Back Clinic Chiropractic Examination. An initial chiropractic examination for musculoskeletal disorders will typically have four parts: a consultation, case history, and physical examination. Laboratory analysis and X-ray examination may be performed. Our office provides additional Functional and Integrative Wellness Assessments in order to bring greater insight into a patient’s physiological presentations.
Consultation:
The patient will meet the chiropractor which will assess and question a brief synopsis of his or her lower back pain, such as:
Duration and frequency of symptoms
Description of the symptoms (e.g. burning, throbbing)
Areas of pain
What makes the pain feel better (e.g. sitting, stretching)
What makes the pain feel worse (e.g. standing, lifting).
Case history. The chiropractor identifies the area(s) of complaint and the nature of the back pain by asking questions and learning more about different areas of the patient’s history, including:
Family history
Dietary habits
Past history of other treatments (chiropractic, osteopathic, medical and other)
Occupational history
Psychosocial history
Other areas to probe, often based on responses to the above questions.
Physical examination: We will utilize a variety of methods to determine the spinal segments that require chiropractic treatments, including but not limited to static and motion palpation techniques determining spinal segments that are hypo mobile (restricted in their movement) or fixated. Depending on the results of the above examination, a chiropractor may use additional diagnostic tests, such as:
X-ray to locate subluxations (the altered position of the vertebra)
A device that detects the temperature of the skin in the paraspinal region to identify spinal areas with a significant temperature variance that requires manipulation.
Laboratory Diagnostics: If needed we also use a variety of lab diagnostic protocols in order to determine a complete clinical picture of the patient. We have teamed up with the top labs in the city in order to give our patients the optimal clinical picture and appropriate treatments.
Around 3 million individuals suffer from plantar fasciitis
Heel pain
Foot pain
Spurs
Tight tendons
Stiffness
Signs of a long day, wearing the wrong shoes, both or you may have a condition known as plantar fasciitis. We don’t take our health seriously until we go through excruciating pain or some form of debilitation. Feet are the foundation of the body and when they are not at 100% there are going to be problems.
Identifying, diagnosing, and treating plantar fasciitis can be fast and easy with chiropractic orthotics!
What is it?
Plantar Fasciitis is inflammation of the tissues in your foot.
People think it only affects the heel, however, it can affect any or all of the bottom of the foot. Because it�s the tissue between the toes and heel that gets inflamed.
The tissue is called �fascia� hence the name of the condition: plantar fasciitis.
Heel spurs were once thought to be the cause of the discomfort, but now is a symptom of plantar fasciitis.
Many people who have plantar fasciitis wake up with stabbing pain in the bottom of their feet during the first few steps of their day.
Early morning pain and stiffness is a big indication of PF.
Also called �policeman�s heel,� pain and discomfort also arise after long periods of standing, walking, exercise.
The fascia in the foot acts as a shock absorber, which helps support the arch of the foot.
With time, increased tension, small tears begin to happen in the fascia, that leads to the inflammation.
Who gets Plantar Fasciitis?
People that stand on their feet for long hours, such as:
Factory workers
Teachers
Doctors
Nurses
Retail employees
Are at a higher risk of developing plantar fasciitis.
Improper Footwear/Posture
Wearing improper shoes, meaning too tight, too loose is another contributing factor.
Shoes that have arch support and heel protection are considered best and help to avoid pain and discomfort.
Poor posture
Abnormal walking gait
When heel or foot pain is not treated, it can lead to
Back
Knee
Hip problems�
Many adjust their walking to compensate for the pain and discomfort that can lead to more problems.
Being flat-footed raises the likelihood of developing plantar fasciitis regardless of age or lifestyle.
Other Contributing Factors
Weight also contributes to plantar fasciitis because it puts greater stress and tension on the feet as they hold the body. Exercise can help, but be sure that they are exercises specifically designed to help treat plantar fasciitis. Because certain types of exercise like running, aerobics, jumping, and dance-based workouts can lead to heel pain and plantar fasciitis.
Diagnosis
Identifying and diagnosing plantar fasciitis is straightforward and relatively easy. Diagnosing plantar fasciitis does not require an X-Ray or MRI, which is one reason many people avoid seeking treatment. But it’s best to seek the advice of a trusted healthcare professional.
Treatment
There are several ways to treat plantar fasciitis:
Rest is one of the best remedies, especially if it is caused by exercise or excessive stress.
Icing the area can help manage the pain
Stretching and/or light physical therapy
Stretches that focus on the Achilles tendon and lower leg muscles help stabilize and strengthen the ankles and heels.
This helps to:
Stand
Walk
Workout
Move around
Chiropractic and physical therapy can help with:
Stretching the muscles and tendons
Work out and tension
Provide day-to-day stretches
Kinesio taping along the bottom of the foot, heel, and lower leg but should be done first by a professional like your chiropractor to show the proper and most effective method then you can do it yourself.
