Carpal tunnel and Woman’s Day December 14, 2009
Posted by nathanwei in Arthritis Treatment, Nerve entrapment, carpal tunnel syndrome.Tags: Arthritis Treatment, carpal tunnel syndrome, Nerve entrapment
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An article in the January 2010 issue of Woman’s Day magazine described carpal tunnel syndrome- the diagnosis and treatment. Near the end was a sentence that said that surgery should be considered a treatment of last resort. I agree 100% with that assertion, but the author neglected to mention many options.
My colleagues and I presented a paper at the American College of Rheumatology meeting in November 2009 describing a minimally invasive procedure using a small needle and ultrasound guidance.
This technique has prevented the need for surgery in many patients. While not 100% effective for everybody, it sure beats the knife. Here it is…
Ultrasound-Guided Percutaneous Injection, Hydrodissection, and Fenestration for Carpal Tunnel Syndrome
Tuesday, October 20, 2009
Hall D (Pennsylvania Convention Center)
Daniel G. Malone, University of Wisconsin, Madison, WI, Thomas B. Clark, MSKUS, Vista, CA and Nathan Wei, Arthritis & Osteo Ctr of MD, Frederick, MD
Purpose: Carpal tunnel syndrome, caused by compression of the median nerve deep to the flexor retinaculum, is the most common entrapment neuropathy. Most patients are initially treated with conservative measures such as splinting. When conservative measures fail, interventional techniques are considered the next step. Many studies have appeared comparing open surgical flexor retinaculum release to blind injections of corticosteroids into the carpal tunnel, but neither technique has proven superior to the other. Advantages of injection are: lower level of invasiveness, faster recovery, and ease of the technique. Occasional failures and complications occur with all techniques.
Method: We have been using an ultrasound-guided procedure of percutaneous hydrodissection of the median nerve away from the deep surface of the flexor retinaculum, followed by fenestration of the flexor retinaculum along a path parallel to the long axis of the arm, starting from the level of the distal palmar crease and progressing proximally to the level of the radio-lunate joint, the intent being to lower the pressure exerted by the flexor retinaculum on the nerve (panel 1). We have treated a series of 39 wrists in 29 patients with electrically-proven carpal tunnel syndrome, using this technique of hydrodissection and fenestration, performed using standard injection equipment and a GE LogiQ e ultrasound system with a 12 MHz linear array probe. All patients had typical carpal tunnel syndrome symptoms and presented to us for interventional treatment, conservative measures having failed. No patient had had previous surgery, and 2 had had blind carpal tunnel steroid injections, without hydrodissection or fenestration. Outcomes were defined as:
Excellent-all symptoms resolved,
Fair-some residual symptoms, or return of symptoms, but improved compared to prior to procedure,
Failure-required open surgical release.
Follow-up periods after procedure ranged from 5-64 weeks, averaging 38 weeks (as of late June 09). Patients were contacted by telephone, or seen in follow-up in clinic, to determine outcomes.
Results:
Excellent—31 wrists
Fair—5 wrists
Failure—3 wrists
No complications were encountered.
Conclusion:
Ultrasound-guided hydrodissection and fenestration is a viable, easy, relatively non-invasive therapy for carpal tunnel syndrome that can result in prolonged symptom relief, and may be a way to postpone, or even obviate the need for, open release.
Keywords: carpal tunnel syndrome and ultrasound
Disclosure: D. G. Malone, General Electric, 5 ; T. B. Clark, General Electric, 5 ; N. Wei, None.
My heel kills… could it be plantar fasciitis? December 7, 2009
Posted by nathanwei in Arthritis Treatment, Heel pain, PRP-Platelet rich plasma, Tendonitis, prp.Tags: Arthritis Treatment, Heel pain, plantar fasciitis, prp
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Plantar fasciitis is an extremely common problem, particularly in the summer when people walk around in flip flps all the time. But I still see alot of it now in people where it is a chronic condition.
