The Need for early and dedicated Rheumatologic Services

Autoimmune Disease are a major health problem.

Researchers have recognized 80-100 different autoimmune diseases and suspect at least 40 additional diseases such as Parkinson’s may have an autoimmune basis. These conditions are chronic and can be life-threatening.

Autoimmune diseases are one of the top 10 leading causes of death in women in all age groups up to 64 years of age. Autoimmune diseases however face critical obstacles in diagnosis and treatment.

Despite the fact that little is known about autoimmune conditions by the general public and even some health care professionals , statistics comparing it to other diseases show its major impact on health care services and the disparities in care and resources provided to it.

The National Institute of Health, NIH in America estimates up to 23.5 million Americans have an autoimmune disease, AD. In comparison, cancer affects up to 9 million and heart disease up to 22 million.

NIH estimates annual direct health care costs for AD to be in the range of $100 billion (source: NIH presentation by Dr. Fauci, NIAID). In comparison, cancers costs are $57 billion (source: NIH,ACS), and heart and stroke costs are $200 billion (source: NIH, AHA).

But despite these numbers showing its impact, NIH research funding for AD in 2003 came to $591 million. In comparison, cancer funding came to $6.1 billion; and heart and stroke, to $2.4 billion (source: NIH). Understanding autoimmune conditions would benefit other diseases, as understanding how to control the immune system activity will benefit transplant recipients, cancer patients, AIDS patients and even infectious disease patients.

The first rheumatology clinic in Ghana was started at the Korlebu Teaching hospital in 2009 by Dr Dzifa Dey joined later by the late Dr Joan Agama.

Currently, there are only two centres providing dedicated rheumatologic services in Ghana, with the second one in Kumasi. Records in Accra show rising number of patients but no increase in specialist trained.

The importance of having dedicated care cannot be overemphasized. Early diagnosis and treatment are core principles in the management of patients with rheumatic disease. For those with inflammatory arthritis, the benefits of early and adequate reduction in inflammation have been well-demonstrated both from an individual and a socio-economic perspective. Timely and effective treatment increases the likelihood of disease going into remission and continuity of employment in addition to reducing the number of co-morbid conditions such as heart disease and cancer commonly associated with chronic inflammation.

Early institution of treatment greatly improves quality of life when started at an early stage in the disease course.

Despite this knowledge that early treatment is beneficial, many patients with rheumatic disease endure significant delays before first review by a rheumatologist. Worldwide there is a growing shortage of rheumatologists even though large numbers of symptomatic patients are being diagnosed, meaning we have long waiting lists and in some cases up to three months wait  to get an appointment to see specialists for conditions that a few days delay can be critical.

 

Given the evidence that autoimmune and rheumatic conditions are on the rise it is imperative that such services are given the needed attention, manpower and resources. Training more doctors and utilizing other health providers such as dedicated nurse practitioners, physician assistants, providing health facilities with resources to manage these conditions properly before it becomes a major problem on the health care system is a must. There are too few rheumatologic providers currently to meet the health needs of patients.

 

The writer is a Physician Specialist & Rheumatologist

Managing Chronic Pain – “Pain is a more terrible lord of mankind than even death itself.”- Albert Schweitzwer

Pain is invariable at one point or the other in our lives.  It warns us that something is amiss, preventing us from further harm, telling us that we should take medicine or see a doctor or avoid what may be the problem.

What is pain?

The International Association for the Study of Pain describes it as: An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

There are two basic types of pain, acute and chronic.

• Acute pain, usually, results from damage to tissues, disease, and inflammation. It is typically sudden onset for example, after trauma or surgery, and may be accompanied by anxiety or emotional distress. The cause of acute pain can usually be diagnosed and treated within given period of time.  In some rare instances, it can become chronic.
• Chronic pain is widely believed to represent disease itself. It is pain that persists for more than 6 weeks. It can be aggravated by environmental and psychological factors and can be resistant to treatments. It can often cause severe problems for patients.