Chiropractic orthotics, or custom insoles, can help immensely because they are custom made to each individual.
There are a variety of types designed for various types of pain and discomfort.
Custom chiropractic orthotics can work in nearly any type of shoe.
Athletic/Tennis/Skate shoes
Work Shoes/Boots
High heels
Sandals
They are easily and custom made specifically to your body, which factors in your weight, posture, and gait.
If you�re experiencing any of the symptoms like heel pain, throbbing pain when you wake-up, or pain along the arch of your foot, then don’t hesitate and make an appointment with us today!
Our chiropractic/physical therapy team will teach you how to make small adjustments to your lifestyle, show you how to stretch properly, and how to use custom chiropractic orthotics to get you back on your feet with comfort, control and freedom to live your life.
Manage *PLANTAR FASCIITIS PAIN* with Custom Foot Orthotics | El Paso, TX (2019)
Gloria underwent foot pain that stretched throughout her body. Her plantar fasciitis developed because of her regular activities. Gloria explains how her well-being has been influenced by her afflictions. The custom made foot orthotics supplied for her by Dr. Alex Jimenez, a chiropractor in El Paso, TX, tremendously helped relieve her foot pain and plantar fasciitis symptoms. Gloria explains the comfort that the custom-made foot orthotics supplied for her symptoms. Gloria highly recommends Dr. Alex Jimenez as the non-surgical selection for foot pain and plantar fasciitis treatment, among other problems.
What’s Afoot
Particularly true with foot dysfunction is when the mechanics of the foot are off, which can throw off the alignment of the entire body.�Overpronation and oversupination in the foot�can lead to severe and�chronic back pain. Ankle pain refers to any type of pain or discomfort in the ankle. This pain could generally be due to an injury, such as a sprain, or due to another health issue. As stated by the National University of Health Sciences, or NUHS, an ankle sprain is one of the most frequent causes of foot pain, making up 85 percent of all ankle injuries. A sprain occurs when the ligaments tear or are overstretched.
Chiropractors utilize a combination of treatment techniques and methods to ease ankle and foot pain. Chiropractic care is a safe and effective, alternative treatment option which focuses on the diagnosis, treatment, and prevention of a variety of injuries and conditions associated with the musculoskeletal and nervous system, including foot and ankle pain.
NCBI Resources
Plantar fasciitis/heel pain syndrome�is the most common cause of heel pain, that results from a gradual degeneration of the plantar fascia or sudden trauma.�Individuals describe the pain like sharp stabbing or deep aching in the middle of the heel or along the bottom of the foot that happens when walking or standing. Pain arises in the morning after taking the first few steps or after extended periods of sitting/lying down/non-activity.
If you have never been to see a chiropractor before, you may be wondering what you should expect. You likely have seen a video or heard someone talk about a chiropractic adjustment. Having your back or neck adjusted is definitely a big part of the process�but what else do you need to know? Continue reading to discover the basics of chiropractic and what you have to look forward to.
�Chiropractic Guide for First Time Patients
Your visit begins with a thorough examination.
Don�t expect to walk through the door of the chiropractor and get your back cracked. Chiropractors are highly-trained professionals that focus on individualized treatments and getting the best possible results. That means getting a clear picture of what your condition is and identifying the ideal treatments before starting with the adjustments.
The chiropractor will conduct a full physical examination to identify your injuries, any movement difficulties, etc. He or she will also ask a number of questions to find out how you feel and why you think you feel the way you do.
You might get an adjustment.
There are a lot of ways to adjust the human body, which are not limited to the standard adjustments you may have seen on TV or in movies. Your chiropractor can adjust not only your back but all of your joints, including knees, ankles, elbows and more. He or she can also use different tools to facilitate adjustments and employ techniques that range from extremely gentle to more forceful.
The adjustment you get will be based on your unique circumstances and the opinion of the chiropractor.
You might not get an adjustment.
It can be surprising to be told by the chiropractor that you won�t get an adjustment during your visit, but it does happen. Your chiropractor may determine that other therapies are better for your current condition. The adjustment may have to wait until your body is ready for it.
You will be offered alternative therapies.
Chiropractors focus on getting the best results for patients, which often means employing supplemental and complementary therapies in addition to chiropractic adjustments. Some common therapies include massage, decompression, electrical stimulation and more. Massage can relax soft tissues to allow for better adjustments, or to help adjustments stay in place. Decompression can increase blood flow to discs. Electrical stimulation can increase healing times.
You always have the final say in your treatment plan.
While the chiropractor will certainly have recommendations on which therapies are best suited to your needs, in the end, it is you who decides what happens. After your examination, the chiropractor will present the recommended options and let you decide if you want to start treatment.
You will experience improvements sooner rather than later.
Many patients are pleasantly surprised by how effective their chiropractic treatments are. Often after the first visit, you will feel less pain, more mobile and more at ease. A good adjustment and supplemental therapies can do a great deal to alleviate discomfort and stiffness. The good news is that each successive visit will only add to the good feelings you experience.
