WHAT IS FIBROMYALGIA? Fibromyalgia is a common condition that can cause widespread pain. 1 person in every 25 may suffer from it. Women are affected commonly and the condition varies a great deal from one person to another and from day to day.
SYMPTOMS :

• Widespread pain, often made worse by sustained activity
• Tiredness (fatigue) or lack of energy
• Sleep disorders
• Headaches
• Irritability, feeling low or weepy
• Irritable or uncomfortable bowels
• Forgetfulness or poor concentration
• Increased sensitivity (to cold, sound, knocks and bumps)
• Tender (overly sensitive) joints and muscles
• Increased stress, worry or low mood.

What causes it?
No specific physical cause has been found. This doesn’t mean the symptoms are unreal or ‘all in the mind’, but anxiety, physical or mental trauma, and sleep disturbance are thought to play a part. Patient experience increased sensitivity to pressure that wouldn’t normally be painful. Sleep disturbance also contributes to this increased sensitivity. A number of things may lead to sleep disturbance, such as:

• Pain from an injury or another condition such as arthritis
• Stress at work or strain in personal relationships
• Depression brought on by illness or unhappy events

How is fibromyalgia diagnosed?
At present, there aren’t any specific blood tests or scans that can confirm a diagnosis of fibromyalgia – in fact, typically, people with fibromyalgia will have normal results. Patients usually have specific tender points in certain areas of the body. However, guidelines released in 2010 favor a diagnosis if:

• Widespread pain lasting three months or more
• Fatigue and/or waking up feeling unrefreshed
• Problems with thought processes like memory and understanding (cognitive symptoms).

ASSOCIATED CONDITIONS?

• Chronic tiredness (fatigue)
• Depression and anxiety
• Headaches
• Joint pain in various parts of the body
• Spasms in either or both legs (restless leg syndrome)
• Dry eyes
• Irritable bowel syndrome (IBS)

WHO SHOULD TREAT ME? A RHEUMATOLOGIST
HOW CAN I HELP MYSELF

• Learn about and understand your condition.
• Psychological and physical techniques to reduce tension in the body and self-directed anger or frustration.
• Pace your daily activities.
• Follow a graded programme of physical activity (for example swimming, walking or cycling), starting gently and gradually building up.
• Share your experiences with other people.
• Tackle any stress or unhappiness at home or at work.
• Avoid tea, coffee (and any other forms of caffeine) and alcohol close to bedtime.
• Eat a balanced diet and keep to a healthy weight.
• Stop smoking.
• Keep a notepad by your bed – if you think of something you need to do the next day, write it down and then put it out of your mind.
• Try not to sleep during the day.
• Avoid watching TV and using computers, tablets or smartphones in your bedroom.

A Rheumatologist may advise you to go for Physiotherapy,Occupational therapy Pain management and Psychological therapies
MEDICATIONS
Your doctor can prescribe a variety of medications to help with pain, sleep disturbance or depression. These reduce the symptoms to a level that will enable you to start some gentle physical activity and rehabilitation therapies.

What is the outlook?
Fibromyalgia is a long-term (chronic) condition, and recovery varies from person to person. There’s no known cure, but there are treatments, therapies and self-management techniques which can help to improve your symptoms to a great extent.

Encourage your family and friends to
discuss your condition with you
Seek help from a RHEUMATOLOGIST!

Gout is caused by too much uric acid, or urate, in your body. Urate is produced by the breakdown of chemicals called purines in your body; most of which are made naturally by your body but some come from your diet.
People with gout often have kidneys that are unable to flush out extra urate through urine, and when it builds up above a critical level it can form crystals of sodium urate

What causes an attack of gout:
The urate crystals escape from the cartilage and trigger sudden painful inflammation of the joint lining. Several factors can affect the level of urate in your body:

• Inherited conditions
• The bigger the body the more urate is produced each day
• Metabolic syndrome. (high cholesterol in your blood ,high blood pressure or late-onset diabetes)
• Kidney disease
• Some tablets such as diuretics (water tablets)

Symptoms of an attack:

• Extreme pain that comes on quickly in the affected joint (often the big toe)
• Affected joints feeling hot and very tender to the touch
• Affected joints looking swollen with the overlaying skin often shiny and red.

