Dr Ibukun Dedeke, a consultant rheumatologist at the University College Hospital, Ibadan, in this interview with Sade Oguntola, said early symptoms of arthritis, such as joint ache after prolonged activity, are often ignored, with many patients relying on painkillers that mask the problem, rather than treat it. Left unchecked, joints can deteriorate, leading to deformity and severe mobility issues.
Osteoarthritis and rheumatoid arthritis are conditions experienced by many people. What is osteoarthritis? What is arthritis?
The term ‘arthritis’ is actually a general term for joint problems. Arthritis is a term that means joint inflammation. However, not every pain in the joint is due to a joint problem. There are different structures around the joint, and any of these can cause pain. Because of this you need to be evaluated by a specialist to determine the cause of your knee pain.
To the layman, the term ‘arthritis’ means joint pain. However, arthritis is not one disease; there are over a hundred types and causes of arthritis. So, when you come to the specialist, the type of arthritis will be determined as well as its severity. The type and severity determine the effective treatment for it.
What are common types of arthritis in Nigeria?
Osteoarthritis is a type of arthritis, and remains the most common type globally. There are two types of osteoarthritis. The primary osteoarthritis is that which occurs due to years of wear and tear due to daily vigorous use and stress of the joint. It is the commonest type of arthritis in the elderly due to the changes that occur in the joints over time with ageing in addition to the other factors mentioned earlier. The severity may vary depending on how patients are paying attention to their joint health. With the increase in the number of adults that are 60 and above, you can imagine how many Nigerians have osteoarthritis. This is aside from the younger people who have osteoarthritis.
We also have what is termed secondary osteoarthritis which result from joint injury from trauma or due to a joint disease damaging the joint to cause osteoarthritis. Common joint diseases that can damage the joint and subsequently lead to secondary osteoarthritis include what we call inflammatory arthritis like gout and rheumatoid arthritis. These types of arthritis are common in younger people.
Now, what’s the difference between osteoarthritis and inflammatory arthritis? The difference is that for osteoarthritis, the earliest symptom is joint pain with activity-like prolong standing, and walking. For example, individuals that stand for long hours (e.g. standing for two hours); At the end of almost two hours, you may start feeling knee pain. Now, with time, if you don’t change your habit, the pain begins to occur sooner, and last longer. This is a sign of a joint problem starting off. Oftentimes, people that are conscious of their activities change their habit, and it helps. However, some people are not conscious of how their activities affect their joints and ignorantly continue those bad habits.
Pain is a safety and protective sensation in the body. Pain works like a smoke alarm to help locate a problem and solve it. Likewise, the pain sensors areall over our body and are programmed to call attention to any harm or damage occurring in any part of our body. The musculoskeletal system, including the joints, muscles and bones, are mechanical structures involved in standing, walking, and running. And oftentimes, we are not conscious of how these activitiesaffect our joints until we have overdone it, and the joints are injured.
So, in the earlier periods of osteoarthritis, a patient will have knee pain after prolonged use. Oftentimes, when an individual does not identify or understand the pain, he or she reaches out for a painkiller to ‘kill the pain’. People don’t understand that painkillers kill the pain, but they don’t touch the problem. Using a painkiller for a pain that you don’t know what’s causing it is like switching off the smoke alarm before locating the fire. That is how a lot of people use painkillers to the detriment of their joint health.
Over the years, the joint gets worse because they won’t go to complain to the doctor. Instead, they continue to self-medicate with painkillers. Then after a few months or years, they’ll notice that the painkiller has stopped relieving the pain because the disease has gotten worse. Ignorantly, they go on to stronger painkillers. Meanwhile, the patient also begins to see deformity in the limb. Osteoarthritis starts with experiencing pain with activity. After some time, the level of activity the individual can tolerate also progressively reduces due to the pain severity.
Joint swelling that occurs in osteoarthritis typically is at the latter part of the disease when it’s getting severe. In inflammatory arthritis, the pain and swelling occurs early right from the startof the disease. For example, patients that have gouty arthritis experience episodic severe pain and swelling in the affected joints. It commonly affects the base of the big toe. The base of the big toe is painful and swollen, preventing them from wearing shoes because of the excruciating pain.
Which joints are mostly affected by osteoarthritis?
Osteoarthritis is a disease of wear and tear. So, it depends on the joints that you use more commonly. And that oftentimes is influenced by your occupation. People who do a lot of standing have a risk for low back and the knee joint problems. The osteoarthritis of the low back is called spondylosis. Those that do secretarial work have high a risk of developing hand osteoarthritis.
What predisposes people to osteoarthritis and rheumatoid arthritis?
Osteoarthritis is of two forms, primary and secondary. You can’t really prevent the primary osteoarthritis because it is a disease of wear and tear which follows daily use for decades.
For rheumatoid arthritis, there is often a genetic predisposition.
