FAQ Category: General

Neuromonitoring techniques have been developed to help reduce the risk of permanent paralysis during spinal surgery. In a case like this with nerve tissue involved, it can be very complex and challenging to clean up the area without cutting into the nerve or in some cases, the spinal cord itself.

The use of neuromonitoring is an area of controversy in spinal surgery. This is a way of detecting whether or not the patient is in immediate risk of damage being done to the spinal cord or spinal nerve roots. The surgeon can either wake the patient up and test him or her for normal sensation and movement or use a special device that monitors the patient’s neurologic status.

The wake-up test isn’t very practical because it doesn’t measure what’s going on from moment-to-moment. In other words, you can’t keep waking the patient up every minute to find out if everything is okay.

On the other hand, the use of tests such as electromyography, somatosensory evoked potentials (SSEP), and motor-evoked potentials (MEPs) can produce false negatives. A false negative means the test is negative indicating no problem when the patient is really compromised and in danger of paralysis. False negatives can be very serious.

According to a recent study, about 65 per cent of all spinal surgeons do make use of some form of neuromonitoring. The goal is to prevent (and reduce) the risk of new neurologic problems developing during spine surgery.

Some surgeons use more than one neuromonitoring technique in hopes of improving the chances of avoiding complications. Neuromonitoring for simple cases of disc removal isn’t required. There are times when neuromonitoring is highly recommended such as when implants are being put in place to hold the vertebrae apart or to stabilize the spine.

It’s likely that in your father’s case, there was a real need for neuromonitoring. If you have further doubts, ask his surgeon for a more detailed explanation of the decision to use neuromonitoring.

Bone cysts are spaces within a bone that are filled with some type of fluid. Two common benign bone cysts are unicameral and aneurysmal. Unicameral bone cysts are often close to the growth plate next to a joint. They tend to fill up with synovial (joint) fluid.

Aneurysmal bone cysts are more likely to be filled with blood. They affect the long bones (upper arm, thigh, ribs) and back of the spine most often. Aneurysmal bone cysts are considered “benign” meaning they aren’t cancerous and don’t spread. But they can do plenty of damage even causing the bone to break.

The cause of bone cysts remains unknown but there are some theories. Sluggish flow and congestion of fluids, trauma, and local disturbances in blood circulation are some of the more likely causes. There is evidence to support each one of these ideas. Molecular and genetic theories exist as well.

Knowing how bone cysts develop may help with prevention but once they appear, treatment is based more on the natural history and prognosis. Bone cysts don’t usually go away by themselves without some type of treatment. Usually that treatment is surgical removal.

Left alone, they will just get bigger and increase the risk of another bone fracture. If the cyst is large enough, it may be necessary to fill in the empty space (after removal) with a bone graft.

Aneurysmal bone cysts tend to come back even after surgical removal. Efforts are being made to find effective ways to kill any unseen cells left behind. Liquid nitrogen, phenol, and argon beam coagulation are three examples of treatments used to prevent recurrence.

Only a very wide resection (cutting around the edges) of aneurysmal bone cysts has a zero per cent chance of recurrence. Other methods under investigation include arterial embolization. This is a way of injecting blood clots into the blood vessel to close it down and prevent further bleeding.

Systemic lupus erythematosus, otherwise known as “lupus” is a chronic inflammatory disease involving many areas of the body. For some (as yet) unknown reason, the immune system attacks the person’s own tissues and organs.

Inflammation caused by lupus can affect many different body systems. Most often the areas involved include the heart, joints, skin, lungs, blood vessels, liver, kidneys, and nervous system.

As you have experienced, joint disease can be severe enough to cause painful loss of motion and function. Quality of life can suffer with this disability. Treatment for lupus often involves medications. These can be very effective in controlling painful joint symptoms.

The best thing to do is get with your physician and review your situation. This is a good time to look back at what has worked well in the past and re-examine treatment options now. There may be some more effective medications available now. Perhaps a slightly different rehab program would help you regain some motion and function.

When chronic inflammation causes joint destruction, then surgery may be needed. In the past, wrist fusion was the main surgical approach to the problem. Today, thanks to modern technology and improved surgical techniques, a total wrist replacement is possible.

