A Rectocele

What Is A Rectocele? What Causes A Rectocele?


A rectocele, also called a proctocele, results from a tear in the normally tough, fibrous, sheet-like divider between the rectum and vagina (rectovaginal septum), causing a bulge to protrude as a hernia into the vagina when there is a bowel movement. It is mainly caused by childbirth or a hysterectomy. It is more likely to occur as a result of childbirth if the baby weighs over nine pounds, or the birth was fast.

If the rectocele is small the patient may not notice it, there may be no signs or symptoms at all. In larger cases there may be a perceptible protrusion of tissue through the vaginal opening. The woman may experience some discomfort - pain is rare.

According to Medilexicon's medical dictionary a rectocele is:

"Prolapse or herniation of the rectum."

In the majority of cases the patient can treat the rectocele with self-care and other non-surgical methods. Surgery may be required in severe cases.

Males may also develop a rectocele (extremely rare).

What are the signs and symptoms of a rectocele?

A symptom is something the patient senses and describes, while a sign is something other people,
such as the doctor notice. For example, drowsiness may be a symptom while dilated pupils may be a sign.

In mild cases the woman may sense pressure within the vagina, she may feel that her bowels have not been completely emptied after going to the toilet.

In moderate cases an attempt to evacuate can push the stool into the rectocele rather that out through the anus, there may be pain and discomfort during evacuation. There is a higher chance of having constipation. Some women may experience pain during sexual intercourse.

Some women say it feels as if "something is falling out/down" within the pelvis.

In severe cases there may be vaginal bleeding, occasional fecal incontinence, and sometimes the prolapse of the bulge through the mouth of the vagina, or rectal prolapse through the anus.

Many females have rectoceles, but only a few may feel any symptoms.

What can cause a rectocele?

Roctoceles can have several causes, the most common being childbirth, especially when the baby is big (over nine pounds). Rapid births are also common causes. Experts say that using forceps during delivery is more likely to cause vaginal injury than directly cause the tear that leads to a rectocele.
The more vaginal births a woman has had, the higher her risk. However, females who have never given birth can also develop a rectocele.

The following may also cause rectoceles:
  • A drop in estrogen levels when a woman gets older (menopause) can make pelvic tissues less elastic, increasing the risk of developing a rectocele
  • A hysterectomy
  • Chronic constipation
  • Lots of long-term coughing, as in chronic bronchitis
  • Pelvic surgery
  • Sexual abuse during childhood (often an overlooked cause)
  • Obesity or overweight
The underlying cause is the weakening of the pelvic support structures and weakening of the rectovaginal septum.

Females who only have cesarean births have a significantly lower chance of developing rectoceles compared to those who give birth naturally.

How is a rectocele diagnosed?

Doctors can usually diagnose a rectocele after examining the vagina and rectum. However, determining how big it is can sometimes be difficult. The patient may have to answer a questionnaire which helps the physician assess the degree of prolapse and whether it is having any impact on the her quality of life.

Imaging tests are not usually needed for an accurate diagnosis. However, the doctor may detect something during the physical examination that requires identification. In such cases an MRI (magnetic resonance imaging) scan or an X-ray may be ordered. Imaging tests can also show how big the rectocele is and how well the patient is emptying her rectum. A defecagram (defecrography) is a type of X-ray study that helps the doctor determine the size of the rectoceles and how well the patient is evacuating.

What are the treatment options for a rectocele?

In mild cases no medical treatment, apart from some pelvic exercises (Kegel exercises), is required. The patient should consume plenty of fluids and eat fiber to avoid constipation. It is important that she avoids prolonged straining when going to the toilet.

A woman with a rectoceles should avoid any type of heavy lifting and/or prolonged coughing.

If the patient is overweight or obese the doctor will advise her to try to lose weight.

The doctor may prescribe stool softeners. Hormone replacement therapy (HRT) may be recommended for post-menopausal women.

A vaginal pessary (plastic/rubber ring inserted into the vagina) helps support the protruding tissues.

Surgery, if necessary, is directed at repairs to the rectovaginal septum, which involves a simple incision (placation) of the vaginal skin.


Don't smoke. Smoking increases the risk of having a chronic cough.

Do your Kegel exercises regularly, especially after you have given birth.

Try to maintain a healthy body weight.

If you have a chronic cough, get it treated.

Avoid constipation and prolonged straining when going to the toilet.


Repetitive Strain Injury (RSI)

What Is Repetitive Strain Injury (RSI)? What Causes Repetitive Strain Injury?

Repetitive strain injury or RSI, also known as repetitive stress injury, repetitive motion injuries, repetitive motion disorder (RMD), cumulative trauma disorder (CTD), occupational overuse syndrome, overuse syndrome, and regional musculoskeletal disorder is a range of painful or uncomfortable conditions of the muscles, tendons, nerves and other soft tissues. RSI is usually caused by repetitive use of a certain part of the body, often somewhere in the upper limbs (arms).

Repetitive strain injury is typically related to an occupation (job), but may also be linked to some kinds of leisure activity. As opposed to a sudden or 'normal' injury, RSI signs and symptoms may continue for much longer.

Experts say that repetitive strain injury is an injury of the musculoskeletal and nervous systems that may be the result of repetitive tasks, forceful exertions, vibrations, pressing against hard surfaces (mechanical compression), or sustained or awkward positions. Conditions such as RSI tend to be linked to both physical and psychosocial stressors (mental stress).

A US study found that acute and sudden computer-related injuries, a separate category to injuries that take a while to emerge like repetitive strain injury, are rising rapidly in the US, and that young children are most affected.