And chronic conditions call for the heavy artillery.
I can’t stand it when I hear about a patient getting a cortisone shot for this condition. It just shouldn’t be done.
Let me tell you what should and can be done…
A tibial nerve block using ultrasound guidance anesthetizes the bottom of the heel. Then using ultrasound guidance I can poke small holes in the plantar fascia and get rid of any spurs that are there at the same time. Then I inject PRP (platelet-rich plasma), a derivative of a patient’s own blood. The PRP is loaded with growth and healing factors which help the plantar fascia to regenerate new tissue. And- gets rid of the pain!
Just did this procedure last week in a patient. He’s doing great!
Cluck… cluck… cluck… how to get your rheumatoid arthritis unstuck! December 3, 2009
Posted by nathanwei in Arthritis, Arthritis Treatment, Rheumatoid Arthritis, health.Tags: Arthritis Treatment, chicken, Rheumatoid Arthritis
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Every once in awhile, there’s a study that warms your heart. Here’s one that stimulates the appetite.
An oral supplement of collagen from chicken breast cartilage may ease the symptoms of rheumatoid arthritis, but not quite as effectively as conventional treatment, according to results of a randomized trial.
Chicken type II collagen supplementation for patients with rheumatoid arthritis (RA) reduced pain, stiffness, and tender and swollen joint counts significantly compared with baseline in a recent report in the journal, Arthritis Research & Therapy. According to lead author, Wei Wei, MD, PhD, (no relation to me… as far as I know) of Anhui Medical University in Hefei, China, and his colleagues.
The supplement was not as effective as methotrexate, using American College of Rheumatology (ACR) measurement criteria.
However, since it has few, if any, side effects, chicken collagen could represent “a promising alternative therapeutic strategy that may be used as a nutritional supplement against RA,” they concluded in their report.
At present, conventional RA treatments aim at suppressing the immune response since RA is an autoimmune process.
But “the supplements may work by inducing oral tolerance, modulating the immune response to type II collagen, which is a major protein in joint cartilage and a potential antigen in the autoimmune process,” the researchers explained.
After 24 weeks of treatment, the chicken collagen supplement had significantly improved the following outcomes compared with baseline:
- Pain on the visual analog scale (3.58 versus 6.02, P<0.01)
- Morning stiffness (36.12 versus 99.26 minutes, P<0.01)
- Tender joint count (6.34 versus 13.34, P<0.01)
- Swollen joint count (4.26 versus 10.38, P<0.01)
- Health Assessment Questionnaire score (0.43 versus 0.82, P<0.01)
- Physician assessment on the visual analog scale (3.81 versus 5.83, P<0.01)
- Patient assessment on the visual analog scale (3.92 versus 6.01, P<0.01)
Methotrexate improved all these indicators to a significantly greater degree than the chicken collagen supplement for pain, Health Assessment Questionnaire score, and patient assessment.
And, chicken collagen was significantly less effective than methotrexate at reducing RA disease activity measured on the 28-joint disease activity score (DAS28, P=0.019).
Adverse event rates, as predicted were significantly lower with the collagen supplements compared with methotrexate.
I like chicken… fried chicken, roasted chicken, broiled chicken, grilled chicken, chicken soup, chicken gravy, chicken croquettes, chicken stew, chicken pot pie…
Mark Victor Hansen and Jack Canfield were right… chicken soup is good for the soul… and also for your joints, I guess.
Why placebos work in arthritis research November 20, 2009
Posted by nathanwei in Arthritis, Arthritis Treatment, Uncategorized.Tags: arthritis relief, arthritis research, Arthritis Treatment, placebo response
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A placebo is a treatment – a drug or a procedure- which contains no known active or therapeutic ingredient.
The word “placebo” comes from the Latin, meaning “I will please.” And placebo-controlled studies, while not required by the FDA, are considered the “gold standard” for clinical trials investigating new drug compounds.