Getting Safe, Highly Effective Treatment
According to the American Chiropractic Association, chiropractic care is one of the safest drug-free, non-invasive treatments available for injuries and degenerative conditions related to your muscles, joints and skeletal system. There are so many benefits, and so few potential downsides, that it is hard to find a reason not to try chiropractic!
31 million Americans experience low back pain at any given time. This condition affects many, but finding the exact cause can be a challenge. Chiropractors are spinal specialists that are trained to not only alleviate pain but also find and help correct the cause of the problem.� Prevention is the best cure for any condition/ailment. When someone sees a chiropractor, they not only find relief for their condition, but they learn ways to prevent their symptoms in the future. Using proper exercise and ergonomics, they can ease the discomfort before it starts.
NCBI Resources
A�chiropractor�is the ideal�medical professional�to consult with for any unexplained pain in the musculoskeletal system. They are highly qualified professionals that their specialty is treating conditions like lower back pain and they are very affordable. If you or a loved one have pain in the lower back, gives us a call. We�re here to help!
Most people think that chiropractic care is something to do if they experience back or neck pain, and rightly so, as these are the most common reasons people visit a chiropractor. But chiropractic does way more than that.
Chiropractic helps with a variety of ailments from headaches to digestive issues and addresses problems like sports injuries, work injuries, arthritis, and injury prevention. Regular trips to the chiropractor are a good idea. Here are three important benefits that you can get from regular chiropractic adjustments.
What Taking an Active Role in Your Health Can Do
Chiropractic is a holistic kind of care that has a chiropractor serve as a guide as your own body uses its own innate ability to heal itself. When you see a chiropractor on a regular basis, even if there is not a pressing problem, you are taking an active role in assuring you are in the best health you can be.
Chiropractic adjustments correct misalignments in the spine that may be blocking nerve function and causing pain to muscles, joints, and ligaments. When you are adjusted by a chiropractor, these blocks are removed and you are able to move and function better than you did before.
A chiropractor can also provide you with nutritional and lifestyle advice, including exercises you can do between visits that will improve strength, flexibility, and various other functions. Without your active participation and cooperation, the success of chiropractic diminishes, so you can feel good about taking responsibility for your own health.
Improved Neurological Conditions
The spine connects to several different areas of the body, including the brain. Adjustments have been shown to increase blood flow to the brain, which in turn improves function in many areas.
The brain and spine are frequent communicators, and the nervous system is often the “wires” that are used to assure proper communication. Stress can trigger misalignments and the breakdown in these systems. Chiropractic is able to identify when stress is placed on these nerves and has even been shown to increase white blood cell count in some patients.
Eliminated Need for Pain Medications
One of the cornerstones of chiropractic is that it does not rely on pain medications or surgery in order to treat pain. Instead, it is designed to trigger your body’s own ability to heal itself without drugs and surgery.
Through methods such as manual adjustment, massage, and electrical muscle stimulation, chiropractic strengthens communication throughout the body in order to help it heal naturally. Chiropractors use important diagnostic tools such as x-rays, laboratory analysis, and reviewing your health history to pursue a treatment plan.
Conversely, when misalignments are allowed to build up over time, there is a greater risk that you will be tempted to seek out pain medications in order to mask the pain temporarily. While occasional use of these is okay, over time they can build up in the system and damage liver function, so it is important to find other methods of pain management whenever possible.
In closing, chiropractic benefits the overall health of people that utilize it consistently. So if you’re ready to experience these benefits yourself, just pick up the phone and give us a call. We’re here to help!
Benefits of Custom-Made *ORTHOTICS* | El Paso, Tx
Overpronation
99% of the population has some degree of foot pronation.
Foot pronation occurs when the foot/feet roll inwards.
People with excessive pronation may experience inward rotation of the knee and forward tilting of the pelvis, which causes pain in the:
Feet
Knees
Hips
Back
Shoulders
Neck
Foot Orthotics
Foot Dysfunction�can very easily cause a domino effect that extends all the way to the back. The feet are the foundation of the body and when there is a problem with the way they function it can cause the entire body to shift out of alignment.
Pronation & Misalignment
For the foot to function correctly, there must be a significant degree of pronation. However, excessive pronation, or overpronation, can cause injury and damage to the foot and ankle. It creates the arch in the foot to flatten, and the ligaments, tendons, and muscles under the foot overstretch.
NCBI Resources
Chiropractic seeks to find the cause of the conditions it is used to treat, including pain, instead of just treating symptoms. Because of this, the chiropractor will work to find the cause of the pain.
Sometimes there are abnormalities of the spine and it causes a misalignment of the natural curvatures or some curvatures may be exaggerated. These unnatural curvatures of the spine are characterized by three health conditions called lordosis, kyphosis, and scoliosis.
It is not intended to be naturally bent, twisted, or curved. The natural state of a healthy spine is somewhat straight with slight curves running front to back so that a side view would reveal them.