Many health care professionals refer to RSI as ULD (upper limb disorder) because it frequently involves the forearm, elbow, wrist or hands. RSI often affects the neck as well.

The following are examples of repetitive strain injuries:

  • Bursitis - happens when the bursa is inflamed. The bursa acts as a cushion between bones, tendons, joints and muscles - bursae are fluid-filled sacs (the plural of bursa is bursae). People with bursitis will feel pain at the site of inflammation.
  • Carpal tunnel syndrome (CTS) - caused by the compression of the median nerve through the carpal tunnel in the wrist area. When constricted, blood cannot flow freely through the hand to the fingers causing individuals with CTS to experience numbness and pain in the hand.
  • Diffuse RSI - conditions are where the patient complains of pain and yet, on examination by a health care professional, nothing physical can be found to be wrong.
  • Dupuytren's contracture - a condition that affects the hands and fingers. It is an uncommon hand deformity in which the connective tissue under the skin of the palm contract and toughen over time. It causes one or more of the fingers on one or both hands to bend into the palm of the hand.
  • Epicondylitis - often occurs as a result of strenuous overuse of the muscles and tendons where the bone and tendon join. Tennis elbow and golfer's elbow are examples.
  • Ganglion - fluid-filled swellings that tend to form on top of joints or tendons in the wrists, hands, and feet. They have the appearance of firm or spongy sacs of liquid and their insides consist of a sticky, clear, thick, jelly-like fluid.
  • Rotator cuff syndrome - inflammation of tendons and muscles in the shoulder.
  • Tendinitis - also known as tendonitis, is the inflammation of a tendon.
  • Tenosynovitis - the sheath around the tendon becomes inflamed, specifically the inner lining of the tendon sheath.
  • Trigger finger - a condition in which one of your fingers or your thumb catches in a bent position. The tendon sheaths of the fingers or thumb become inflamed - the tendon is also inflamed.
RSI is frequently caused by such activities as golf or tennis - activities which require repetitive movements. Signs and symptoms generally persist if left untreated. Experts say that the number of people experiencing RSI as a result of computer use has been increasing for many years. RSI that is caused by typing on a computer keyboard is often referred to as writer's cramp.

Experts often refer to two main types of RSI:
  • Type 1 RSI - usually caused by repetitive tasks, but not always; some people who do not perform repetitive tasks may have Type 1 RSI. The muscles and tendons swell. Examples of Type 1 RSI include:

  • Type 2 RSI - there is a feeling of pain but no obvious inflammation or swelling in the area where symptoms are felt. The National Health Service (NHS), UK, refers to Type 2 RSI "when a person's symptoms do not fit into one of the (above listed) conditions". Also called non-specific pain syndrome.

What are the signs and symptoms of repetitive strain injury (RSI)?

A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.

Signs and symptoms vary, depending on which part of the body is affected, and what caused the problem in the first place. Initially, symptoms may only occur when the individual is doing the repetitive task - they will slowly go away when the person rests. Eventually, though, symptoms may be present all the time (and worsen during the repetitive task) if left untreated.

The most common RSI signs and symptoms include:
  • Tenderness in the affected muscle or joint
  • Pain in the affected muscle or joint
  • A throbbing (pulsating) sensation in the affected area
  • Pins and needles (tingling) in the affected area, especially the hand or arm
  • Loss of sensation in the hand
  • Loss of strength in the hand
Some patients with persistent symptoms may have sleeping problems - the condition is often irreversible at this stage. Early treatment is much more likely to prevent any irreversible damage.

What are the causes of repetitive strain injury (RSI)?

Experts say the causes of RSI are a bit of a mystery. Sometimes there is no swelling in the muscles or tendons, but the patient feels pain and discomfort. We know that often repetitive movements of a part of the body are linked to symptoms - movements, such as typing, using a computer mouse, poor posture while doing a movement, using excessive force, doing the repetitive movements without sufficient breaks, etc. But the precise reason for RSI is not clear. Neither do we know why some people develop RSI and others don't, when doing the same tasks for similar periods.

Some studies indicate that some psycho-social workplace factors, such as stress may be significant contributory factors to RSI. Perhaps stress affects our muscles (makes them tense), which in turn makes us more sensitive to pain.

The following are seen as causes of RSI:
  • The overuse of muscles in our hands, wrists, arms, shoulders, neck and back are linked to RSI symptoms.
  • The area is affected by repeated actions, which are usually performed on a daily basis over a long period.
  • The repetitive actions are done in a cold place.
  • The individual has to use vibrating equipment.
  • Forceful movements are involved.
  • Workstations are poorly organized.
  • Equipment is badly designed.
  • The individual commonly adopts an awkward posture.
  • There are not enough rest breaks.

How is repetitive strain injury (RSI) diagnosed?

There is no objective way to diagnose RSI - there are no tests to confirm a diagnosis. Signs and symptoms could be caused by a wide range of factors.

A health care professional will usually diagnose RSI if the signs and symptoms can be linked to a specific repetitive task, and the symptoms lessen when the task is stopped.

If the patient develops a definable condition, such as frozen shoulder, carpal tunnel syndrome or tendinitis, it may or may not be linked to repetitive tasks.

What are the treatment options for repetitive strain injury (RSI)?

The National Health Service (NHS), UK, advises people to see their doctor as soon as they experience symptoms. Early treatment is more likely to result in effective outcomes.

A GP (general practitioner, primary care physician) will probably ask the patient to stop doing the repetitive movements which may be causing the symptoms. If this is not possible, as may be the case with work-related activities, the individual needs to tell his/her employer.

The aim of treatment is to help ease the pain, and to enable the patient to gain strength and mobility in the affected area.