Gout can cause long-term severe and irreversible joint damage.
Seek help from a RHEUMATOLOGIST if u have these symptoms
A diagnosis is often based on your symptoms and an examination of the affected joints. doctor may suggest :

1. A blood test can measure the amount of urate in your blood. It should be less than360 μmo/L (equivalent to 6mg/dl).

not everyone with a raised level of urate will develop crystals in their joints it’s possible for urate levels in the blood to be normal at the time of an acute attack

2. X-rays of joints will reveal joint damage in long-standing and poorly controlled gout.
3. Ultrasound of joints can be used to detect earlier signs of gout
4. Synovial fluidexaminations: involve taking fluid samples from a joint through a needle and examining them under a microscope. This test can confirm the diagnosis.

Dietary modifications:

Treatment :

• Treating the acute attack of inflammation
• Ongoing treatment to reduce the level of urate in your blood and get rid of urate crystals.

Initial treatments for acute attacks :

• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Colchicine tablets
• Steroids(injected into the joint or muscle, or as tablets)
• Applying ice packs and resting the joints.

Longer-term treatments aim to lower urate levels and reduce the risk of further attacks. These include:

• Allopurinol or febuxostat (which reduce the amount of urate your body makes)
• Uricosuric drugs (which increase the amount of urate your kidneys get rid of).

If you’ve had an attack before,
be on the lookout for early signs of another attack
and take your prescribed treatment as soon as possible. The earlier you start treating an acute attack the better.
SELF HELP MEASURES

• Lose weight if you’re overweight.
• Have a balanced diet and avoid eating excessive amounts of purine-rich foods (for example offal, oily fish, yeast)
• Avoid drinking too much alcohol
• Avoiding dehydration by drinking plenty of water
• Avoid Sugary fizzy drinks and fruit juices can be high in sugar
• Include fruit, vegetables and other foods rich in vitamin C in your diet
• Control blood pressure, diabetes and raised cholesterol

What is the outlook?
Attacks can vary from person to person. In time, though, attacks tend to happen more often and new joints are affected. A continued build-up of urate crystals and formation of hard tophi can damage your cartilage and bone, leading to long-term (chronic) arthritis.
With appropriate help from a rheumatologist andsome changes to your diet and lifestyle, this type of damage can usually be prevented.
Remember NOT EVERYONE with a raised uric acid level
needs treatment to lower it.
Discuss with your rheumatologist for details.

SYSTEMIC LUPUS ERYTHEMATOSUS (SLE)
What is lupus?
Lupus is a disorder which affects the skin and joints and often also involves the internal organs, including the heart or kidney. Lupus is an autoimmune disease, which means that your body’s defencesystem, produces antibodies that attack the body’s own tissues.

Lupus is more common in younger women.
Only about 1 in 15 cases of lupus begins after the age of 50 and
it tends to be less severe in people who are over 50.
What are the symptoms of lupus?

• Joint pain
• A skin rash
• Fatigue
• Fever
• Weight loss
• Headaches
• Mouth ulcers
• Hair loss
• Swelling of lymph glands/ Swelling of feet
• Colour changes in the fingers or toes in cold conditions
• Shortness of breath, or pain when breathing in

You will need REGULAR CHECK-UPS with your doctor for early signs of these complications. THE EARLY THE DIAGNOSIS, LESSER THE COMPLICATIONS
What is the outlook?
It is a variable and unpredictable condition and may even be life-threatening for people whose vital organs are affected. It’s hard to predict exactly how lupus will affect you. Most people with lupus don’t have the more serious complications, but your doctor will be on the look-out for these so that early treatment can be given if necessary

How is it diagnosed?
Some of the symptoms of lupus are the same as other, more common conditions, so you’ll probably have a number of tests before the diagnosis is confirmed.