I shall today focus on chronic pain. Managing chronic pain is becoming a serious and expensive public health issue, and a challenge for family, friends, and health care providers who must give support to the individual suffering from the physical as well as the emotional consequences of pain.

Chronic pain if not well managed can be debilitating and reduce the quality of life and well being markedly.

 

How can we manage pain?

World Health Organization devised a step ladder approach to managing cancer pain which has been adapted for other causes of chronic pain.

This involves a stepwise increase or escalation of pain medications. Basically, if the first level does not improve pain then the doctor in consultation with the patient moves up the next level of pain medications which tend to be more potent.

 Mild pain

Paracetamol or a non steroidal anti-inflammatory (NSAID) drug such as ibuprofen usually works at this level.

Mild to moderate pain

Paracetamol combined with an NSAID or either of them is combined with a weak opioid such as hydrocodone, providing greater relief than their individual use.

Moderate to severe pain

Chronic pain medication is used for alleviating long-lasting, ongoing pain and usually involved the mild to moderate drugs plus more potent group of drugs called opiates.

Morphine is the gold standard to which these are compared. While opiates are often used in the management of chronic pain, high doses are associated with an increased risk of opioid overdose. These opiates are prone to abuse of use and guidelines of assessing the patient for the risk of substance abuse, misuse, or addiction must be done.

Other treatment modalities:

Antidepressants and antiepileptic drugs

Some antidepressant and antiepileptic drugs are used in chronic pain management and act primarily within the pain pathways of the central nervous system and peripheral mechanisms. These are in general are more effective in neuropathic pain disorders where the pain is attributed to a nerve pathway rather than musculoskeletal conditions. Drugs such as gabapentin have been widely prescribed for the off-label use of pain control. The list of side effects for these classes of drugs are typically much more than opiate or NSAID treatments for chronic pain, and many antiepileptics cannot be suddenly stopped without the risk of seizure.

Physiotherapy

Physiotherapy and rehabilitation uses therapeutic exercise along with other agents like thermal agents and electrotherapy to treat pain, usually as part of an interdisciplinary or multidisciplinary program.

Acupuncture

Acupuncture involves the insertion and manipulation of needles into specific points on the body to relieve pain or for therapeutic purposes the jury is still out on whether it works.

TENS

Transcutaneous electrical nerve stimulation involves using a small portable machine to stimulate certain nerve path ways that may be involved in the pain process and this however has been found to be ineffective for lower back pain.

Cognitive Behavioral Therapy (CBT).

This helps patients with pain to understand the relationship between pain and muscle tension and ones’ thoughts, emotions, and behaviors. A main goal in treatment is cognitive reorganization to promote helpful thought patterns, engaging in healthy activities such as regular exercise and pacing. Lifestyle changes to improve sleep patterns and to develop better coping skills for pain and other stressors using various techniques such as relaxation, diaphragmatic breathing, and even biofeedback.

Sometimes pain and even medical personnel can make you feel chronic pain is all in your head as it’s so difficult to manage. Though that may not be true you can still use your mind to control pain. Negative emotions can worsen pain and controlling this can help. Coping strategies such as deep breathing, stretching and meditation can control anxiety and your heart rate improving mood and fatigue. Keep doing activities you enjoy and find a pain relieving strategy that works

Let’s get a few tips for managing joint pain depending on what time of the day your pain hits you most.

If you have pain when you wake up:

• Stretch your muscles before your feet hit the floor: To improve morning stiffness associated with inflammatory joint diseases, start by slowly bending and straightening your legs, then move to your arms, wrists and ankles.
• Have a dose of your pain medications and or prednisolone on standby if it has been prescribed for you: Take this as soon as possible. Preferably however try to eat something before or soon after you take it to avoid irritation of the stomach.
• Have a hot shower: A hot shower warms up the fluid in your joints and makes them lubricate the joints better for ease of movement.

Pain in the afternoon:

• Don’t sit still for too long.: Move your body every half hour to prevent your joints from freezing or stiffening. Stand up often.
• Desk exercise: Stretch in your seat. March with your feet in place.