Pain relief - a course of anti-inflammatory painkillers, such as ibuprofen or aspirin may help. Children under 16 years of age should not take aspirin. The following may also help:
  • Use of heat (applying heat to the affected area)
  • Cold packs
  • Elastic supports
  • Firm splints
Steroid injections - these may be administered if there is a well defined inflammation in the affected area.

Sleep - if the patient is having sleeping problems the doctor may prescribe a short course of sleeping tablets. Good sleep may help relax the patient and alter his/her perception and susceptibility to pain.

Physical therapy (UK: physiotherapy), exercise and relaxation techniques - a physical therapist (UK: physiotherapist) may help the patient adopt proper posture, as well as teaching him/her to strengthen muscles. Electrotherapy may also be used - small electrical impulses are placed at specific points of the body to help reduce pain. The following may also provide benefits:
  • Walking
  • Swimming
  • A Danish study found that five exercises reduced neck pain for women office workers.
  • Yoga
  • Tai chi
  • Mediation and relaxation techniques
  • Some say the "Alexander Technique" helps
Scientists at the University of British Columbia, Canada, found that "physical activity is associated with a lower risk of work-related repetitive strain injury".

Occupational Therapy - by analyzing the following factors with the help of an occupational therapist, there may be ways of adopting measures to reduce symptoms:
  • Working with a computer - is your equipment positioned properly. Are your seat, keyboard and mouse positioned in the best way to minimize strain on your hands, fingers, arms, back and neck. Adaptive technology, such as special keyboards, mouse replacements, pen tablets interfaces, and speech recognition software may help.
  • Posture - are you sitting correctly?
  • Breaks - when doing repetitive tasks are you getting enough breaks? There is software that reminds computer users it is time to have a break.
  • Work environment - is there anything your employer might do to improve your working environment?
  • Stress - is there anything you can do to alleviate (treat) your level of stress?
Many patients experience reduced symptoms, or total elimination of symptoms if prevention and treatment measures are carried out. Others, however, continue to suffer regardless. Unfortunately, there are cases of people having to leave/change their jobs.


Restless Legs Syndrome

What Is Restless Legs Syndrome? What Causes Restless Legs Syndrome?

According to the Medilexicon's medical dictionary, restless legs syndrome is "a sense of indescribable uneasiness, twitching, or restlessness that occurs in the legs after going to bed, frequently leading to insomnia, which may be relieved temporarily by walking about; thought to be caused by inadequate circulation or as a side effect of some SSRIs and other psychotropic medications".

If you have RLS (restless legs syndrome) you have a disorder which causes a strong urge to move your legs. This urge is frequently accompanied with strange and unpleasant sensations in your legs. Patients say the only way to relieve those unpleasant feelings is to move their legs.

The following words are from patients as they describe the unpleasant feelings in their legs which trigger their urge to move them:

  • Aching
  • Burning
  • Crawling
  • Creeping
  • Electric shocks
  • Itching
  • Tugging
  • Tingling
Some patients experience those sensations in their arms as well.

A significant number of patients say the sensations occur when they are resting or inactive, and not exclusively after they go to bed. Symptoms tend to worsen in the evening and at night, and are often relieved for a short while in the morning.

Periodic Limb Movement Disorder (PLMD)

The patient's leg twitches or jerks uncontrollably about every 10 to 60 seconds. It usually occurs during sleep and is considered to be a type of sleeping disorder. PLMD makes the sufferer wake up frequently during the night, this undermines the quality and length of sleep. Most people with RLS have PLMD.

Restless legs syndrome can affect sleep

The majority of patients with RLS find it hard to fall asleep, and when they do, they find it difficult to stay asleep throughout the night. Consequently, many RLS sufferers find they are tired and sleepy during the day. Irregular and insufficient sleep can affect the patient's ability to learn, work, concentrate, and carry out normal routine tasks and activities. Lack of sleep can eventually lead to mood swings, irritability, depression, an undermined immune system, and other physical and health problems.

RLS is classed from mild to severe.

This depends on:
  • How often the symptoms occur
  • How severe the symptoms are
  • How effective moving around is in relieving the symptoms
  • The degree of sleep disturbance suffered

There are two main types of Restless Legs Syndrome

Primary RLS (idiopathic RLS)

Primary means the cause is not known. The RLS starts before the age of 45, and tends to be hereditary. This type of RLS can even start during childhood. Patients usually have this type for life once it starts. Symptoms will gradually worsen over time. Symptoms will also occur more often over time. Patient's whose symptoms are classed as mild may have long periods with no symptoms at all. This is the most common type of RLS.
Secondary RLS

Secondary means it is caused by another disease process or condition. The RLS generally starts after the age of 45, and does not tend to be hereditary. Patients with this type will experience a more abrupt onset. Symptoms do not usually worsen as time goes by.

RLS may be triggered by other conditions and diseases

The following diseases and symptoms have been known to trigger RLS: When the RLS is triggered by a disease or condition the symptoms will start abruptly - there is not a gradual onset. Patients with the type of RLS that usually starts later in life will experience worse symptoms if the RLS is triggered by a medical condition or because they are taking certain medications.

What is the outlook for a Restless Leg Patient? What is the prognosis?

Symptoms of RLS generally worsen over time. Some people, however, may experience weeks or months without any symptoms at all.

If the RLS has been triggered by a condition, illness or medication, it may go away as soon as the trigger has gone, or has been relieved. Women who get RLS during their pregnancy tend to get better as soon as their baby is born. RLS patients who had kidney failure and then a kidney transplant will generally get better after the transplant (just dialysis will not usually relieve RLS).

What is the treatment for Restless Legs Syndrome?