Viewing the spine from the back, you should see something completely different � a spine that runs straight down, top to bottom with no side to side curves. This doesn�t always happen though.
The spine is comprised of vertebrae, small bones that are stacked on top of each other with impact cushioning discs between each one. These bones act as joints, allowing the spine to bend and twist in a variety of ways.
They gently curve, sloping slightly inward at the small of the back, and again slightly at the neck. The pull of gravity, combined with body movement, can put a great deal of stress on the spine and these slight curves help absorb some of the impact.
Different conditions for different types of spinal curvatures
Each of these three spinal curvature disorders affects a certain area of the spine in a very specific way.
Hyper or Hypo Lordosis � This spinal curvature disorder affects the lower back, causing the spine to curve inwards or outwards significantly.
Hyper or Hypo Kyphosis � This spinal curvature disorder affects the upper back, causing the spine to bow, resulting in that area rounding or flattening abnormally.
Scoliosis � This spinal curvature disorder can affect the entire spine, causing it to curve sideways, forming a C or S shape.
What are the symptoms?
Each type of curvature exhibits its own set of symptoms. While some symptoms may overlap, many are unique to the specific curvature disorder.
Lordosis
A �swayback� appearance where the buttocks stick out or are more pronounced.
Discomfort in the back, typically in the lumbar region
When lying on a hard surface on the back, the lower back area does not touch the surface, even when attempting to tuck the pelvis and straighten the lower back.
Difficulty with certain movements
Back pain
Kyphosis
A curve or hump to the upper back
Upper back pain and fatigue after sitting or standing for long periods (Scheuermann�s kyphosis)
Leg or back fatigue
The head bends far forward instead of being more upright
Scoliosis
Hips or waist are uneven
One shoulder blade is higher than the other
The person leans to one side
What are the causes?
Many different health issues can cause the spine to become misaligned or to form a spinal curvature. Each of the spinal conditions mentioned is affected by different conditions and situations.
Lordosis
Osteoporosis
Achondroplasia
Discitis
Obesity
Spondylolisthesis
Kyphosis
Kyphosis
Arthritis
Tumors on or in the spine
Congenital kyphosis (abnormal development of the vertebrae while the person is in utero)
Spina bifida
Scheuermann’s disease
Spine infections
Osteoporosis
Habitual slouching or poor posture
Scoliosis is still a bit of a mystery to doctors. They are not certain what exactly causes the most common form of scoliosis that is typically seen in children and adolescents. Some of the causes that they have pinpointed include:
There are screenings available for both children and adults to identify any spinal curvatures in their early stages through your chiropractor. Early detection of these disorders is crucial in identifying them before they become too serious.
Personalized Spine & *SCIATICA TREATMENT* | El Paso, TX (2019)
The spinal cord and brain make up the central nervous system while the spinal nerves that branch to the spinal cord and cranial nerves that branch to the brain makes up the peripheral nervous system.
There are thirty-one sets of nerves that extend out of the spinal cord and are connected to it by the nerve root. Each nerve branches out about a half inch from the spinal cord before dividing into smaller branches. The dorsal rami are on the posterior side of the branch while the larger ventral rami are on the anterior side.
The dorsal rami provide nerve function for the skin of the trunk and posterior muscles. The ventral rami from T1 to T12 provide nerve function to the skin of the trunk as well as the lateral and anterior muscles. The anterior divisions that remain for plexuses, networks that provide nerve function to the body. Each plexus has specific areas on the body for skin sensitivity as well as certain muscles. Their point where they exit the spine determines how they are numbered. The four primary plexuses are:
Cervical plexus, C1 � C4, innervates the diaphragm, shoulder, and neck
Brachial plexus, C5 � T1, innervates the upper limbs
Lumbar plexus, T12/L1 � L4, innervates the thigh
Sacral plexus, L4 � S4, innervates the leg and foot.
These spinal nerves have two sets of fibers: motor and sensory. Motor fibers facilitate movement and provide nerve function to the muscles. Sensory fibers facilitate sensitivities to touch, temperature and other stimuli. They provide nerve function to the skin.
What are Myotomes and Dermatomes?
A group of muscles that are innervated by the motor fibers that stem from a specific nerve root is called a myotome. An area of the skin that is innervated by the sensory fibers that stem from a specific nerve root is called a dermatome. These patterns of myotome and dermatome are almost always identical from person to person. There are occasionally variances, but that is rare.
This consistency allows doctors to treat nerve pain in patients. If a specific area is hurting, they know that it is attributed to a certain myotome or dermatome, whichever the case may be, and its corresponding nerve root. Problems with nerve damage are often the result of stretching the nerve or compressing it.
When the nerves are injured in specific areas like the lumbosacral or brachial plexus, it presents as sensory and motor deficits in the limbs that correspond to them. Myotomes and dermatomes are used to assess the extent of the damage.