The first known placebo controlled trial took place in 1907.
The placebo effect occurs because a patient believes a treatment will change his or her condition. Sometimes placebos have therapeutic effects and a patient’s condition will improve.
In medicine this occurs because of three reasons. First, the patient desires the treatment to work. Second, the patient wants to please the investigator. Third, the investigator believes the treatment will work.
And that’s why the best designed studies are placebo controlled and double-blinded (meaning neither the patient nor the physician knows whether the patient is receiving real drug or not).
The placebo effect is strong. In 1955, HK Beecher published a study (Beecher, HK. The powerful placebo. J Am Med Assoc. 1955; 150(17): 1602-1606) and concluded that 32% of patients responded to placebo across 26 studies.
When you think about it, a 32% response to a “sugar pill” is pretty darned impressive. Which is why, it’s critical to look at things two ways. First, to truly assess whether a drug or procedure is really effective, it’s important to subtract placebo effect.
And the other way to look at the situation is to think, “Wow… if only we could harness the placebo effect and use it to help our patients more…”
So, I hope that explains why we use placebo-controlled methods in arthritis research. Personally, I would love to be able to use the placebo effect to help patients improve.
Rheumatoid Arthritis is a Metastatic Disease! November 10, 2009
Posted by nathanwei in Arthritis, Arthritis Treatment, Rheumatoid Arthritis.Tags: Arthritis Treatment, Rheumatoid Arthritis
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The more I learn about rheumatoid arthritis, the less I know. The basic science in rheumatoid arthritis can often be dreadfully boring and “so-what” in its results.
But…every so often a study comes out that is so elegant, so completely understandable, and so full of promise, I could just scream. I came across this study on the internet and actually I wrote an article about it but I thought I’d post it in its entirety here first. So here goes…
How does rheumatoid arthritis attack the whole body?
One of the mysteries in the understanding of a complicated disease like rheumatoid arthritis is… how does it attack so many joints? What causes it to spread?
Rheumatoid arthritis is a chronic, systemic, autoimmune condition that usually starts in a single joint but then spreads to involve multiple joints. The hallmark of the disease is its symmetrical joint involvement. Also, because internal organs may be affected, it is a disease that carries with it substantial morbidity (complications) as well as mortality (death).
Rheumatoid arthritis is very different from the other common form of arthritis, osteoarthritis, which is basically a wear and tear problem localized to weight-bearing joints. Osteoarthritis does not produce the destructive changes that are characteristic of rheumatoid disease.
Recent research has provided tantalizing evidence as to how rheumatoid arthritis spreads.
Researchers at Justus-Liebig University in Bad Nauheim, Germany recently published the results of their work in Nature Medicine demonstrating the critical role of rheumatoid arthritis synovial fibroblasts (RASFs) in the spread of the disease.
Fibroblasts are a type of cell that is primarily involved in the wound healing process. They are responsible for the laying down of connective tissue. However, when turned on in a particular fashion, they morph from Dr. Jeckyll into Mr Hyde.
These “turned-on” fibroblasts, now known as “rheumatoid arthritis synovial fibroblasts”, are present in abundance in the synovium- the lining of the joint. These RASFs become very destructive and are felt to be one of the major culprits responsible for the damage to cartilage found in rheumatoid arthritis.
To elucidate the mechanism by which RASFs could spread arthritis from joint to joint, lead author Elena Neumann and her colleagues took human cartilage and implanted it under the skin of mice genetically engineered not to reject tissue from a different species. The implantations were done in the flanks. On one flank, the mice received healthy, normal human cartilage; on the other, they received cartilage loaded with human RASFs.
A control group of mice who received normal healthy cartilage in both flanks showed minimal damage, as did mice that received implants of fibroblasts from patients with osteoarthritis.
