Pain Free at Last Providence rheumatologists provide treatments for the aches of arthritis. Written by DAWN HOFFMAN Photgraphed by MICHAEL NEVEUX When Aimee Bower s feet started hurting during her recreational hikes in the fall of 1999, she didn t take it too seriously and neither did her primary care physician. She was diagnosed with metatarsalgia, a sports-related condition marked by inflammation in the balls of the feet. Her doctor said the pain would go away with the help of foot soaks, well-padded shoes and some Advil. But over the next few months the pain spread far beyond Bower s feet, to her knees, arms, elbows, shoulders, fingers and jaw. My symptoms were just getting worse and worse, says Bower, 44, of Venice, who works in data analysis. Everything was hurting. I couldn t turn the key in my car ignition. I couldn t walk upstairs. It hurt to lift my arms to wash my hair. It hurt just to roll over in bed. It was very scary and extremely painful. Bower didn t get any relief until the following spring when, due to the severity of her symptoms, she finally was referred to Orrin M. Troum, MD, a rheumatologist at Providence Saint John s Health Center. He immediately began treating Bower for rheumatoid arthritis, an autoimmune condition that attacks the joints and affects an estimated 1.5 million Americans, mostly women. The disease usually strikes between the ages of 40 and 60, but it can appear in people of all ages, even children, according to the Arthritis Foundation. If not detected early, rheumatoid arthritis can be an extremely painful and debilitating condition. Without treatment, patients have a 50% chance of total disability within 10 years, says Dr. Troum. But through early diagnosis and proper care with the range of effective tools and powerful treatments available today, patients like Bower can maintain active, healthy lives with remarkably little or no pain. My goal as a doctor is to get all of my patients in remission or at the point of low disease activity, Dr. Troum says. Bower is now back to hiking and more. I can go play volleyball on the beach for hours and go backpacking too, she says. I m as active as I ve ever been, with no pain or impairment. Overall, the prognosis is excellent for rheumatology patients who are getting the standard of care, says Eileen Schwartz Breyde, MD, of the Facey Medical Group in Burbank. There have been so many advances in the field, she says. I have patients with rheumatoid arthritis who never thought they would feel good again, and they are functioning normally with treatment. It s important for people who have painful joints to seek early treatment with a rheumatologist. Many people make the mistake of brushing off recurring aches, pains and joint stiffness, especially those that occur in the mornings, as mere annoyances 12 PROVIDENCE WINTER 2015
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that simply will go away on their own. Recognize that it s not just a little stiffness or a little arthritis, Dr. Troum says. And make sure your doctor isn t hastily ruling out more serious issues either. Don t let your symptoms be dismissed. Postponing a medical consultation can allow an inflammatory type of rheumatoid disease to progress and damage joints, says William Liu, MD, a rheumatologist with Providence Medical Institute in Redondo Beach. Some patients may think the symptoms are not important and will go away, he says. But if there s inflammation going on, like rheumatoid arthritis, it s really important to evaluate that. The hardest part is to make sure it s the right diagnosis. Gout, in particular, is a type of inflammatory arthritis that is often overlooked, notes Dr. Breyde. It occurs when uric acid builds up in the blood and causes joint inflammation. It is, unfortunately, frequently undertreated and can be very destructive. It can be a very serious problem when it s not managed properly. Patients with painful joints may try to treat themselves at home with over-thecounter nonsteroidal anti-inflammatory drugs (NSAIDs), like Advil or ibuprofen. But liberal use of NSAIDs can cause problems, she says. A full dose of Tylenol, 2,000 milligrams a day, may be a safer way to combat milder arthritic aches and pains, she says. The key is to ask a doctor for advice. The problem is people take NSAIDs without consideration of the possible side effects. They think that because they are over-the-counter they must be safe, Dr. Breyde says. They can cause gastritis, bleeding ulcers, high blood pressure. There is a possible link to cardiac events. Kidney function decreases if you take these medications for a long period of time. I think it s a good idea for patients to see their doctors and find out what they can safely take. The pain and suffering of rheumatoid arthritis results when the immune system goes haywire and starts attacking the synovium, the thin membrane that lines the joints. No one knows the cause of rheumatoid arthritis, though doctors suspect 14 PROVIDENCE WINTER 2015
that genetics plays a role. Other risk factors include smoking and poor dental hygiene. When the joints are attacked, fluid can build up and cause pain, inflammation and swelling, progressively damaging the cartilage and bone, decreasing mobility and potentially causing joint deformities. In some patients, symptoms may periodically improve, with periods of mild disease activity followed by flares of increased disease activity and more symptoms. Eventually, poorly controlled disease can affect other areas besides joints, including the heart, lungs and skin. Thankfully, physicians now have an arsenal of medications to help do just that, including disease-modifying antirheumatic drugs, or DMARDs, such as methotrexate, that inhibit inflammation and work to alter the course of the disease and prevent joint destruction. Another new class of medications, called biologics (or biologic response modifiers), has helped many patients recover, Dr. Liu says. These genetically engineered drugs act on abnormalities of the immune system that lead to the joint inflammation. In the past 15 