How are Myotomes and Dermatomes used to Assess Nerve Damage?
When a doctor tests for nerve root damage in a patient, he or she will often test the myotomes or dermatomes for the nerves assigned to that location. A dermatome is examined for abnormal sensation, such as hypersensitivity or lack of sensitivity.
This is done by using stimulus inducing tools such as a pen, paper clip, pinwheel, fingernails, cotton ball, or pads of the fingers. The patient is instructed to provide feedback regarding their response. Some of the abnormal sensation responses include:
A myotome is tested for nerve damage in the muscles which presents as muscle weakness. This grading scale, which assigns a rating to the degree of muscle weakness, is often used:
5 � Normal � Complete range of motion against gravity with full resistance
4 � Good � Complete range of motion against gravity with some resistance
3 � Fair � Complete range of motion against gravity with no resistance, active ROM
2 � Poor � Complete range of motion with some assistance and gravity eliminated
1 � Trace � Evidence of slight muscular contraction, no joint motion evident
0 � Zero � No evidence of muscle contraction
During a typical chiropractic exam, your chiropractor will assess both dermatomes and myotomes for potential neurological problems. This gives them additional insight on how to treat your condition, whether it’s related to a subluxation of vertebral bodies or other, other disease processes.
It is estimated that scoliosis affects anywhere from 2 to 3 percent of children and adults in the United States. That is roughly six to nine million people. While it seems to develop most commonly within specific age ranges for boys and girls, it can also develop in infancy. Every year, approximately 30,000 children are fitted with a scoliosis back brace while 38,000 people have spinal fusion surgery to correct the problem. Scoliosis screenings can have tremendous benefits by identifying both risk factors for scoliosis and allowing for early treatment.
The earlier you detect scoliosis, the easier it is to treat.
Scoliosis typically develops in childhood. For girls, it usually occurs between 7 and 14 years of age. Boys develop it a little later, between 6 and 16 years of age.
Getting a scoliosis screening each year during these critical age ranges allow doctors to identify the condition early and begin treating it before it gets serious. Advanced scoliosis can require extensive treatments, bracing, and even surgery.
Chiropractic has been shown to help scoliosis, as do stretching, special exercises, and physical therapy. There are spinal adjustments that chiropractors do that are specific to the treatment of scoliosis.
When addressing the condition early on, the Cobb angle can be stopped from progressing and even reduced so that the spine has a more natural curve. Non-surgical treatments tend to be much more effective in the earlier stages of scoliosis, so early detection and early diagnosis are critical.
Identifying high-risk cases early can address current issues and prevent future ones.
Chiropractors can identify certain scoliosis risk factors in children before the condition even develops. A scoliosis screening allows them to spot tension in a child�s spinal cord � a common sign that they will develop scoliosis.
When parents are aware that their child is in a high-risk category for developing scoliosis, they can take proactive measures with home monitoring for the signs of scoliosis as well as keeping up with the course of recommended screenings. They will know to look for the signs and can address them quickly so that treatment can be started at the earliest possible time.
Help researchers and doctors become more effective in treating scoliosis.
The early stages and development of scoliosis are still shrouded in mystery for researchers and doctors. While there have been great strides made in better understanding the condition, there is still much left to learn.
There have been many studies that have aided doctors in identifying high-risk children and making early stage diagnoses, such as how the�angle of the ankle and foot are linked to scoliosis. However, screening, diagnosis, and treatment are vital to maintaining the flow of data for more studies to be conducted and more research to be done.
More mainstream screenings mean�identifying more cases of scoliosis at the early stages. This would have a two-prong effect on research. It would provide more data to be reviewed and studied, and it would increase interest in the condition as more cases of early stage scoliosis is found. This would further spur research.
Avoid the �waiting game� of seeing if scoliosis will progress.
Any parent who has had to wait for the results of a test or to see if a condition will develop or worsen knows well the anxiety of playing that waiting game. A family is usually the first person to discover scoliosis in a child.
While they may suspect a problem, or know that a problem exists, they may take a �wait and see� approach in getting treatment. If the curve worsens they may eventually seek treatment, but the constant nagging of not knowing if the curve will get worse � and the anxiety it produces � can impact not only the parents� peace of mind�but the child�s as well.
Scoliosis screenings provide peace of mind and monitor the child�s development so that if their scoliosis does progress or become a problem it can be addressed in the quickest, most efficient way possible.
About 1.5 million people in the United States have rheumatoid arthritis. Rheumatoid arthritis, or RA, is a chronic, autoimmune disease characterized by pain and inflammation of the joints. With RA, the immune system, which protects our well-being by attacking foreign substances like bacteria and viruses, mistakenly attacks the joints. Rheumatoid arthritis most commonly affects the joints of the hands, feet, wrists, elbows, knees and ankles. Many healthcare professionals recommend early diagnosis and treatment of RA.