Treating an underlying condition

If the underlying condition/illness that triggers the RLS is treated, the RLS might either go away or improve - this is especially the case with iron deficiency and peripheral neuropathy.

Lifestyle changes and OTC medications

Some simple lifestyle changes and OTC (over-the-counter) medications may help alleviate RLS symptoms, such as:
  • Painkillers - if symptoms are very mild, ibuprofen has been found to relieve patients' symptoms.
  • Warm baths - relaxing in a warm bath and massaging your legs may help relax your muscles and reduce the intensity of symptoms
  • Warm or cool packs - some patients prefer warm packs, other find cool packs work better, while some say that alternating from hot-cold-hot works best.
  • Relaxation techniques - experts say that stress can make RLS worse. Relaxation techniques, such as Yoga and Tai Chi are known to help RLS patients enormously.
  • Sleep routine and environment - RLS patients who are tired tend to experience worsened symptoms. A cool and quiet bedroom helps people sleep better. Go to bed at the same time every night, and get up at the same time every morning. Many patients say they have managed to get a better night's sleep by going to bed a bit later.
  • Exercise and physical activity - exercise can help RLS, but can also make it worse. The majority of patients comment that moderate exercise helps symptoms a lot, while too much exercise sometimes makes them worse. Many also say that working out late in the evening does not help them.
  • Caffeine - some patients have found that their symptoms improve if they either cut back on caffeine or stop consuming it altogether. Drinks containing coffee, tea, chocolate and many sodas have caffeine in them. If abstaining from caffeine helps relieve symptoms, it will do so usually after a few weeks - so, it is important to persevere.
  • Alcohol - some patients have found that either cutting down on alcohol or abstaining completely helps.
  • Tobacco - this can be an RLS trigger for some people. So, either cutting down or giving up smoking altogether may help.

When other therapies have not worked, the doctor may prescribe medication for RLS. A doctor may prescribe one of the medicines below, or a combination - this depends on the individual patient.
  • Alpha 2 agonists - these may help in cases of primary RLS, but will have no effect on periodic limb movement during sleep. They are used to stimulate the alpha 2 receptors in the brain stem. Alpha 2 agonists activate neurons that make the part of the nervous system that controls muscle movement and sensations less active. Catapres (clonidine hydrochloride) is an Alpha 2 agonist.
  • Anticonvulsants - these are for patients who experience pain, neuropathy, or have symptoms during the daytime. Anticonvulsants are used for treating muscle spasms. Neurontin (gabapentin) is a popular anticonvulsant.
  • Benzodiazepines - these (sedative) medications help the patient sleep through the symptoms of RLS. If a patient with RLS has persistent sleeping problems the doctor may prescribe a benzodiazepine. Restoril (temazepam), Xanax (alprazolam), and Konopin (clonazepam) are common benzodiazepines.
  • Dopaminergic agents - these raise the levels of dopamine - a neurotransmitter - in the brain. They are used for treating the unpleasant leg sensations experienced by RLS patients. Levodopa and carbidopa are common dopaminergic agents.
  • Dopamine agonists - these also raise brain dopamine levels. Some elderly patients may find the side-effects are not worth the benefits. However, dopamine agonists are said to have a smaller probability of side-effects compared to levodopa. Dopamine agonists are used for the treatment of unpleasant leg sensations. Permax (pergolide mesylate), (Parlodel) bromocriptine mesylate, Mirapex (pramipexole), and Requip (ropinirole hydrochloride) are common dopamine agonists.
  • Opiates - these are used for treating pain, but they can also relieve RLS symptoms. Doctors may prescribe these when other medications have failed. Codeine and propoxyphene are examples of low dose opiates, while are oxycodone hydrochloride, methadone hydrochloride, and levorphanol tartrate are examples of common high dose opiates. For further information about opioids please visit All About Opioids and Opioid-Induced Constipation (OIC).
Parkinson's disease and Epilepsy drugs are sometimes used for RLS patients as they can reduce involuntary movements.

Diagnosis of Restless Legs Syndrome

The doctor relies on a good medical history and a physical examination when making a diagnosis. According to Wikipedia, sleep registration in a laboratory (polysomnography) is not necessary for the diagnosis.

When considering the differential diagnosis the doctor should look out for peripheral neuropathy, radiculopathy (conditions which have caused damage to the nerve roots which connect the spine to the rest of the nervous system) and leg cramps - in these conditions the urge to move is less pronounced than the level of pain.

The doctor must also consider akathisia, a side effect of some antidepressants and antipsychotic medications - there is a more constant form of leg restlessness without discomfort or unpleasant sensations.

A Doppler ultrasound evaluation of the vascular system will eliminate any venous disorders, which commonly trigger RLS.


Rheumatic Fever

What Is Rheumatic Fever? What Causes Rheumatic Fever?

Rheumatic fever is an inflammatory disease that may develop as a complication of a streptococcus infection, such as strep throat or scarlet fever (caused by Streptococcus pyogenes or group A beta-hemolytic streptococcus). If it does develop, it will usually do so two to three weeks after the Group A streptococcal infection.

Rheumatic fever mainly affects children aged between 5 and 15 years; however, it can affect adults and younger children. Boys and girls have the same risk of developing the disease; girls and women tend to have more severe symptoms. The disease may cause long term effects on the skin, heart, brain and joints. Rheumatic fever may cause permanent damage to the heart valves (rheumatic heart disease). Rheumatic fever has the potential to cause heart failure, stroke and even death.

Even though there is no current cure for rheumatic fever, antibiotics, anti-inflammatory drugs and anticonvulsants may be used to relieve symptoms and prevent recurrences.