1. Anti-nuclear antibody (ANA) test, + in 95%
2. Anti-double-stranded DNA (anti-dsDNA) antibody test
3. Anti-Ro antibody test
4. Complement level test :levels go down when lupus is more active.
5. Erythrocyte sedimentation rate (ESR) test
6. Kidney and liver function tests( especially in early years of diagnosis)
7. Blood cell counts

Who should treat me?
A RHEUMATOLOGIST
TREATMENT
There’s no cure for lupus at present, but the disease is most often very treatable and usually responds well to a number of different types of drugs – especially when treatment is started in the early stages of the disease.
AVOID SUNLIGHT:
Too much ultraviolet light from sunlight can cause a red rash across the cheeks and the bridge of the nose, often known as the butterfly rash.
Keep your skin covered or use suncream of SPF 50 or greater
Raynaud’s phenomenon: blue/white/red discoloration of digits in cold: keep hands and chest warm and covered

A RHEUMATOLOGIST MAY ADVISE YOU SPECIALIZED TREATMENT WITH :

• Non-steroidal anti-inflammatory drugs (NSAIDs)
• Steroid tablets, creams or injections
• Conventional disease-modifying anti-rheumatic drugs (DMARDs)
• Drugs to control high blood pressure and high cholesterol
• Biological therapies.

PREGNANCY AND LUPUS
Most women with lupus should be able to have a baby if they wish to, but it’s best to discuss your plans with your doctor before trying to get pregnant so that your treatments can be altered if need be.
ALWAYS PLAN A PREGNANCY,
WHERE POSSIBLE, AT A TIME WHEN LUPUS IS INACTIVE

OSTEOARTHRITIS OF THE KNEE
Osteoarthritis is a condition that affects the joints, causing pain and stiffness.
It’s by far the most common form of joint disease,
and the knee is one of the most commonly affected joints.
A NORMAL JOINT:
A joint is formed by two bones.The end of each bone is covered with cartilage which has a smooth, slippery surface that allows the ends of the bones to move against each other almost without friction. When a joint develops osteoarthritis, some of the cartilage covering the ends of the bones gradually roughens and becomes thin and the knee develops swelling and pain.

THE SYMPTOMS:

• Pain
• Stiffness
• A grating or grinding sensation when the joint moves (crepitus)
• Bony swelling
• Excess fluid
• Restricted movement
• Joint instability
• Weakness and thinning of thigh muscle.

FIGURE: RISK FACTORS FOR OSTEOARTHRITIS

There’s no cure for osteoarthritis as yet, but there’s a lot that
you can do to improveyour symptoms

• Lose weight if you’re overweight
• Exercise regularly (both muscle-strengthening and general aerobic exercise aerobic exercise)

REDUCE STRESS ON THE AFFECTED JOINT

• Break the harder jobs up into chunks and do something more gentle in between
• Use a walking stick/walker
• Use the handrail for support when going up or down stairs
• Don’t keep your knee still in a bent position for too long
• Modify your home, car or workplace to reduce unnecessary strain.
• Wear appropriate footwearlow-heeled shoes with soft, thick soles (joggers)
• Apply heat or ice packs
• Use painkillers or anti-inflammatory creams, gels and tablets

What treatments are there?
If you still have pain after trying self-help measures, seek help from
A RHEUMATOLOGIST
He would examine you and he may advise you to go for an X-ray.
(It is not always required)
A rheumatologist may recommend the following treatments:

• Capsaicin cream
• Stronger painkillers
• Steroid injections into the painful joint
• Surgery, including joint replacement

BEWARE : Always follow your rheumatologists advise
for proper dose and duration of medicine
There are some medications which don’t have proven role yet, but are still used

• Glucosamine and chondroitin
• Acupunture

OSTEOPOROSIS
Osteoporosis is a condition which makes the bones fragile.
There are usually no symptoms, and it’s often only discovered when you break a
bone in a minor accident or fall
Bone is a living tissue, but as we get older it’s not able to renew itself as well and our bones start to thin. This happens to everybody to some degree, but when the bones become fragile it’s called osteoporosis.

Who is at risk ?
It’s more common in women, particularly after the menopause You’re at greater risk of developing osteoporosis if you:

• Havesteroid treatment for more than three months
• Have a family history of osteoporosis
• Don’t do much weight-bearing exercise
• Are a heavy drinker or smoker.
• Have a Low body weight
• Have an early menopause(in females), (before the age of 45)
• Had your ovaries removed/surgery (females).