Abstract
Rheumatoid arthritis is the most commonly diagnosed systemic inflammatory arthritis. Women, smokers, and those with a family history of the disease are most often affected. Criteria for diagnosis include having at least one joint with definite swelling that is not explained by another disease. The likelihood of a rheumatoid arthritis diagnosis increases with the number of small joints involved. In a patient with inflammatory arthritis, the presence of a rheumatoid factor or anti-citrullinated protein antibody, or elevated C-reactive protein level or erythrocyte sedimentation rate suggests a diagnosis of rheumatoid arthritis. Initial laboratory evaluation should also include complete blood count with dif- ferential and assessment of renal and hepatic function. Patients taking biologic agents should be tested for hepatitis B, hepatitis C, and tuberculosis. Earlier diagnosis of rheumatoid arthritis allows for earlier treatment with disease-modifying antirheumatic agents. Combinations of medications are often used to control the disease. Methotrexate is typically the first-line drug for rheumatoid arthritis. Biologic agents, such as tumor necrosis factor inhibitors, are generally considered second-line agents or can be added for dual therapy. The goals of treatment include minimiza- tion of joint pain and swelling, prevention of radiographic damage and visible deformity, and continuation of work and personal activities. Joint replacement is indicated for patients with severe joint damage whose symptoms are poorly controlled by medical management. (Am Fam Physician. 2011;84(11):1245-1252. Copyright � 2011 American Academy of Family Physicians.)
Rheumatoid arthritis (RA) is the most common inflammatory arthritis, with a lifetime prevalence of up to 1 percent worldwide.1 Onset can occur at any age, but peaks between 30 and 50 years.2 Disability is common and significant. In a large U.S. cohort, 35 percent of patients with RA had work disability after 10 years.3
Etiology and Pathophysiology
Like many autoimmune diseases, the etiology of RA is multifactorial. Genetic susceptibility is evident in familial clustering and monozygotic twin studies, with 50 percent of RA risk attributable to genetic factors.4 Genetic associations for RA include human leukocyte antigen-DR45 and -DRB1, and a variety of alleles called the shared epitope.6,7 Genome-wide association studies have identified additional genetic signatures that increase the risk of RA and other autoimmune diseases, including STAT4 gene and CD40 locus.5 Smoking is the major environmental trigger for RA, especially in those with a genetic predisposition.8 Although infections may unmask an autoimmune response, no particular pathogen has been proven to cause RA.9
RA is characterized by inflammatory pathways that lead to proliferation of synovial cells in joints. Subsequent pannus formation may lead to underlying cartilage destruction and bony erosions. Overproduction of pro-inflammatory cytokines, including tumor necrosis factor (TNF) and interleukin-6, drives the destructive process.10
Risk Factors
Older age, a family history of the disease, and female sex are associated with increased risk of RA, although the sex differential is less prominent in older patients.1 Both current and prior cigarette smoking increases the risk of RA (relative risk [RR] = 1.4, up to 2.2 for more than 40-pack-year smokers).11
Pregnancy often causes RA remission, likely because of immunologic tolerance.12 Parity may have long-lasting impact; RA is less likely to be diagnosed in parous women than in nulliparous women (RR = 0.61).13,14 Breastfeeding decreases the risk of RA (RR = 0.5 in women who breastfeed for at least 24 months), whereas early menarche�(RR = 1.3 for those with menarche at 10 years of age or younger) and very irregular menstrual periods (RR = 1.5) increase risk.14 Use of oral contraceptive pills or vitamin E does not affect RA risk.15
Diagnosis
Typical Presentation
Patients with RA typically present with pain and stiffness in multiple joints. The wrists, proximal interphalangeal joints, and metacarpophalangeal joints are most commonly involved. Morning stiffness lasting more than one hour suggests an inflammatory etiology. Boggy swelling due to synovitis may be visible (Figure 1), or subtle synovial thickening may be palpable on joint examination. Patients may also present with more indolent arthralgias before the onset of clinically apparent joint swelling. Systemic symptoms of fatigue, weight loss, and low-grade fever may occur with active disease.
Diagnostic Criteria
In 2010, the American College of Rheumatology and European League Against Rheumatism collaborated to create new classification criteria for RA (Table 1).16 The new criteria are an effort to diagnose RA earlier in patients who may not meet the 1987 American College of Rheumatology classification criteria. The 2010 criteria do not include presence of rheumatoid nodules or radiographic erosive changes, both of which are less likely in early RA. Symmetric arthri- tis is also not required in the 2010 criteria, allowing for early asymmetric presentation.
In addition, Dutch researchers have developed and validated a clinical prediction rule for RA (Table 2).17,18 The purpose of this rule is to help identify patients with undifferentiated arthritis that is most likely to progress to RA, and to guide follow-up and referral.