The disease is fairly rare in most developed nations, but is still common in many other parts of the world, particularly in sub-Saharan Africa, south central Asia, and the indigenous population of Australia and New Zealand. Before the widespread introduction of antibiotics and increased levels of public sanitation and living standards, rheumatic fever used to be one of the leading causes of acquired heart disease in developed nations.

The National Health Service (NHS), UK, estimates that approximately 1 in every 100,000 people is affected by rheumatic fever in England annually.

Patients aged between 25 and 35 years may have recurring episodes of rheumatic fever.

According to Medilexicon's medical dictionary:

    Rheumatic Fever is " a subacute febrile syndrome occurring after group A β-hemolytic streptococcal infection (usually pharyngitis) and mediated by an immune response to the organism; most often seen in children and young adults; features include fever, myocarditis (causing tachycardia and sometimes acute cardiac failure), endocarditis (with valvular incompetence, followed after healing by scarring), and migratory polyarthritis; less often, subcutaneous nodules, erythema marginatum, and Sydenham chorea; relapses can occur after reinfection with streptococci."

What are the signs and symptoms of rheumatic fever?

A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.
According to The Mayo Clinic (USA), rheumatic fever signs and symptoms generally develop 2 to 4 weeks after a streptococcal throat infection (1 to 5 weeks according to the National Health Service, UK).

As you can see below, there are many possible signs and symptoms linked to rheumatic fever - a patient will not necessarily have them all:
  • Arthritis (joint pain and swelling) - generally starts in the knees and ankles, and then works its way to other joints in the body
  • Bumps and lumps (nodules) under the skin
  • Chest pain
  • Chorea - uncontrollable jerking of knees, elbows, wrists and ankles
  • Headache
  • High fever - above 39C (102F)
  • Inappropriate crying or laughing
  • Irritability, moodiness
  • Nosebleeds
  • Pain in one joint that migrates to another joint
  • Pain in the abdomen
  • Palpitations - sensation that the heart is fluttering or pounding hard
  • Panting (shortness of breath)
  • Red blotchy skin rash
  • Short attention span
  • Sweating
  • Tiredness (fatigue)
  • Vomiting
  • Weight loss

What are the risk factors for rheumatic fever?

A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2.
  • Genetics - some individuals possibly carry genes (or a gene) that make them more susceptible to developing rheumatic fever. A person with a family history of rheumatic fever has a higher risk of developing it himself/herself.
  • Type of strep bacteria - some strep bacteria strains are more likely to lead to rheumatic fever than others.
  • Environment - such factors are overcrowding, poor sanitation and poor access to healthcare increase the risk of rheumatic fever.

What are the causes of rheumatic fever?

Rheumatic fever may develop as a complication after a throat infection with Streptococcus pyogenes, or group A streptococcus (a bacterium). Strep throat, and less commonly scarlet fever are infections caused by Group A streptococcus infections. Group A streptococcus skin infections, as well as infections in other parts of the body may lead to rheumatic fever (much less common).

Although experts are not completely sure what the link between strep infection and rheumatic fever is, they believe that the bacterium upsets the patient's immune system. Strep bacteria have a protein which is similar to one found in some tissues in our body. Immune system cells that would usually target the bacterium may subsequently start attacking the body's own tissues, as if they were toxins or infectious agents; especially tissues of the heart, joints, CNS (central nervous system) and skin, resulting in inflammation.

Inflammation can cause the following symptoms:
  • Inflammation of the heart - chest pain, fatigue, shortness of breath
  • Inflammation of the joints - arthritis symptoms
  • Inflammation of the skin - skin rashes and nodules
  • Inflammation of the CNS (central nervous system) - chorea (jerking), personality changes
If the patient who is infected with strep bacteria takes the complete antibiotic treatment, the chances of rheumatic fever developing are negligible (zero or tiny). However, if the patient has at least one episode of untreated strep throat or scarlet fever, his/her risk of developing rheumatic fever increases significantly.

Diagnosis of rheumatic fever

According to the National Health Service (NHS), UK, there are so many different rheumatic fever symptoms that a checklist is needed to help in the diagnosis process - this checklist is called the Jones Criteria. The Jones Criteria involves checking whether the patient has specific signs and symptoms strongly linked to rheumatic fevers. These signs and symptoms are collectively known as criteria.

There are two types of criteria:
  • Major criteria - signs and symptoms are strongly linked to rheumatic fever. They include:

    • Inflammation of the heart (carditis)
    • Several joints have become swollen, painful and stiff (polyarthritis)
    • The patient has jerky involuntary movements (chorea)
    • There is a red or pink skin rash (erythema marginatum)
    • There are small nodules (lumps and bumps) under the skin, especially on the elbows, ankles, knees and knuckles (subcutaneous nodules)
  • Minor criteria - signs and symptoms are moderately linked to rheumatic fever:

    • The patient has joint pain, but it is not as severe as arthritis joint pain (arthralgia)
    • Elevated body temperature - usually over 102F (39C)
    • Elevated erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) - types of blood tests that detect inflammatory conditions
    • Irregular heart rhythm
A confident rheumatic fever diagnosis can be made if:
  • Two or more major criteria are detected
  • One major and two minor criteria are detected
Some of the signs and symptoms may be detected just by examining and interviewing the patient. Others will require testing. Testing may include:
  • ECG (electrocardiogram) - up to 12 adhesive electrodes are attached to the skin on certain parts of the body, usually the arms, legs and chest. The ECG (a device) measures the electrical activity of the patient's heart, revealing any possible abnormalities in heart rhythms. Abnormal heart rhythms usually occur when there is inflammation of the heart - a common complication of rheumatic fever. Early detection with subsequent prompt treatment is important.
  • Electrocardiography - this device uses sound waves that produce images of the heart. The test enables the doctor to see whether there is any inflammation of the heart. Heart valve damage, if present, may also be revealed in this test (much less likely early on in the disease).
  • Blood tests

    • CRP rates - blood tests can detect higher-than-normal levels of CRP (C reactive protein), which is produced by the liver. High CRP blood levels means there is inflammation.
    • Erythrocyte sedimentation rate (ESR) - a sample of red blood cells are placed in a test tube of liquid, their rate of descent is measured. If the cells descend faster than normal it could mean the patient has an inflammatory condition.
    • Test for strep infection - if the patient has already been diagnosed with a strep infection the doctor may not order additional tests.