Another striking discovery occurred when the researchers sacrificed the mice and examined the spleens. The mice which developed rheumatoid arthritis had spleens packed with RASFs. The spleen is the major organ responsible for filtering blood. The fact that RASFs are found in such abundance in the spleens of the rheumatoid arthritis mice provides strong evidence that RASFs travel through the blood stream to do their damage rather than just secrete chemicals that go into the blood stream.
Apparently RASFs can travel via the blood stream and then leave by crawling through the spaces between cells that form the lining of the blood vessels to invade other joints and other organ systems.
When the researchers look at the joints of the sacrificed mice, they didn’t find RASFs. They hypothesized that it takes time for the RASFs to travel to other joints and can only enter cartilage if there is already some minor damage. This would explain why it often takes many months for rheumatoid arthritis to spread.
The scientific findings have therapeutic implications since treatments designed to prevent RASFs from entering the bloodstream, traveling through the blood stream, or leaving the blood stream to attack healthy tissue could potentially prevent the spread of rheumatoid arthritis.
I personally think this is one of the most exciting bits of news in a long time and the authors should be commended for such fine work.
Surprise… surprise… oldies work just as well as the newbies! November 2, 2009
Posted by nathanwei in Arthritis, Arthritis Medications, Arthritis Treatment, Rheumatoid Arthritis, arthritis medication.Tags: arthritis relief, Arthritis Treatment, Rheumatoid Arthritis, rheumatoid arthritis treatment
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A study from the recent ACR meeting in Philadelphia raised a few eyebrows. This study, described on the Medscape website, is outlined as follows…
The study, entitled the Treatment of Early Aggressive Rheumatoid Arthritis (TEAR) trial, demonstrated that a triple-drug combination of older drugs (methotrexate, sulfasalazine, and hydroxychloroquine) worked just as well as the combination of methotrexate and a TNF-inhibitor in patients with rheumatoid arthritis.
Dr. Larry Moreland, the chief investigator of the group that performed the study commented, “”Most rheumatologists would have predicted that the biologic therapy [anti-tumor necrosis factor agent] would be better. We still need to see the x-ray results, which will be available in 2010, to see if either treatment [approach] is better.”
These findings raise obvious questions about the value of more expensive therapy with new biologic agents for RA patients. Dr. Moreland went on to say that biologic therapy might be better for specific subsets of patients, but exactly which subsets will have preferential benefit is currently unknown.
[NW note: I personally feel this study supports the need to examine synovial biomarkers (signposts in the lining of the joints) in patients with RA. By knowing what markers a patient has, we might be able to better predict what therapy a given patient will respond to. This would cut down on guesswork, using the inappropriate drug, and facilitating an improved therapeutic outcome.]
Bad Teeth… Bad Joints October 27, 2009
Posted by nathanwei in Arthritis, Arthritis Medications, Arthritis Treatment, Rheumatoid Arthritis, arthritis medication, health, nathan wei.Tags: arthritis relief, Arthritis Treatment, Osteoarthritis, Rheumatoid Arthritis
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A recent article appeared in the October issue of Rheumatology News.
Dr. Jerry Molitor and colleagues at the University of Minnesota School of Medicine conducted a retrospective study looking at patients with a history of periodontitis. They found that among non-smokers, the presence of periodontitis conferred a significant risk for the delopment of rheumatoid arthritis (RA).
They suggested the antibacterial effect of minocycline may explain the previosuly observed improvement of RA in patients treated with this antibiotic.
Additionally, they proposed screening periodonitis patients with a family history of rheumatoid arthritis for antibodies to anti-CCP which are a risk factor for the future development of RA.
Interesting food for thought. So make sure you brush often and floss regularly.
Blogging From ACR October 21, 2009
Posted by nathanwei in Arthritis, Arthritis Medications, Arthritis Treatment, Hip Pain, Knee Pain, Low back pain, Osteoarthritis, Psoriatic arthritis, Rheumatoid Arthritis, arthritis medication, health, hip, knee, nathan wei, shoulder.Tags: Arthritis Medications, Arthritis Treatment, Osteoarthritis, Rheumatoid Arthritis, rheumatoid arthritis treatment
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I’ve been busy this past week serving as the official American College of Rheumatology Blogger for Medscape. The meeting was held in my home town, Philadelphia.