Patients with rheumatoid arthritis are the one most likely in need of a wrist replacement. But people like yourself with lupus may find this is a helpful treatment as well.

You are among many millions of people who would agree with you. Pilates exercise is fun, fascinating, and almost addictive for some people.

Pilates is actually the name of the German born man (Joseph Pilates) who first developed this technique back in the mid-1900s. It was almost a lost art until about 10 years ago. And then the momentum behind the Pilates movement seemed to snowball. The word spread and now it is a technique that is offered in classes at the local YMCA, health club, fitness center and even physical therapy clinics.

Mr. Pilates believed that using his exercise approach, brain cells would be activated and even improve thought processes. His focus on precision, learning coordinated and rhythmical movement patterns, and breathing were meant to be for each individual person. But today’s approach is more of a group training in classes like you are probably taking.

According to a recent review of 90 articles published since 1995, there is a scientific foundation but limited evidence for Pilates. Actually, only nine of the 90 published studies were high enough quality to be considered in the review. But those studies did show that some of the Pilates techniques designed to align, lengthen, and protect the spine are effective in developing strength of the abdominal and trunk muscles.

As it turns out, the combined use of focus, breathing, rhythmical movement, and precision results in total body strengthening (not just the core or central muscles of the abdomen and trunk).

Weaker muscles start to contract and participate in the movement when stronger muscles are engaged. With improved muscle control comes better alignment and protection of the spine. The end result is the ability to perform even more advanced skilled movements with perfect balance and coordination.

Although it is believed that anyone of any age in any condition can benefit from Pilates exercises, research to support this with actual evidence is still lacking. It’s clear that any form of exercise is beneficial for your overall health, so don’t stop what you are doing!

As your niece has been telling you, physical therapists have developed a method of examination for patients with low back pain called treatment-based classification.

This three-step approach tries to match symptoms with a treatment approach that works best for those symptoms. Instead of just applying the same treatment techniques to everyone and hoping for the best, this approach is based on research and evidence available so far.

The therapist starts by making sure the patient doesn’t have a serious underlying pathology causing the low back pain. This process is called screening for referral. Anyone with signs of infection, inflammation, malignancy, or fractures must receive immediate medical attention before physical therapy treatment can begin.

Once the patient has been cleared, conservative (nonoperative) care under the direction of the physical therapist is next. During this second stage, the therapist evaluates the patient in order to decide which treatment approach will work best. As part of the process, the patient fills out several surveys that help identify levels of pain and disability.

The athlete is managed using treatments divided up on the basis of three stages. The goal of treatment is to reduce pain, improve function, speed up recovery, and prevent loss of practice and/or play time. Once the stage has been identified, then special tests are performed that have been found reliable in predicting which type of treatment will have the best outcomes. Let’s take a look at the three stages.

Stage I is more acute during the early days following an injury. Usually, this person has difficulty standing, sitting, or walking for very long or very far. Treatment during this stage is often with advice, manual therapy, and specific exercises. The athlete’s posture is modified when appropriate. Core training of the trunk and abdominal muscles help stabilize the lumbar spine.

Stage II describes the patient who can stand, sit, and walk but has trouble with basic daily skills (e.g., vacuuming, lifting, jogging, driving). Stage III means the patient can manage daily activities but isn’t able to participate in sports. Stage III is more of the chronic phase where patients experience recurrence of their low back pain that can be very limiting.

Treatment approaches for these two groups are still under investigation. Though the therapist has many treatment techniques available, predicting which one (or combination of techniques) will yield the best result remains unknown. Some of the treatment intervention will address pain while others focus on flexibility, strength, posture, and aerobic capacity. Endurance and neuromuscular control are also targeted in the more advanced levels of training (stage III).

Athletes in stage III are ready for sports-specific exercises. This approach is called functional training. It moves the athlete from limited practice time back to full participation in the sport of their choice. One of the long-term goals of treatment using this approach is to prevent future episodes of repeated back injury/pain.

To summarize, it sounds like your niece is part of the physical therapists who are busy researching, studying, and developing an evidence-based approach to low back pain. Rather than applying treatment willy-nilly, they carefully examine each patient using a three-step classification-based approach. Staging the patient (stage I, II, or III) based on level of pain, disability, and function helps direct treatment. This treatment-based classification yields a rapid recovery and return to normal activities.