What are the treatment options for rheumatic fever?

The medical team's aims are to destroy the bacteria, relieve symptoms, control inflammation and prevent recurrences of rheumatic fever.

Antibiotics - the patient, usually a child, will probably be prescribed penicillin or some other antibiotic to destroy any remaining strep bacteria in the body.
  • Preventing recurrence - after completing the full course of antibiotics, the patient will be prescribed another course of antibiotics to prevent recurrence. This preventive treatment will generally continue until the patient is about 20 years old. If the patient is older, for example a teenager when rheumatic fever develops for the first time, preventive treatments may continue beyond the age of 20 years.
  • Heart inflammation - some patients may be advised to continue taking preventive antibiotic treatment for much longer, in some cases for the rest of their lives.

    It is important to get rid any streptococcocal bacteria. If any is left inside the body and the patient has another throat infection, there is a serious risk of a recurrence of rheumatic fever. Repeated occurrences of rheumatic fever significantly raise the risk of heart damage (sometimes permanent).
Anti-inflammatory treatment - an anti-inflammatory drug, such as or naproxen (Anaprox, Naprosyn, etc.) may be prescribed. These medications reduce pain, inflammation and fever. A corticosteroid, such as prednisone may be prescribed if the patient does not respond to anti-inflammatory medications or there is inflammation of the heart.

Aspirin is not usually recommended for children aged less than 16 years because there is a risk of developing Reye's syndrome, which can cause liver and brain damage, and even death. However, an exception is usually made when the child has rheumatic fever because the dose is small and the results are very good - in other words, the benefits are far greater than the risks.

Anti-convulsant medications - if chorea symptoms are severe an anticonvulsant, such as valproic acid (Depakene, Stavzor) or carbamazepine (Carbatrol, Equetro) may be prescribed.

Long term care - any child who had rheumatic fever will need to know later on that he/she once had rheumatic fever. As an adult the individual should discuss this with his/her doctor. Heart damage from rheumatic fever may not appear for many years after the illness.

What are the possible complications of rheumatic fever?

Rheumatic fever symptoms, specifically inflammation, may persist for several weeks, months, and in some cases much longer, causing long-term problems.

Rheumatic heart disease - the most common and most serious complication. According to the National Health Service (NHS), UK, an estimated 9% to 34% of rheumatic fever cases have this complication. Rheumatic heart disease means permanent damage to the heart caused by the inflammation of rheumatic fever. The most common complication occurs with the mitral valve - the valve between the two left chambers of the heart. Sometimes other valves may also be affected. The following conditions may result:
  • Valve stenosis - the valve narrows, causing a drop in blood flow.
  • Valve regurgitation - blood flows in the wrong direction because of a leak.
  • Heart muscle damage - inflammation can weaken the heart muscle, leading to improper pumping function of the heart.
These conditions may also develop if there is damage to heart tissue, and/or damage to the mitral valve or other heart valves:
  • Heart failure - even though it may sound like it, heart failure does not necessarily mean that the heart has failed. Heart failure is a serious condition in which the heart is not pumping blood around the body efficiently. The patient's left side, right side, or even both sides of the body can be affected.
  • Atrial fibrillation - the human heart has two upper chambers and two lower chambers. The upper chambers are called the left atrium and the right atrium - the plural of atrium is atria. The two lower chambers are the the left ventricle and the right ventricle. When the two upper chambers - the atria - contract at an excessively high rate, and in an irregular way, the patient has atrial fibrillation.


Rheumatoid Arthritis

What Are The Possible Complications Of Rheumatoid Arthritis?

Rheumatoid arthritis can be both a disfiguring and debilitating disease. Joint damage can make it extremely difficult, and sometimes impossible to perform daily activities. Most patients initially find that daily tasks become tiring; eventually some people cannot do them at all. Fortunately, new therapies are more effective in slowing down or halting joint damage.
Rheumatoid arthritis is often unpredictable; the patient never knows when his/her next flare up will occur. Some days are better than others. This unpredictability raises the risk of developing depression, heightened anxiety and feelings of stress.
Patients with rheumatoid arthritis have a higher risk of developing the following conditions:
  • Carpal tunnel syndrome - a type of nerve damage (neuropathy) caused by compression and irritation of the median nerve in the wrist. There is a bony canal in the palm side of the wrist that provides passage for the median nerve to the hand - it is called the carpal tunnel. Carpal tunnel syndrome is a common condition in people with rheumatoid arthritis. Typical symptoms include aching, numbness and tingling in the fingers, thumb, and part of the hand.
  • Inflammation elsewhere - people with rheumatoid arthritis may have inflammation in their lungs, heart, blood vessels, eyes and other parts of the body.
  • Tendon rupture - the tendons can become inflamed. In severe cases of inflammation the tendon can rupture, especially on the backs of the fingers.
  • Cervical myelopathy - dislocation of the joints at the top of the spine, resulting in added pressure to the spinal cord. This condition can greatly affect the patient’s mobility. Cervical myelopathy risk grows the longer the patient has had rheumatoid arthritis.
  • Vasculitis - inflammation of the blood vessels, which can lead to weakening, thickening, narrowing and scarring of blood vessels. In advanced cases blood flow to organs and tissues may be affected.
  • Susceptibility to infections - a person with rheumatoid arthritis has a higher risk of catching colds, flu, pneumonia and other infections. The risk is higher if they are taking immunosuppressant medications. Patients should make sure their vaccinations, such as flu jabs, are up-to-date.