Here’s the link:
Would welcome comments
For Natural Herbal Freaks… Some Good News! September 28, 2009
Posted by nathanwei in Arthritis, Arthritis Treatment, Osteoarthritis, health.Tags: arthritis relief, Arthritis Treatment, herbs
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Now that the stem cell/ PRP launch is out of the way, I can breathe a bit.
Let’s go off in a different direction. I’ve talked about conventional medicines and not-so-conventional procedures. Now let me provide an update on some herbal remedies for arthritis…
This interesting study was written about by Anastasia Stephens in the Daily Mail on September 26, 2009. According to research presented at the British Pharmaceutical Conference, ” when taken orally, concentrated extracts from two types of basil – Ocimum americanum and Ocimum tenuiflorum – reduced joint swelling by up to 73 per cent within just 24 hours.
‘We assessed the antiinflammatory capacity of both plants and found they were similar to those seen with diclofenac, an antiinflammatory drug widely used in the treatment of arthritis,’ says Vaibhav Shinde, of Poona College of Pharmacy in India, who conducted the research.
But unlike diclofenac and other drugs of its type, basil has not so far been found to cause side effects such as gastro-intestinal irritation and abdominal burning and pain. These can be significant problems for arthritis sufferers who take daily pain-relieving medication.
The investigators theorized that “eugenol, the oil that gives basil its distinctive aroma,” may be “the active molecule responsible for the anti-inflammatory effect.”
Another herbal remedy, turmeric, was described by Carole Jackson for Bottom Line’s Daily Health News. She interviewed registered herbalist David Winston, RH (AHG), a founding member of the American Herbalists Guild.
According to Winston, turmeric has a wide variety of healing abilities including powerful anti-inflammatory components which safely reduce the pain and swelling of arthritis, carpal tunnel syndrome, bursitis and tendonitis.
A typical dose of turmeric is two to four milliliters (ml) of the tincture three times a day, or two capsules of the powdered herb two to three times daily. Turmeric should be used with caution in individuals prone to bleeding and, because it stimulates bile secretion, it should not be used by people with a bile duct blockage.
Joe and Teresa Graedon of The People’s Pharmacy reported that celery seed was a traditional treatment for rheumatism. Ethnobotanist James Duke, PhD, author of The Green Pharmacy, attests that celery seed extracts have helped him ward off gout attacks.
Many other readers of the People’s Pharmacy website say that sour cherries can also help against gout. One reader reported: “I used tart cherries to cure a gout attack and it worked. The real news is that the pain from osteoarthritis of the hip joint diminished also.”
Remember…the effects of these herbs will be modest at best. But they are worth knowing about.
An anniversary and the stem cell/PRP program past the halfway point September 24, 2009
Posted by nathanwei in Arthritis, Arthritis Treatment, Hip Pain, Knee Pain, Osteoarthritis, PRP-Platelet rich plasma, Prolotherapy, Stem Cells, Tendonitis, health, hip, knee, nathan wei, platelet-rich plasma, prp, shoulder, stem cell.Tags: Arthritis Treatment, Osteoarthritis, prp, Stem Cells
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Wow! Yesterday was our 25th anniversary. Judy is in Boston helping her parents out. One of them had a medical event. Things are under control. At least up there.
Here… it’s a different story.
I can’t believe we started the stem cell/PRP launch just a couple of days ago. We’re past the halfway point and my staff and I are thinking about “pulling the project off the shelves soon. Permanently or temporarily. Can’t say.
My advice… get it while you still can
http://www.domainnamesanity.com/webumake/wwwsites/www.aocm.org/StemcellandPRP.html
You’ll be glad you did.