How can I help myself?
The following will help to reduce your risk of developing osteoporosis:

• Plenty of calcium and vitamin D as part of a well -balanced diet.
Dairy products such as milk, cheese and yogurt , milk made from soya, rice or oats
• Exercise regularly, especially activities that involve walking or running.
• Stop smoking.
• Don’t drink too much alcohol.

A RHEUMATOLOGIST IS THE RIGHT PERSON TO TREAT YOU
Your rheumatologist would advise you a special test “DEXA SCAN” for diagnosis. This test measures bone density.The possible results are:

• Normal–Risk of a low-impact fracture is low
• Osteopenia– Your bone is weaker but your risk of a low-impact fracture is relatively small.
• Osteoporosis– You have a greater risk of low-impact fractures and you may need treatment – discuss this with your doctor.

This test is done before starting treatment and later at 2-5 years intervals as per your doctors advise.
What treatments are there?
There are a number of treatments available, including:

• Calcium and vitamin D
• Bisphosphonates(e.galendronate, risedronate)
• Teriparatide
• Raloxifene
• Denosumab
• Strontiumranelate.

Usually bisphosphonates are advised along with calcium and vitamin D supplements

How to take bisphosphonates?
Available as IV , PO form

• Take it on an empty stomach with a glass or two of plain tap water.
• don’t eat anything or drink anything other than tap water for at least 30 minutes afterwards (for effective absorption)
• Stay upright (sitting, standing or walking) for up to an hour

Side Effects Inform your doctor:
Gastritis(commonest) ,skin rashes, a sore mouth, flu-like symptoms, jaw painbone pain /muscle pain, headaches
REMEMBER Your bone density should start to improve
after 6–12 months
Bone renewal is a slow process soit’s important to continue treatment as your rheumatologist advises – even thoughyou won’t be able to feel whether it’s working.

Longer-term treatment can sometimes have side-effects your
doctor may suggest a break from your treatment after 3–5 years

PSORIATIC ARTHRITIS
Psoriatic arthritis is a condition that causes painful inflammation of the joints and is often linked with the scaly skin condition; psoriasis.
However, some people develop the arthritic symptoms before the psoriasis, while others will never develop the skin condition.
Psoriasis can affect people of any age, both male and female, but psoriatic arthritis tends to affect more adults than young people.

Symptoms include

• A red, scaly rash (psoriasis)
• Swollen, stiff and painful joints
• Sausage-like swelling of fingers or toes
• Thickening, discoloration and pitting of the nails
• Pain and swelling at the back of the heel
• Back pain ( greater after rest /upon waking up in morning)
• Fatigue

Psoriatic arthritis CAN AFFECT OTHER PARTS OF BODY TOO :

1. A patient may develop a painful red eye. Don’t ignore it. It can cause blindness
2. People may also have a slightly greater risk of developing heart disease.

TREATMENT:
The processes of inflammation are similar in the skin and joints,
so treatments aimed at one area of the condition often
help the other as well
SEEK HELP FROM A RHEUMATOLOGIST

How is it diagnosed?
It’s important that psoriatic arthritis is diagnosed early so treatment can be started as soon as possible.
There’s no specific test for psoriatic arthritis, but the diagnosis is based on your symptoms and a physical examination. Your doctor will check for psoriasis and may ask if there’s a history of psoriasis or psoriatic arthritis in your family.
With history and appropriate blood tests and radiologic findings, your doctor should be able to reach the diagnosis. Once treatment is started, regular follow-up and monitoring is necessary. You may be given some of the following treatments, depending on your symptoms:

• Pain relieving drugs
• Disease-modifying anti-rheumatic drugs (DMARDs)
• Biological therapies (newer,costly therapies used if other DMARDs are not working
• Steroid injections
• Ointments/ light therapy for skin
• Exercise and physiotherapy
• Surgery

Seek timely help from a rheumatologist as
Earlier the treatment better the outcome

RHEUMATOID ARTHRITIS
It is an autoimmune disease that causes inflammation in your joints. This means that your immune system starts attacking your body’s own tissues instead of germs and viruses
Rheumatoid arthritis causes inflammation in the joint lining. This result in red, painful and swollen joints. The redness is caused by the flow of blood increasing. As a result, the inflamed joint may feel warmer than usual.
COMMON SYMPTOMS:
Symptoms of rheumatoid arthritis tend to come and go. You may have flare-ups when your symptoms become worse than normal. Common symptoms of rheumatoid arthritis include:

1. Joint pain and swelling
2. Stiffness
3. Tiredness (fatigue), depression, irritability
4. Anemia
5. Flu-like symptoms, such as feeling generally ill, feeling hot and sweating.