Rheumatoid Arthritis

What Are The Treatment Options For Rheumatoid Arthritis?

Treatment for rheumatoid arthritis is aimed at reducing inflammation to the joints, relieving pain, minimizing any disability caused by pain, joint damage or deformity, and either slowing down or preventing damage to the joints. There is no current cure for the disease. With the help of an occupational therapist and physical therapist (UK: physiotherapist) patients can learn how to protect their joints. Depending on the degree of damage to the joints, surgery may sometimes be needed.
If the patient has had inflamed joints for over six weeks the GP (general practitioner, primary care physician) will most likely refer him/her to a rheumatologist (an arthritis specialist doctor), so that diagnosis can be confirmed and treatment started as soon as possible.

The rheumatology team

Treatment of rheumatoid arthritis is a team effort involving at its core:
  • The patient
  • The specialist (rheumatologist)
  • The nurse practitioner
Other members of the rheumatology team include the:
  • Chiropodist
  • GP (general practitioner)
  • Occupational therapist
  • Orthopaedic surgeon
  • Orthotist
  • Pharmacist
  • Physical therapist (UK: physiotherapist)
  • Podiatrist
  • Primary care nurse
Although not automatically part of every rheumatology team, patients may also benefit from counseling (UK: counselling) services.

Medications for rheumatoid arthritis

During the initial stages of the disease the doctor will usually prescribe medications that are known to have the fewest side effects. As the disease progresses, stronger medications may be required. Many rheumatoid arthritis medications have potentially serious side effects.
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) - these are used for pain relief as well as reducing inflammation. Examples include Advil or Motrin, which are both OTC (over the counter, no prescription required). NSAIDs will not slow down the progression of the disease. When taken in high doses or over a long period they may cause complications. Side effects may include:
    • A higher risk of bruising
    • Gastric ulcers
    • Hypertension - high blood pressure
    • Kidney damage
    • Liver damage
    • Some heart problems
    • Stomach bleeding
    • Tinnitus - ringing in the ears
    Cox-2 selective inhibitors, another type of NSAID, are designed to be less harmful for the stomach. However, some research has linked them to a higher risk of strokes, hypertension, heart disease and heart attacks. If the patient has a history of hypertension, high cholesterol or smokes the doctor needs to be told.
  • Corticosteroids - these are effective at reducing inflammation, pain, as well as slowing down joint damage. They are usually recommended when NSAIDs have not helped. If the patient has a single inflamed joint the doctor may inject the steroid into the joint. Effective relief is usually felt rapidly and the effect can last from weeks to months, depending on the severity of symptoms. Examples include prednisone (Lodotra) and methylprednisolone (Medrol). Corticosteroids are generally used for acute symptoms (short term flare ups) - the dosage is then gradually reduced (tapered off). Long term use can have serious side effects. Side effects may include:
    • A higher risk of bruising
    • Cataracts
    • Diabetes
    • Round face
    • Weight gain
    • Osteoporosis
    • Glaucoma
    • Muscle weakness
    • Thinning of the skin
  • DMARDs (disease-modifying antirheumatic drugs) - this medication may slow down the progression of the disease, as well as preventing permanent damage to the joints and other tissues. The earlier the patient starts taking a DMARD the more effective it will be. It may take from four to six months before the patient starts noticing any beneficial effects. It is important to keep taking the medication even if initially it does not appear to be working. Some patients may have to try different types of DMARD before hitting on the most suitable one. This medication is usually taken indefinitely.

    Examples include leflunomide (Arava), methotrexate (Rheumatrex, Trexall), sulfasalazine (Azulfidine), minocycline (Dynacin, Minocin), and hydroxychloroquine (Plaquenil). Side effects may include:
    • Liver damage
    • Bone marrow suppression
    • Lung infections (severe)
  • Immunosuppressants - as rheumatoid arthritis is an auto-immune disease, suppressing the immune system helps reduce the damage to good tissue. Examples include cyclosporine (Neoral, Sandimmune, Gengraf), azathioprine (Imuran, Azasan), and cyclophosphamide (Cytoxan).

    Tumor necrosis factor-alpha inhibitors (TNF-alpha inhibitors) - the human body produces tumor necrosis factor-alpha (TNF-alpha). TNF-alpha is an inflammatory substance. TNF-alpha inhibitors are used for the reduction of pain, morning stiffness and swollen or tender joints. Results are usually noticed within two weeks of starting treatment. Examples include (Enbrel), infliximab (Remicade) and adalimumab (Humira). Possible side effects include:
    • A higher risk of infection
    • Blood disorders
    • Congestive heart failure
    • Demyelinating diseases - erosion of the myelin sheath that normally protects nerve fibers, exposing the fibers, resulting in problems in nerve impulse conduction. This may affect several physical systems.
    • Irritation at the injection site
    • Lymphoma

Occupational therapy

An occupational therapist can help the patient learn new and effective ways of carrying out daily tasks so that stress to painful joints is minimized. For example, if the patient has sore arms and wants to push open a door, it may be better to lean into it rather than using the arms.
If the patient has painful fingers a specially devised gripping and grabbing tool may help.