It turns out that the simple idea of using the body’s own platelets with its powerful growth factors to speed up healing is more complex than originally thought. What started out as a way to remove a person’s own plasma and platelets and inject them into injured tendons, ligaments, or muscles quickly opened up Pandora’s box.

One concern raised by a group of expert scientists who reviewed 5000 published studies on this treatment is the lack of quality control over platelet-rich plasma. There is no way to standardize the product because the body simply doesn’t produce the same amount of platelets every hour of every day in every person. What you eat, how well you sleep, medications you take, and even the exercise you get can all affect platelet levels in the blood.

There’s more than one way to extract (remove) the platelet-rich plasma (PRP) and that can also affect the quality of the product. Other components of the blood (such as white blood cells) may get in the sample used and alter the body’s healing response (not always favorably).

A closer look at the different studies highlighted some of the difficulties in comparing one study to another. That may explain why results can be opposite from study to study. One common theme seems to be that platelet-rich plasma may be most effective for chronic musculoskeletal injuries. It’s not a given that the results obtained in one condition will be the same for another type of soft tissue injury.

Another problem is the wide range of tissue types being treated (e.g., cartilage, bone, tendons, ligaments, muscles). Results seem to differ within the tissue types so that how platelet-rich plasma affects a ligament in the knee may not be the same as the effects on a similar ligament in the ankle.

And a major stumbling block in the research that’s being done on platelet-rich plasma (PRP) is the way results are recorded. Some studies look at patient response in terms of pain levels and activities of living. Others are measuring strength after treatment or speed of wound healing during recovery.

The treatment isn’t bogus at all. It’s just that there are some concerns that need to be addressed before platelet-rich plasma is used for any and all soft tissue injuries. For example, we need to determine who’s a good candidate for this treatment? What kind of conditions can be treated effectively with platelet-rich plasma? How long should we wait after having platelet-rich plasma before resuming normal activities?

Engineering healing with platelet-rich plasma is an exciting area of research and study. If successful, it could result in fast, effective healing of all types of soft tissue injuries. We’re not quite ready for any real treatment guidelines yet but we are a step closer to organizing and directing future studies.

Anything that has to do with Tiger Woods is always hot news. So when he did receive a treatment of blood injection (his own blood) following anterior cruciate ligament (ACL) surgery, the media picked right up on it.

Platelet-rich plasma or PRP is the clear portion of blood (plasma) with the blood clotting platelets. It is taken from the patient so doesn’t require blood donors. The growth factors contained within the platelets enhance the body’s natural ability to heal itself. PRP is used to improve healing and shorten recovery time from acute and chronic soft tissue injuries.

It has been used for years after plastic surgery and surgery on the mouth, jaw, and neck. It seems to promote bone graft healing. Researchers have found a way to combine this substance with other chemicals to make it into a putty or gel that can be painted on a surgical site to speed up healing.

Blood injection therapy of this type has been used for knee osteoarthritis, degenerative cartilage, spinal fusion, bone fractures that don’t heal, and poor wound healing. This treatment technique is fairly new in the sports medicine treatment of musculoskeletal problems, but gaining popularity quickly.

Although very popular with some medical experts, the use of platelet-rich plasma is still considered highly controversial. There just isn’t enough scientific evidence yet to offer clear treatment guidelines for who, how, when, and why to use this treatment.
You may be a good candidate but your orthopedic surgeon would have to be the one to evaluate you and make that determination.

Bursitis is not an age-dependent condition. This condition can affect people of all ages. Older adults are the most likely to develop pain, swelling, and tenderness around a joint from bursitis. But younger folks can be affected, too.

Causes of bursitis include trauma, inflammation, and infection. When trauma is the cause, it may be the result of a direct blow or a fall onto the knee, elbow, hip, or heel that damages the bursa. So you see how this can happen to anyone.

An injury can causes bleeding into the bursa sac because the blood vessels in the tissues that make up the bursa are damaged and torn. In the skin, this would simply form a bruise, but in a bursa blood may actually fill the bursa sac. This causes the bursa to swell up like a rubber balloon filled with water.

The blood in the bursa is thought to cause an inflammatory reaction. The walls of the bursa may thicken and remain thickened and tender even after the blood has been absorbed by the body. This thickening and swelling of the bursa is what we refer to as bursitis.