Diagnostic Tests
Autoimmune diseases such as RA are often characterized by the presence of autoanti- bodies. Rheumatoid factor is not specific for RA and may be present in patients with other diseases, such as hepatitis C, and in healthy older persons. Anti-citrullinated protein antibody is more specific for RA and may play a role in disease pathogenesis.6 Approxi- mately 50 to 80 percent of persons with RA have rheumatoid factor, anti-citrullinated protein antibody, or both.10 Patients with RA may have a positive antinuclear antibody test result, and the test is of prognostic impor- tance in juvenile forms of this disease.19 C-reactive protein levels and erythrocyte sedimentation rate are often increased with active RA, and these acute phase reactants are part of the new RA classification criteria.16 C-reactive protein levels and erythrocyte sedimentation rate may also be used to follow disease activity and response to medication.
Baseline complete blood count with differential and assessment of renal and hepatic function are helpful because the results may influence treatment options (e.g., a patient with renal insufficiency or significant thrombocytopenia likely would not be prescribed a nonsteroidal anti-inflammatory drug [NSAID]). Mild anemia of chronic disease occurs in 33 to 60 percent of all patients with RA,20 although gastrointestinal blood loss should also be considered in patients taking corticosteroids or NSAIDs. Methotrexate is contraindicated in patients with hepatic disease, such as hepatitis C, and in patients with significant renal impairment.21 Biologic therapy, such as a TNF inhibitor, requires a negative tuberculin test or treatment for latent tuberculosis. Hepatitis B reactivation can also occur with TNF inhibitor use.22 Radiography of hands and feet should be performed to evaluate for characteristic periarticular erosive changes,�which may be indicative of a more aggressive RA subtype.10
Differential Diagnosis
Skin findings suggest systemic lupus erythematosus, systemic sclerosis, or psoriatic arthritis. Polymyalgia rheumatica should be considered in an older patient with symptoms primarily in the shoulder and hip, and the patient should be asked questions related to associated temporal arteritis.
Chest radiography is helpful to evaluate for sarcoidosis as an etiology of arthritis.�Patients with inflammatory back symptoms, a history of inflammatory bowel disease, or inflammatory eye disease may have spondyloarthropathy. Persons with less than six weeks of symptoms may have a viral process, such as parvovirus. Recurrent self-limited episodes of acute joint swelling suggest crystal arthropathy, and arthrocentesis should be performed to evaluate for monosodium urate monohydrate or calcium pyrophosphate dihydrate crystals. The presence of numerous myofascial trigger points and somatic symptoms may suggest fibromyalgia, which can coexist with RA. To help guide diagnosis and determine treatment strategy, patients with inflammatory arthritis should be promptly referred to a rheumatology subspecialist.16,17
Rheumatoid arthritis, or RA, is the most common type of arthritis. RA is an autoimmune disease, caused when the immune system, the human body’s defense system, attacks its own cells and tissues, particularly the joints. Rheumatoid arthritis is frequently identified by symptoms of pain and inflammation, often affecting the small joints of the hands, wrists and feet. According to many healthcare professionals, early diagnosis and treatment of RA is essential to prevent further joint damage and decrease painful symptoms. Dr. Alex Jimenez D.C., C.C.S.T. Insight
Treatment
After RA has been diagnosed and an initial evaluation performed, treatment should begin. Recent guidelines have addressed the management of RA,21,22 but patient preference also plays an important role. There are special considerations for women of childbearing age because many medications have deleterious effects on pregnancy. Goals of therapy include minimizing joint pain and swelling, preventing deformity (such as ulnar deviation) and radiographic damage (such as erosions), maintaining quality of life (personal and work), and controlling extra-articular manifestations. Disease-modifying antirheumatic drugs (DMARDs) are the mainstay of RA therapy.