Less commonly

• weight loss
• inflammation in the eyes
• rheumatoid nodules (fleshy lumps below the elbows or on hands and feet)
• inflammation of other body parts- lungs and blood vessels and the membrane around your heart, though rare.

Rheumatoid arthritis varies from one person to another but it usually starts quite slowly. A few joints – often your fingers, wrists or the balls of your feet – become uncomfortable and may swell, often intermittently.
You may also feel stiff when you wake up in the morning.

If you have painful, swollen joints and stiffness in the morning that lasts for longer than half an hour, you should see your doctor.
Research shows that the sooner you start treatment for rheumatoid arthritis, the more effective it’s likely to be, so early diagnosis is important.
OUTLOOK
Because rheumatoid arthritis can affect different people in different ways, we can’t predict how the condition might develop for you 75% of people will continue having some joint pain, swelling and flare-ups. 20% will always have very mild rheumatoid arthritis. 5% will develop severe disease with extensive disability.
SEEK HELP FROM A RHEUMATOLOGIST
HOW IS RHEUMATOID ARTHRITIS DIAGNOSED?
No single test can give a definite diagnosis of rheumatoid arthritis in the early stages of the condition.
Doctors have to arrive at a diagnosis based on your symptoms, a physical examination and the results of x-rays, scans and blood tests.

TESTS INCLUDING GETTING:

• ESR AND CRP
• RF-IgM
• Anti CCP

XRAYS OF HANDS to look for erosions and joint damage

TREATMENT OPTIONS:
Regular physiotherapy and foot wear are necessary
Four main groups of drugs are used to treat rheumatoid arthritis:

1. Painkillers (analgesics)
2. Non-steroidal anti-inflammatory drugs (NSAIDs)
3. Disease-modifying anti-rheumatic drugs (DMARDs)
4. Steroids

REMEMBER: Most people with rheumatoid arthritis need to take more than one drug. This is because different drugs work in different ways.
A common combination is a painkiller, an NSAID and one or more DMARD.

Because DMARDs take some time to start working you may also be given a steroid, which can reduce the inflammation and ease your symptoms while the DMARDs are taking effect
REGULAR FOLLOW-UP IS THE MOST IMPORTANT PART OF TREATMENT
THE SAFETY AND EFFICACY OF DRUGS NEEDS MONITORING AT REGULAR INTERVALS

SHOULDER PAIN
The shoulder is the most mobile joint in the body and
can be affected by a number of painful conditions
Most shoulder problems only affect a small area and don’t last very long
Some shoulder problems may be part of a general condition such as

• Rheumatoid arthritis
• Osteoarthritisor
• Polymyalgia rheumatica

There are several other possible causes of shoulder pain, including:

• Inflammationor damage to the muscles and tendons
• Tension in the muscles between theneck and shoulder (poor upper back or neck posture, often linked to their work)
• Inflammation in the sac of soft tissue (bursa) that normally allows the muscles and tendons to slide smoothly over the shoulder bones
• Damage to the bones and cartilage: arthritis.

SHOULD I SEE A DOCTOR:
You should also see your doctor as soon as possible if you:

• Develop severe pain in both shoulders
• Also have pain in your hips or thighs
• Feel feverish

These can be signs of a condition called polymyalgia rheumatica, which needs prompt treatment
SELF HELP MEASURES:

• Appropriate sleep habits/pillow size
• Heat/cold therapy
• Pain killers
• Proper posture(most important)

Posture care:

• Avoid slouching, particularly when sitting at a desk.
• Change your position frequently and sit in a supported upright position
• Your upper body posture improves if your lower back is supported. You may need to place a pillow or cushion behind your lower back.
• It’s important to ensure your arm is supported and that you feel comfortable.
• Look into a mirror and make a conscious effort to hold your shoulder blades up and back. This should make your chest stand out as if you were taking a deep breath.
• If your shoulder is painful to lie on, sleeping may reduce the discomfort by lying on your good side with a pillow under your neck.