The bursae can become irritated and inflamed in other ways. For example, in the case of prepatellar (knee) bursitis, repeated injury can lead to irritation and thickening of the bursa over time. People who work on their knees, such as carpet layers and plumbers, can repeatedly injure the prepatellar bursa (pad in front of and behind the patellar tendon just below the knee cap). This repeated injury can lead to irritation and thickening of the bursa over time.

When infection is the cause of bursitis, it is usually from a staph or strep infection. The bacteria enter the body close to the affected joint through a cut or small opening in the skin. A minor skin infection of the skin over the bursa can spread down into the bursa. In this case, instead of blood or inflammatory fluid in the bursa, pus fills it. The area around the bursa becomes hot, red, and very tender.

Bacteria can travel to the joint via the bloodstream but it’s not thought that this is the way infectious bursitis develops. That’s because there isn’t much of a blood supply to the bursa.

Age-related changes in the soft tissues certainly can lead to bursitis. But bursitis can also be associated with some other systemic diseases such as sarcoidosis (and inflammatory condition) or gout. Usually, the physician who diagnoses the problem can see a pattern that might suggest the underlying cause. If you’re interested, ask your doctor what he or she thinks might be the cause of your bursitis.

Don’t hesitate to ask your surgeon this question. It is a common problem. Almost all adults (up to 95 per cent) ingest some form of caffeine everyday. Many people have a total caffeine intake up to 400 mg/day (that’s considered a high level). That may not be surprising when you consider caffeine is a substance in a variety of beverages as well as some foods and medications.

Caffeine withdrawal can produce headache and fatigue for anyone who has a chronic caffeine addiction. Withdrawal headaches can last up to a week. You don’t have to cope with headache pain as well as the effects of surgery. Restoring caffeine just after surgery can be helpful in reducing or avoiding post-operative headaches.

There’s no need to go “cold turkey” so-to-speak unless facing a prolonged period of fasting for surgery or other medical testing. But you should know that caffeine is a psychoactive agent.

Psychoactive means it has a stimulating effect on the central nervous system. Given its effects on the nervous system, some even consider this substance a drug. It certainly has addictive qualities and causes withdrawal. Eliminating moderate-to-high levels of caffeine from your diet may be a good idea and beneficial to your overall health.

Psoriasis is a disease that most people think of as primarily a skin disease because the condition causes a persistent rash in various areas of the body. Psoriatic arthritis is a type of joint disease that occurs in roughly seven percent of people who have psoriasis.

Psoriatic arthritis affects people of all ages, but most get it between the ages of 30 and 50. Usually a patient has psoriasis (the skin rash) for many years before the arthritis develops, and the arthritis comes on slowly. Patients with psoriatic arthritis must manage both the outbreaks of itchy, scaly skin and the pain and stiffness of arthritis.

One of the most commonly used medications for the treatment of psoriatic arthritis (PsA) is a disease-modifying antirheumatic drug (DMARD) called methotrexate. DMARDs like methotrexate not only control symptoms, they also slow the progression of disease. That’s what makes them “disease-modifying”.

Methotrexate may not be as effective with psoriatic arthritis as it is with rheumatoid arthritis without the psoriasis. Some patients don’t respond at all while others have an adverse reaction to the medication. And in some cases, it may be necessary to combine methotrexate with another drug (e.g., infliximab) to get the desired results (decreased joint pain, swelling, and stiffness).

Infliximab is a type of disease-modifying medication in a class called anti-tumor necrosis factor (TNF) agents. The anti-TNF agents are a special type of antibody referred to as human monoclonal antibodies. They specifically target (and inhibit) tumor necrosis factor.

Tumor necrosis factor (TNF) promotes the inflammatory response, which in turn causes many of the clinical problems associated with autoimmune disorders such as rheumatoid arthritis. Golimumab is another new TNF-inhibitor that has been approved by the FDA for use with patients who have active moderate-to-severe psoriatic arthritis (PsA).

Your doctor will help you figure out which treatment approach might work best for you. Sometimes it takes a while (through trial and error) to find the right medication or best combination of therapies to get the optimal results.