But people will say, “I want to rest; it’s paining me”
Exercise is the food of the musculoskeletal system. Just as you need to eat every day, the musculoskeletal system needs daily exercises at the right quantity. A lot of people that have bad experiences with exercise are doing the wrong thing. If it is not prescribed and followed according to instructions, that can lead to injury. They’ll say, oh, I need to exercise this week. They now do two hours of exercise on Monday, or three hours of exercise. I have done my exercise for the week. That’s what a lot of people do. The beauty and the benefit of exercise come from doing it moderately and regularly. It’s not in the intensity. It’s not in it being prolonged. If it’s too long, it’s going to have a negative effect. So, exercise is very good. However, it must be done safely. And if you want to have a healthy musculoskeletal system, you have to have healthy exercise. Now, the simplest exercise I often prescribed to my patients is walking exercise. It’s free, a moderate walk for 30 to 40 minutes, every day, or Mondays to Fridays. Walking engages the largest number of muscles that are involved with activity or movement. Even when there is a disease of the musculoskeletal system, we don’t want to completely stop exercise. If someone is ill, you don’t say they should stop eating. You give smaller quantities or different forms of food. It is adjusted in a way that is not too much to cause more damage but enough to maintain function. For the muscles, exercise keeps them strong, and it keeps them flexible. For the joints, it keeps the joints flexible. And then for the bone, it keeps the bone thick and strong. It is very common for elderly patients to rest the joint. When they say,’ Mama, Mama, you don’t need to do anything; just sit down.’ That is a wrong way to approach joint care and may lead to worsening of the joint damage. And that’s why we recommend that you see the specialist so that they can instruct you on the proper thing to do.
Any rules to follow when walking as an exercise?
Walking is a very good form of exercise because of the group of muscles that are involved in it. And it’s very cheap. Now, what are the tips to have a healthy walk? The footwear for the walking exercise is vital. A walking shoe is preferred, not slippers or heavy boots, but rather a light tennis shoe. It allows the free and relaxed movement of your legs. Walking should be on level ground, not stony or rough. It can strain the knee and make that walking experience bad. I always tell patients this: what you need when you want to exercise is time and space. Any space in your house or around the house is good. Then, set out the time for the walk. The timing allows us to quantify how much exercise you’re doing. Lots of people use these fitness aids to help them to count the number of steps they have taken in a day. But those fitness gadgets are not often accurate. Some of them count even when you’re in the car. So, they end up being given a false impression of the number of steps taken in a day.
The thinking that my going to the office is enough exercise is wrong; it is a fallacy. When you dedicate time for exercise, the hormonal changes and the chemical changes in your body are different from what it is when you move around in your work place. When in the office, your body is using stress hormone to get activities done. Too much stress hormone is unhealthy for the body.
But when you have a dedicated period for exercise, you are more relaxed at this time; you are not rushing anywhere. Some people will listen to music during this time, which further relaxes them. During this period the stress hormonal level is very low and that allows the whole body to get the health benefits of exercise.
Are there non-medical or non-drug therapies to relieve pains related to arthritis?
Pain is very stressful to the body, both physically and emotionally. So, I don’t castigate patients for reaching out for painkillers when they’re in pain. But they need to understand that there’s a reason for that pain and to look for its cause. Although there are over-the-counter medications for pain control, there are some restrictions regarding the use of non-steroidal anti-inflammatory drugs, particularly in people with peptic ulcers. Of course, the first painkiller to take for pain is paracetamol. It is still the safest pain medication. However, if the pain persists after using paracetamol for a day or two, we expect you to see a doctor rather than switch from one medication to another all in a bid to avoid going to the hospital.
Is there a cure for osteoarthritis?
Osteoarthritis has no cure. The treatment is to control the disease in an attempt to preserve the residual joint function and possibly relieve some of the pain.
For severe osteoarthritis in which there is significant joint damage, surgery is recommended.
People sell so many supplements and ointments they claim can help with osteoarthritis. What’s your take on that?
A lot of claims on these supplements for joint problems are false, and a lot of them are based on pain control. Those supplements and ointments do not cure osteoarthritis, and that’s why helping patients understand that the pain is not the problem, but the type of joint disease. When someone offers them a medication that promises to ‘remove’ pain, they will understand that even though such drug reduce pain, it is not removing the disease. Thus, they will be able to make an informed decision.
Are there things you recommend for people to cope better with osteoarthritis?
The starting point is assessing the severity, making that diagnosis, and determining the severity, and that is what will also determine the plan for that patient. Medication use is limited to helping to modify the pain as much as possible.
We also recommend joint-friendly exercises that help the function and the strength of that joint and that limb. Physiotherapists are the healthy exercise specialists that help recommend healthy exercises that help rehabilitation of the musculoskeletal system. They assess and quantify the exercise that is required based on the type of joint disease, the severity of the damage, the limitations they have, and all that.
Another recommendation is losing weight, especially for weight-bearing joints like the knees and the low back. Oftentimes, we found patients that have lost weight have significant relief in their joint symptoms, simply because the load has been reduced, not because the osteoarthritis is gone. So, we encourage dietary modifications to lose weight, and exercise also complements that.
Cold weather exacerbates symptoms of joint problems, especially during the cold season. The stiffness and aches worsen with cold weather. So, we always advise that patients keep those joints warm to prevent their symptoms from flaring up.
Will practices like massaging the aching or swollen joint with shea butter, hot balm and hot water worsen the conditions?
We do not massage joints. Massaging joints will make it worse. We massage muscles, not joints. The usefulness of hot balms and hot water is limited and should be done according to medical advice by your doctor.
How about those ointments that you apply lightly and yet feel the heat right inside your joints?
We recommend that medicated gels and creams be used according to prescription by your doctor. A lot of people misuse them both in quantity and frequency.
Are there infections that contribute to individuals coming down with arthritis?
The role of infections in the etiology of arthritis depends on the type of arthritis. Osteoarthritis, which is the commonest type of arthritis, has no association with infections generally. It is only if the infection is in the joint that it can now cause joint damage that leads to osteoarthritis.
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