Reducing the strain

Generally it’s best to carry out your normal activities,
but don’t overdo it.
If the problem continues for more than two weeks,
or gets worse, you should see a doctor.
DIAGNOSIS:
Each shoulder problem has its own pattern of symptoms.
Your doctor or physiotherapist will need to establish which movements produce the most pain, as this could indicate where the problem is.
Usually your symptoms and the doctor’s examination of your shoulder will give all the information needed to plan your treatment. However, your doctor may suggest tests if considered necessary

What tests are there?

• Blood tests ,to rule out arthritis
• X-rays
• Ultrasound of the shoulder joint
• MRI
• Nerve conduction studies

WHAT IS FROZEN SHOULDER
(adhesive capsulitis)
A ‘frozen’ shoulder is where the joint capsule tightens, preventing movement. We don’t know why this happens, though it sometimes follows an injury, a heart attack or stroke, and it’s more common in people with diabetes.
The condition will usually resolve itself in time
but it may take as long as two to three years. Pain can be severe, especially at night and you may experience sudden muscle pains, called muscle spasm.

TREATMENT MODALITIES
If your shoulder pain doesn’t improve with simple medications, other treatments are available. Your doctor will be able to give more specific advice. Options include:

1. Strong pain killers
2. Physiotherapy
3. Steroid injections into the joint
4. Surgery including joint replacement

Physiotherapy and exercises are important after surgery to help regain movement

SYSTEMIC SCLEROSIS
(SCLERODERMA)
The word scleroderma means hard skin (sclero = hard, derma = skin).
Systemic sclerosis causes tightening of the skin. It is an autoimmune disease, which means the immune system attacks the body's own tissues. It's one of a number of conditions called connective tissue diseases.
Systemic sclerosis is rare, but women are 3–4 times more likely than men to develop it. It usually starts between the ages of 25–55 years.

SYMPTOMS:
Systemic sclerosis can cause a range of symptoms affecting many different parts of your body:

1. Increased sensitivity to the cold
2. Changes in the skin
3. Pain or stiffness in the joints or muscles
4. Digestive problems.

Sensitivity to the cold:
Your fingers or toes turn white then blue/red in the cold

Changes in the skin

• The skin on your hands, arms and face thickening and hardening
• Your hands and/or feet swelling, especially in the morning
• Shiny skin, without its usual creases
• The skin on your face stiffening, making it difficult to open your mouth wide, and sometimes your lips becoming thinner
• Small red blood spots on your face, hands and arms
• Small, white chalky calcium lumps under your skin (calcinosis) in long standing disease

Digestive problems

• Difficulty swallowing food due to tightening of food pipe
• Heart burn/acidity
• Diarrhea/constipation

Joint problems
Pain stiffness swelling in joints

COMPLICATIONS may develop in a small number of patients

1. Scarring (fibrosis) of their lungs, causing shortness of breath, a dry cough
2. Narrowing of the blood vessels of their lungs
3. Kidney problems resulting in high blood pressure

a regular follow up with A RHEUMATOLOGIST is extremely important as earlier the complications are noted ,better the outcome
WHICH TESTS ARE DONE:

• Blood tests
• X-rays and computerised tomography (CT) scans
• Breathing tests
• A heart scan (echocardiogram or ECG)
• Stomach tests, for example an endoscopy
• A skin biopsy, if needed

SELF HELP MEASURES

• Eat six small meals a day instead of three larger ones
• Eat slowly, chew thoroughly
• drink plenty of water with meals
• Taking your largest meal in the middle of the day can help you to avoid heartburn.
• Don't eat too much in the evening to make sure you have time for digestion before you go to bed.
• Raise the head of your bed a few inches to stop acid coming back up from your stomach
• Keep your hands and chest warm, use mittens and sweater
• Regular exercise to prevent contractures

TREATMENT OPTIONS
Usually include managing all the four salient symptoms with the use of pain killers,NSAIDS, Stomach protection agent, skin moisturizing agents, measures to keep chest and peripheries warm. Specific treatment includes

• Steroids
• Immunosuppressive agent
• Blood pressure and cholesterol lowering drugs if needed