There are also alternative kinds of therapy as well that help manage the disease such as acupuncture, Reiki, Therapeutic Touch, BodyTalk, and even hypnosis. Some patients seem to get a better response by combining traditional treatment (medications) with these complementary approaches.

Psoriatic arthritis is a type of joint disease that occurs in roughly less than 10 percent of people who have psoriasis. Usually a patient has psoriasis (the skin rash) for many years before the arthritis develops, and the arthritis comes on slowly. Patients with psoriatic arthritis must manage both the outbreaks of itchy, scaly skin and the pain and stiffness of arthritis.

One of the most commonly used medications for the treatment of psoriatic arthritis (PsA) are disease-modifying antirheumatic drugs (DMARDs). DMARDs not only control symptoms, they also slow the progression of disease. That’s what makes them “disease-modifying”.

The use of disease-modifying antirheumatic drugs (DMARDs) has changed the quality of life for many patients suffering from the effects of psoriatic arthritis. For those individuals who do not do well with these drugs, there aren’t very many other choices. But scientists point to a “therapeutic pipeline” of drugs that may be available in the near future.

Oral medications (pills taken by mouth) currently under investigation for the treatment of psoriatic arthritis include ustekinumab, apremilast, and tofacitinib. Each of these medications works in a slightly different way to regulate the immune system.

Ustekinumab (Stelara, Centocor) is a human monoclonal antibody. It is directed against two specific interleukins (interleukin 12 and 23). Interleukins are naturally occurring proteins that regulate the immune system and inflammatory disorders like rheumatoid arthritis. In Phase III trials for moderate-to-severe psoriasis, ustekinumab was safe and effective, especially for patients who failed to respond to other standard medications.

Apremilast works as an anti-inflammatory by suppressing more than one pro-inflammatory cells including, TNF-alpha, interleukins 6, 17 & 23, and interferon-gamma (among others). It is currently in Phase III clinical trials for the treatment of psoriasis, psoriatic arthritis, and other chronic inflammatory diseases. Early stage studies found this medication to be safe and well-tolerated with few side effects.

Tofacitinib inhibits Janus kinase, an enzyme that acts as a special signaling messenger in the immune system. Tofacitinib is currently in phase two trials with psoriasis and will be tested next with psoriatic arthritis. Tests are scheduled to run until January 2015. So it may be a while before we see this one on the market for psoriatic arthritis.

Eliminating coffee can be an effective way to reduce migraine headaches. Caffeine in its various forms is considered a psychoactive agent. Psychoactive means it has a stimulating effect on the central nervous system.

Many migraine sufferers are addicted to caffeine and don’t realize its role in causing headaches. But there have been enough studies showing the link between caffeine consumption and headaches to take this seriously. And it’s not just coffee that we are talking about.

Don’t forget caffeine in tea, soft drinks, energy drinks, and chocolate. There is caffeine in many over-the-counter drugs (for cold symptoms, headache pain relievers) and some prescription medications.

Taking caffeine in any form decreases our fatigue and boosts our energy level — that’s why so many people reach for that cup of coffee, latte, espresso, or chocolate bar. Chronic fatigue from too many late nights and lack of sleep makes an early morning jolt of java or energy bar necessary to jump start the day.

Your physician is right that cutting out caffeine is a must if you want to beat the migraines. But good nutrition and getting enough sleep are also important. If eliminating caffeine in all its forms does not stop the headaches, there may be other triggering factors to consider.

For example, certain foods (e.g., aged cheese and other dairy products, vinegar, lunch meats, alcohol, nuts, yeast products) are known to produce headaches in some people. Caffeine reduction is a good place to start. if that is not completely successful, your physician will help you find other triggers as well.

Lupus is a chronic inflammatory autoimmune disorder that can affect just the skin (face, neck, scalp) or target organs and any system in the body. Autoimmune means that the immune system mistakenly attacks body parts in an effort to get rid of them. Why a person’s immune system sees your own body as foreign or something to attack remains a mystery.

Symptoms vary depending on the body part, cells, or systems affected. There can be a skin rash, severe joint pain, extreme fatigue, inflammation of blood vessels, and hair loss. Headaches, irritability, and depression signal autoantibodies reacting with the nervous system.