DMARDs
DMARDs can be biologic or nonbiologic (Table 3).23 Biologic agents include monoclonal antibodies and recombinant receptors to block cytokines that promote the inflammatory cascade responsible for RA symptoms. Methotrexate is recommended as the first- line treatment in patients with active RA, unless contraindicated or not tolerated.21 Leflunomide (Arava) may be used as an alternative to methotrexate, although gastrointestinal adverse effects are more common. Sulfasalazine (Azulfidine) or hydroxychloroquine (Plaquenil) pro-inflammatory as monotherapy in patients with low disease�activity or without poor prognostic features (e.g., seronegative, non-erosive RA).21,22
Combination therapy with two or more DMARDs is more effective than monotherapy; however, adverse effects may also be greater.24 If RA is not well controlled with a nonbiologic DMARD, a biologic DMARD should be initiated.21,22 TNF inhibitors are the first-line biologic therapy and are the most studied of these agents. If TNF inhibitors are ineffective, additional biologic therapies can be considered. Simultaneous use of more than one biologic therapy (e.g., adalimumab [Humira] with abatacept [Orencia]) is not�recommended because of an unacceptable rate of adverse effects.21
NSAIDs and Corticosteroids
Drug therapy for RA may involve NSAIDs and oral, intramuscular, or intra-articular corticosteroids for controlling pain and inflammation. Ideally, NSAIDs and corticosteroids are used only for short-term management. DMARDs are the preferred therapy.21,22
Complementary Therapies
Dietary interventions, including vegetarian and Mediterranean diets, have been�studied in the treatment of RA without convincing evidence of benefit.25,26 Despite some favorable outcomes, there is a lack of evidence for the effectiveness of acupuncture in placebo-controlled trials of patients with RA.27,28 In addition, thermotherapy and therapeutic ultrasound for RA have not been studied adequately.29,30 A Cochrane review of herbal treatments for RA concluded that gamma-linolenic acid (from evening primrose or black currant seed oil) and Tripterygium wilfordii (thunder god vine) have potential benefits.31 It is important to inform patients that serious adverse effects have been reported with use of herbal therapy.31
Exercise and Physical Therapy
Results of randomized controlled trials sup- port physical exercise to improve quality of life and muscle strength in patients with RA.32,33 Exercise training programs have not been shown to have deleterious effects on RA disease activity, pain scores, or radiographic joint damage.34 Tai chi has been shown to improve ankle range of motion in persons with RA, although randomized trials are limited.35 Randomized controlled trials of Iyengar yoga in young adults with RA are underway.36
Duration of Treatment
Remission is obtainable in 10 to 50 percent of patients with RA, depending on how remission is defined and the intensity of therapy.10 Remission is more likely in males, nonsmokers, persons younger than 40 years, and in those with late-onset disease (patients older than 65 years), with shorter duration of disease, with milder disease activity, without elevated acute phase reactants, and without positive rheumatoid factor or anti-citrullinated protein antibody findings.37
After the disease is controlled, medication dosages may be cautiously decreased to the minimum amount necessary. Patients will require frequent monitoring to ensure stable symptoms, and prompt increase in medication is recommended with disease flare-ups.22
Joint Replacement
Joint replacement is indicated when there is severe joint damage and unsatisfactory control of symptoms with medical management. Long-term outcomes are support, with only 4 to 13 percent of large joint replacements requiring revision within 10 years.38 The hip and knee are the most commonly replaced joints.
Long-Term Monitoring
Although RA is considered a disease of the joints, it is also a systemic disease capable of involving multiple organ systems. Extra-articular manifestations of RA are included in Table 4.1,2,10
Patients with RA have a twofold increased risk of lymphoma, which is thought to be caused by the underlying inflammatory�process, and not a consequence of medical treatment.39 Patients with RA are also at an increased risk of coronary artery disease, and physicians should work with patients to modify risk factors, such as smoking, high blood pressure, and high cholesterol.40,41 Class III or IV congestive heart failure (CHF) is a contraindication for using TNF inhibitors, which can worsen CHF outcomes.21 In patients with RA and malignancy, caution is needed with continued use of DMARDs, especially TNF inhibitors. Biologic DMARDs, methotrexate, and leflunomide should not be initiated in patients with active herpes zoster, significant fungal infection, or bacterial infection requiring antibiotics.21 Complications of RA and its treatments are listed in Table 5.1,2,10
Prognosis
Patients with RA live three to 12 years less than the general population.40 Increased mortality in these patients is mainly due to accelerated cardiovascular disease, especially in those with high disease activity and chronic inflammation. The relatively new biologic therapies may reverse progression of atherosclerosis and extend life in those with RA.41
Data Sources: A PubMed search was completed in Clinical Queries using the key terms rheumatoid arthritis, extra-articular manifestations, and disease-modifying antirheumatic agents. The search included meta-analyses, randomized controlled trials, clinical trials, and reviews. Also searched were the Agency for Healthcare Research and Quality evidence reports, Clinical Evidence, the Cochrane database, Essential Evidence, and UpToDate. Search date: September 20, 2010.
Author disclosure: No relevant financial affiliations to disclose.
In conclusion, rheumatoid arthritis is a chronic, autoimmune disease which causes painful symptoms, such as pain and discomfort, inflammation and swelling of the joints, among others. The joint damage characterized as RA is symmetrical, meaning it generally affects both sides of the body. Early�diagnosis is essential for treatment of RA. The scope of our information is limited to chiropractic and spinal health issues. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at�915-850-0900�.
Curated by Dr. Alex Jimenez
Additional Topic Discussion: Relieving Knee Pain without Surgery
Knee pain is a well-known symptom which can occur due to a variety of knee injuries and/or conditions, including�sports injuries. The knee is one of the most complex joints in the human body as it is made-up of the intersection of four bones, four ligaments, various tendons, two menisci, and cartilage. According to the American Academy of Family Physicians, the most common causes of knee pain include patellar subluxation, patellar tendinitis or jumper’s knee, and Osgood-Schlatter disease. Although knee pain is most likely to occur in people over 60 years old, knee pain can also occur in children and adolescents. Knee pain can be treated at home following the RICE methods, however, severe knee injuries may require immediate medical attention, including chiropractic care.
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