years amazing progress has been made with the new biologics, he says. We can take care of 95% of rheumatoid arthritis with a combination of methotrexate and a biologic. Biologics carry some rare but serious side effects, such as the risk of infection. Some patients hear or read about these side effects and fear taking the medications. But these agents are very effective and the benefits most often outweigh the risks, Dr. Breyde says. What a lot of people don t realize is, with untreated rheumatoid arthritis life expectancy can be less compared to patients who are adequately treated. It can be disabling and interfere with many activities of daily living, she explains. People get very nervous about what the Food and Drug Administration tells them in, for instance, TV commercials. It s very scary, but they aren t really seeing all of the details about the studies that have been performed prior to approval by the FDA. It is very frequently safer to take these agents than leave rheumatoid arthritis untreated. There is a nearly 100% probability that untreated rheumatoid arthritis will cause permanent harm to a patient s health but the chance of serious side effects from these treatments is very low. Patients with rheumatoid arthritis need to have a meaningful discussion with their rheumatologist so they can make an FACTS ABOUT RHEUMATOID ARTHRITIS HOW RHEUMATOID ARTHRITIS ATTACKS JOINTS Nearly 1.5 million Americans have RA. The disease affects nearly three times as many women as men. RA usually develops between the ages of 30 and 60 in women and later in life in men. The severity of RA can vary widely among individuals. There is no cure for RA, but there are many medications that help ease symptoms. Early diagnosis is important to prevent joint damage. Source: National Institute of Arthritis and Musculoskeletal and Skin Diseases (1) The ends of the bones in the joints are covered by a tough, elastic tissue called cartilage. A capsule surrounding each joint is lined with a type of tissue called synovium, which produces synovial fluid, a clear substance that lubricates and nourishes the cartilage and bones inside the joint capsule. (2) Rheumatoid arthritis is an autoimmune disease which means the immune system, that normally helps protect the body from infection and disease, attacks joint tissues for unknown reasons. White blood cells travel to the synovium and cause inflammation. The synovium thickens and makes the joint swollen, painful and sometimes warm to the touch. (3) As rheumatoid arthritis progresses, the inflamed synovium invades and destroys the cartilage and bone within the joint. The surrounding muscles, ligaments and tendons that support and stabilize the joint become weak and unable to work normally. WINTER 2015 PROVIDENCE 15
informed decision about treatment. Along with the introduction of the powerful disease-modifying medications for rheumatoid arthritis, doctors today also are using newer imaging technologies to better assess the health of joints in order to specifically tailor treatments to individual patients and monitor their disease progression, Dr. Troum says. In the past, doctors have used X-rays to view joint damage. But X-rays aren t as good at revealing all of the signs of rheumatoid arthritis such as inflammation and bone erosion compared to ultrasounds and MRI, and additionally expose patients to a small amount of radiation, he notes. Dr. Troum, current president of The International Society for Musculoskeletal Imaging in Rheumatology (ISEMIR), is a big advocate of the newer imaging scans for rheumatoid arthritis treatment, especially in the early stages. Ultrasound and MRI imaging show how active the disease is in a patient and how much damage has occurred, William Liu, MD; Eileen Schwartz Breyde, MD; Orrin M. Troum, MD says Dr. Troum, who has published review articles on the subject. When doctors see the extent of the disease, they can better determine whether medications are working and how aggressive to be with future treatments. For the last few years, Bower has been in remission while on a treatment regimen of methotrexate and the biologic etanercept (brand name Enbrel). Bower also takes fish oil supplements for their purported antiinflammatory properties. She couldn t be happier with her treatment results. I feel fine, with no pain, tenderness or any problems, she says. Over the years, she also found that Iyengar yoga has helped. It felt good, especially in the beginning when I was really in a lot of pain, she says. It just felt good to stretch and do something healthy for myself. Information on exercise, a healthy diet and psychosocial support should be part of each patient s treatment package, Dr. Liu says. People in the early phase of treatment, when joints may still be swollen, can do gentle exercises to increase joint range-ofmotion and improve muscle strength. Later, many patients find water exercise, low-impact aerobics, yoga and other activities bolster both their physical and mental health. An important aspect of this kind of chronic illness is addressing a patient s attitude and how the patient copes with the problem, he says. Conversely, patients should be wary of prescriptions for narcotics to cope with pain, Dr. Breyde says. I try not to use narcotics for treatment of chronic pain, she says. It can be a deadend. There are a lot of other medications and modalities we can use to treat chronic pain that won t interfere with a patient s life or cause problems like addiction or dependency. I want to keep patients working, exercising, doing hobbies and enjoying their lives. With the current treatments for rheumatoid arthritis, they can do those things. Looking back at her early struggles with rheumatoid arthritis, Bower is very thankful that she found the care she needed. When I was first diagnosed, I was in pain and scared and wondering, What s wrong with me? Bower says. I would go online and get information, and I would end up in tears reading about people being completely debilitated. I feel so fortunate to have Dr. Troum as my doctor. 16 PROVIDENCE WINTER 2015