Some patients report problems with shortness of breath, seizures, strokes, and/or difficulty with memory. Anemia, hepatitis, nausea, vomiting, diarrhea, and abdominal pain are among the many other symptoms possible.

The standard means of treatment has been with corticosteroids (antiinflammatory drugs) and medications that suppress the overactive immune system. Drugs to treat malaria have also been helpful. But now with the introduction ofBenlysta (belimumab), patients have a new treatment option.

The drug is administered intravenously (through a vein) once a month. It is designed to target B-lymphocyte stimulator protein. The goal is to reduce the number of abnormal B-cells. The effect is to turn down the immune system response.

Benlysta is the first drug to be developed specifically to treat lupus. It is considered safe, effective, and provides tolerable treatments. Not everyone can benefit from this drug and there are some potential side effects.

In drug trials before Benlysta was approved for public use, only one in three patients experienced relief from their symptoms. Because Benlysta weakens the immune system, patients taking the drug are at an increased risk for infections, cancers, depression, and suicide. The drug was not specifically studied in African-Americans, the group affected by lupus most often.

Lupus sufferers may find Benlysta helpful in reducing flare-ups, providing less fatigue, and resuming a more normal lifestyle. Patients who have had success using this drug for their lupus say their quality of life is much improved. With no cure for lupus and treatment only able to target the symptoms, Benlysta may give some patients a new lease on life.

If you are still interested, see your physician to find out if this drug may help you.

Lupus is a chronic inflammatory autoimmune disorder. Autoimmune means that the immune system mistakenly attacks body parts in an effort to get rid of them. Why a person’s immune system sees your own body as foreign or something to attack remains a mystery.

In any case, the immune system can no longer tell the difference between healthy and harmful tissues in the body so it starts to attack healthy organs. Lupus is associated with inflammation, joint pain, and arthritis.

Lupus can affect just the skin (face, neck, scalp). This condition is called discoid lupus. Or it can target organs and any system in the body. This second form of lupus is called systemic lupus erythematosus or SLE.

According to the Lupus Foundation of America about 1.5 million Americans have some form of lupus. Systemic lupus erythematosus (SLE) rarely develops in older people. It is primarily a disease of young women in their childbearing years. Men and children can develop lupus but this happens much less often than in women.

Lupus (SLE) is three times more common in African American women than in Caucasian women and is also more common in women of Hispanic, Asian, and Native American descent. It is believed that both genetic and environmental factors play a role in the development of the disease.

Other risk factors include physical or mental stress, which can provoke neuroendocrine changes affecting immune cell function; streptococcal or viral infections; exposure to sunlight or ultraviolet light, which can cause inflammation and tissue damage; immunization; pregnancy; and abnormal estrogen metabolism.

There is currently no cure, only treatments to manage lupus. The standard treatment has been with corticosteroids (antiinflammatory drugs) and medications that suppress the overactive immune system.

Drugs to treat malaria have also been helpful. In March of 2011, the FDA approved a drug called Benlysta (belimumab), giving patients with lupus a new treatment option. This is the first drug to be specifically designed for lupus patients.

Benlysta may allow patients to reduce the amount of corticosteroids they are currently using to manage the inflammatory symptoms of lupus. And that’s important because these drugs can do more organ damage over the long term than the disease itself. In addition to reduced lupus symptoms, patients receiving this new drug reported fewer flare-ups, less fatigue, and better quality of life.

Vitamin D helps regulate calcium in the body needed for good bone health. The body makes its own vitamin D through foods we eat and from sun exposure of the skin. Calcium is absorbed from the gastrointestinal tract but requires enough vitamin D to do so. The two chemicals are linked together very closely through hormone regulation.

The difference between insufficiency and deficiency is a matter of degree. Vitamin D insufficiency is defined as a blood level of 25-hydroxyvitamin-D (25 OHD) that falls below 32 ng/mL. 25 OHD is a chemical compound that must be present in the body in order for vitamin D to be made. It is called a precursor (comes before) chemical.

Vitamin D deficiency occurs when 25 OHD levels fall below 20 ng/mL. The levels for insufficiency and deficiency are actually determined by another factor — and that is the amount of 25 OHD needed to keep parathyroid levels in the normal range.

Without going into the complex physiology of the body to explain the interactions between the hormonal systems, suffice it to say that vitamin D levels and parathyroid function are intimately linked together.

