtags including “Top today,” “Top this week” and “All time high.” Click on any of the hashtags to learn more information, such as the user-provided definition and related tags.

The final arbiter of the usefulness of the #mskstu hashtag will be the students themselves. So please help get the word out there and contribute your own special teaching tips to help make it worthwhile!

 

 

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