If you have pain at night:

• Keep your bed warm: this helps to keep your joint and muscles relaxed.
• Sleep promoting foods: Some foods have the amino acid tryptophan which helps promote sleep. Eat these snacks an hour or two before bed. E.g. low fat yoghurt, oat etc
• Check your medications: some medications interfere with sleep like prednisolone ask your doctor if you can take them at a different time.

If you have pain exercising:

• Making time to stretch and strengthen your quadriceps and abs that is your thigh and abdominal muscles, this would take the pressure of your knees and ankles the usually site of pain.
• Take your pain medications before exercise.
• Get enough sleep
• Try other forms of exercise such as water based exercises like swimming and water aerobics. Which take pressure off your joints whilst giving you a three dimensional training effect as the water resists your movement in all directions.
• Talk to an expert, if you can afford to hire a personal trainer he or she can ensure your workout is safe and secure and develope an exercise routine that still works for you.

 

Pain affects our quality of life , let us take some measures so it doesn’t dictate our life.

There is Rheum to Bloom

Heralding Education in Autoimmune Rheumatic Disorders (HEARD) Campaign and “RheumChat” Project.
The “RheumChat” project is a toll-free telemedicine short code service (*844*555*3#) that will help screen for persons suffering from autoimmune rheumatic conditions in all parts of the country and improve their access to care by directing them to the nearest partner health centre, while the HEARD campaign is aimed at increasing awareness about Autoimmune Rheumatic Disorders in Ghana using simple animation videos and other materials in English, French and selected local languages such as Twi, Ga, Ewe and Dagbani.

The aim of these projects, according to Dr. Dzifa Dey, Director of tRi and one of only two consultant rheumatologists at the Korle – Bu Teaching Hospital in her welcome address, is to hopefully draw out more individuals who are silently suffering from this condition and to create awareness to the public about autoimmune rheumatic conditions in an easily accessible, convenient and fast manner using the little capacity the organization has and building on it.
Also, according to her, there is a lack of rheumatologists worldwide with Ghana having only 3 for a population of 30 million. There are few dedicated clinics, lack of manpower to provide even the basic care. Poor knowledge and disease recognition among medical personnel, lack of awareness among the public, unavailability of diagnostic facilities and essential drugs that will help manage these patients. This leads to shockingly high reported early death rates in Africa between 34 to 49% in some diseases within 5 years.

The launch of this project which was held virtually via the zoom platform on the 31st of August was attended by Dr. Baffour Awuah, Advisor to the Minister of Health, Dr. Opoku Ware Ampomah, CEO of Korle-Bu Teaching Hospital, Dr. Naa Adorkor Sodzi-Tettey representing the Medical Women’s Association, Apostle Lyanne Koffi, a member of the board of tRi Ghana and representatives from healthcare centres, pharmacies and health-related NGOs.

We can if we tRi together.
Let’s make Autoimmune conditions HEARD.
Let’s tRi to HOPE

Autoimmune diseases occur when the body’s disease fighting cells get confused and attack itself. The body’s own immune system begins to attack normal tissues cells and organs within the body. Depending on the part of the body it sees as foreign, that is where the immune system attacks and causes the disease to manifest.

Last week we took a look at the causes of back pain.  Depending on whether your back pain is acute or chronic, here are some few tips on what you can do to manage it.

Autoimmune diseases – when the body fights itself.  – Dzifa Dey

I struggled to explain to the gentleman who brought his wife to the clinic what an autoimmune disease is, as against his strong belief of a spiritual source to his wife’s illness. I could understand his skeptical look as he looked at me as if to say “ huh and you say it’s not spiritual!!! ”. As an African, with our natural belief in the spiritual and supernatural the thought of a disease that is caused by the body attacking itself understandably begins to sound supernatural.

That sounds very obnoxious right?

Working in the UK during my specialization was an insight into what the life of a doctor should ideally be. When I clock into work, I know I am on call. You are handed the beep and it runs your life. Immediately it rings you have to call back and attend to that emergency.