A blood test is required to find out your own vitamin D status. Your physician, nurse practitioner, or physician’s assitant can order this test for you. The results will be used to guide you regarding any changes required in diet, sun exposure, or vitamin supplementation you may need.

Arthritis comes in many forms including one called psoriatic arthritis (PsA). Psoriasis is a disease that most people think of as primarily a skin disease because the condition causes a persistent rash in various areas of the body. Psoriatic arthritis is a type of joint disease that occurs in roughly seven percent of people who have psoriasis.

Psoriatic arthritis affects people of all ages, but most get it between the ages of 30 and 50. Usually a patient has psoriasis (the skin rash) for many years before the arthritis develops, and the arthritis comes on slowly. But this is not always the case. No matter what, patients with psoriatic arthritis must manage both the outbreaks of itchy, scaly skin and the pain and stiffness of arthritis.

Psoriatic arthritis (PsA) can be a very aggressive disease. It can affect the small joints of the hands and feet causing considerable damage and disability. People who have psoriatic arthritis also tend to develop other chronic problems such as diabetes, metabolic syndrome, and heart disease.

Tissue inflammation affecting the skin, joints, nails, and tendons can really put a damper on activities, mood, and perceived quality of life. You may see evidence of decline in your brother over time.

Family support is very important for patients with this condition. Some patients don’t like to go to the doctor and start to miss appointments or extend the time between appointments more than they should. This is a mistake since keeping up on controlling the disease with medication is vital. Your encouragement and care in your brother’s life will be needed in this phase of his life.

Psoriatic arthritis (PsA) can be a very aggressive disease. Based on the evidence we have so far, it is believed that early recognition and treatment of this problem yields better results.

There is often a wide range of signs and symptoms involving many different body parts. Physicians must use several diagnostic tools such as X-rays, ultrasonography, and MRIs to catch them all.

Each one of these tests provides a little different information. For example, X-rays show early signs of bone erosion but do not reveal anything about the condition of tendons, ligaments, or other soft tissues often affected by psoriatic arthritis.

Ultrasonography, the use of sound waves to create a picture of what’s going on inside, provides a better look at the whole package: bones, joints, and soft tissues. This diagnostic test is also noninvasive and does not expose you to any radiation. Ultrasound also has the ability to show small changes in the nails and early signs of inflammation in tendons and small joints.

MRIs can show bone marrow edema, tenosynovitis, and early joint erosion. Tenosynovitis is the inflammation of the fluid-filled sheath (called the synovium) that surrounds a tendon. Changes in the small joints of the hands and feet don’t show up well on MRIs like they do with ultrasonography.

One advantage MRIs do have over ultrasonography is the availability of whole body MRI. By scanning the entire body, it is possible to identify areas of inflammation undetected by clinical exam. And whole-body ultrasonography just isn’t reasonable.

Knowing that the correct management of this condition depends on early detection of bone, joint, and soft tissue pathology helps us understand the need for improved diagnostic and treatment approaches.

The potential for severe progression of disease may be halted (or at least slowed) with a management approach that includes (repeated or serial) diagnostic imaging throughout the course of treatment.

It sounds like your rheumatologist is right on target with the evidence we have today about the best way to care for patients with psoriatic arthritis.

Your physician must be familiar with the new theories around conditions like fibromyalgia that generate pain, pain, and more pain. Even areas that have never been injured seem to get in the act. That describes a phenomenon called central sensitization.

Nerve cells called neurons in the spinal cord that transmit pain information from body part(s) to brain don’t just pass the information along — they remain excited about the information. They generate pain messages that are too much (intensity) for too long (duration).

At the same time, the person’s threshold (level at which a response occurs) lowers so there’s a faster response to less input. Not only that but other nearby tissues get in on the act. They aren’t injured or damaged but they set up the same pain-inducing racket in the nervous system. That phenomenon is called field-expansion.

Many questions revolve around risk factors or predictive factors. In other words, why do some people become so sensitive and others do not? Are there environmental, social, genetic, and/or psychologic triggers? What is happening at the cellular and molecular levels? Are there separate mechanisms for what turns the pain on and what keeps it going or sustains it?

Scientists have been able to find out that it’s not just a matter of some pain switch getting turned on in the hand or foot (or other body part) that’s injured. There’s much more to it than that. It appears that in some people, the central nervous system is overly sensitive. Words like hypersensitive, exaggerated, or ramped up are used to describe it.

The question becomes, what can be done about it? If we can understand the mechanism, it may be possible to turn it off — or better yet, keep it from getting turned on in the first place. We know now that various parts of the nervous system from the individual cells to the message pathways (like a relay system) and brain are adaptable and changeable. That’s referred to as neural plasticity.

Scientists may be able develop ways to work with neural plasticity. Right now, they are looking for ways to turn down the excitability of neurons in the central nervous system or even turn them off. If they are successful, it could give patients like yourself who have suffered chronic pain a new lease on life, and keep others from suffering the same fate in the first place.

For the last 25 years, the National Institutes of Health (NIH) have contributed a great deal of money to research on the topic of pain. Trying to find out why pain starts, why it spreads, and why it doesn’t stop in some people has been a challenge. The most likely reason is something called central sensitization.

As much as 100 years ago, physicians realized that something gets turned on in the central nervous system that contributes to the start and spread of pain that doesn’t get turned off. The injury or local trauma has long since healed but the patient continues to experience daily, ongoing, and often very disabling pain.

That is the crux of central sensitization. Nerve cells called neurons in the spinal cord transmitting pain information from body part to brain don’t just pass the information along — they remain excited about the information. It’s too much (intensity) for too long (duration).

At the same time, the person’s threshold (level at which a response occurs) lowers so there’s a faster response to less input. Not only that but other nearby tissues get in on the act. They aren’t injured or damaged but they set up the same pain-inducing racket in the nervous system. That phenomenon is called field-expansion.

All that is the scientific explanation for what you have described as your experience over the last two years. Most research is geared toward finding drugs (medications) to stop pain (or at least the perception of pain).

But you are in luck because there are many people now who are also interested in finding non-pharmaceutical (non-drug) approaches to chronic pain. Exercise tops the list because it has been shown to release endorphins (natural morphine).

And now that we understand the pain mechanisms better, there’s much more focus on acupuncture as a successful treatment method. An even less invasive approach might include any of the energy healing medicines such as Reiki, BodyTalk, Myofascial Release, Therapeutic Touch, Healing Hands, and so on.

Find out what your community offers and give some of these alternative approaches a try. Talk with your doctor about newer medications available. It may be possible to combine a short-term pharmaceutical treatment with some of these other healing pathways to achieve the pain control you are looking for.

You are right: necrotizing fasciitis (NF) is a rare condition but one that can have deadly consequences. It’s an infection of the soft tissues — primarily the fascia or connective tissue.

NF is caused by a bacteria or fungus — there are over 25 different types known to cause NF. Some of the more common names you may recognize: e coli, staphylococcus, streptococcus, enterococcus. Many times there is more than one organism present contributing to the problem.

There are certain risk factors associated with NF. Most people who develop NF have suffered some type of skin or soft tissue injury or trauma. It can be something as minor as a skin abrasion or scratch, insect bite, or cut.

Chronic skin ulcers, severe burns, open wounds from surgery or other infections can also put a person at increased risk for this condition. Age can be a risk factor. Older adults often experience a decline in their immune system function.

Other known risk factors include diabetes or other chronic diseases, intravenous drug abuse, and immunodeficiency. Immunodeficiency refers to a depressed immune system — usually from something like AIDS, organ transplantation, arthritis, or autoimmune diseases.

Early, accurate diagnosis and immediate intervention with antibiotics, surgery, and supportive therapy are essential to preventing loss of limb and ensuring full recovery. Tissue biopsy and lab tests are used to identify as many of the organisms present. The patient is started on a broad spectrum antibiotic that will kill as many as possible and prevent further spread of the bacteria. Once the bacteria present is identified, then the patient may be switched to a more specific antibiotic.

Surgery may be needed. The surgeon removes as much of the pus and necrotic (dead) tissue as possible. This procedure is called debridement. In many cases, the process has to be repeated several times (serial debridement).

Along with antibiotics and debridement, there’s a third key part to successful treatment. This is referred to as adjunctive therapy and can include oxygen therapy, intravenous immunoglobulin therapy, and nutritional support.