If the above-mentioned treatments have not been effective enough, the doctor may consider surgery to repair damaged joints, allowing the patient to subsequently use that joint again. Surgical intervention may also help correct deformities, or reduce pain. The following procedures may be considered:
  • Arthroplasty - total replacement of the joint. The damaged parts are surgically removed and a prosthesis (artificial joint) made of metal and plastic is inserted.
  • Tendon repair - if the tendons around the joint are loosened or ruptured, surgery may help restore them.
  • Synovectomy - this involves the removal of the joint lining, if the synovium (lining around the joint) is inflamed and causing pain.
  • Arthrodesis - if a joint replacement is not an option, the joint may be surgically fixed to promote a bone fusion; the joint is realigned or stabilized. Also called artificial ankylosis, syndesis.


When a flare-up occurs the patient should rest as much as possible. Exerting very swollen and painful joints frequently results in worsening symptoms.
Generally, when flare ups are not present, the patient should exercise regularly; this will help their general health and mobility. If rheumatoid arthritis has caused muscles around the joints to become weak, exercise will help strengthen them. Exercises that do not strain the joints are best, such as swimming. A qualified physical therapist (UK: physiotherapist) can teach the patient exercises that improve mobility.
  • Applying heat or cold - tense and painful muscles may benefit from the application of heat. A 15 minute hot bath or shower may help. Some people find that using a hot pack or an electric heating pad (set at lowest setting) helps.

    Pain may be dulled with cold treatment. The numbing effect of cold may also decrease muscle spasms. Patients with poor circulation or numbness should not use cold treatments. Examples of cold treatment include cold packs, soaking the affected joint in cold water, and ice massage.

    Some people benefit from placing the affected joints in warm water for a few minutes, followed by cool water for one minute; repeating the cycle for about 30 minutes, ending with a warm water soak.
  • Relaxation - finding ways of alleviating mental stress may help control pain. Examples include hypnosis, guided imagery, deep breathing and muscle relaxation.
  • Complementary therapies - these are commonly used by people with rheumatoid arthritis. Few studies have been carried out on how effective they are. Examples include:
    • Acupuncture
    • Chiropractic
    • Electrotherapy
    • Hydrotherapy
    • Massage
    • Nutritional supplements - for example, fish oil, glucosamine sulphate and chondriotin.
    • Osteopathy

Rheumatoid Arthritis

How Is Rheumatoid Arthritis Diagnosed?

In its early stages rheumatoid arthritis may be difficult to diagnose. Its signs and symptoms - especially stiffness and inflammation - are similar to several other conditions.
A GP (general practitioner, primary care physician) will carry out a physical examination. The doctor will carefully check the joints to see if there is any swelling (e.g. “pain on squeeze test” on the knuckles), as well as determining how easily they move. The patient will be asked about symptoms. To help the doctor make a correct diagnosis, the National Health Service (NHS), UK, urges patients to tell the doctor about all their symptoms, and not just the ones they consider to be important.
The doctor may also order the following tests:

Blood tests

  • Erythrocyte sedimentation rate (ESR or sed rate) - this blood test detects and monitors inflammation in the body by measuring the rate at which red blood cells in a test tube separate from blood serum over a set period, becoming sediment in the bottom of the test tube. A high sedimentation rate is linked to more inflammation. In other words, if the red blood cells sink faster to the bottom of the test tube, it could mean that the patient has an inflammatory condition, such as rheumatoid arthritis.
  • C-reactive protein (CRP) - CRP is produced by the liver. A higher CRP level is linked to the presence of inflammation in the body.
  • Anemia - a significant proportion of patients with rheumatoid arthritis also have anemia; when not enough oxygen is carried in the blood, because of a lack of red blood cells. If the patient is found to have anemia it does not necessarily mean they have rheumatoid arthritis.
  • Rheumatoid factor - this blood test determines whether rheumatoid factor (an antibody) is present in the patient’s blood. The majority of rheumatoid arthritis patients have this abnormal antibody in their bloodstream (according to the National Rheumatoid Arthritis Society, UK, 30% of patients with rheumatoid arthritis do not have rheumatoid factor). During the early stages of the disease it is sometimes difficult to detect rheumatoid factor. As this antibody is present in a small proportion of people without rheumatoid arthritis, this test cannot confirm the disease definitively.
Imaging scans and X-rays - an X-ray of the patient’s joints can help the doctor determine what type of arthritis is present. Several X-rays can help track the progression of rheumatoid arthritis in the joints over time.
MRI (magnetic resonance imaging) scans - can help the doctor determine more specifically what damage has been done to a joint. An MRI machine uses a magnetic field and radio waves to create detailed images of the body.

Diagnostic criteria

In 1987, the American College of Rheumatology defined the following criteria for the classification of rheumatoid arthritis:
  • Morning stiffness of more than an hour most mornings for a period of at least six weeks.
  • Arthritis and soft-tissue swelling of more than 3 of 14 joints/joint groups, present for a period of at least six weeks.
  • Arthritis of hand joints, which are present for a period of at least six weeks.
  • Symmetric arthritis, which is present for a period of at least six weeks.
  • Subcutaneous nodules in specific places.
  • Rheumatoid factor at a level > the 95th percentile.
  • Radiological changes suggestive of joint erosion.
For a classification of rheumatoid arthritis at least four of the above criteria need to be met. These criteria were primarily intended to categorize research, rather than for the diagnosis of routine clinical care. For example: in the case of the presence of bone erosion on X-ray, prevention of bone erosion is one of the principal aims of treatment because it is usually irreversible. There may sometimes be a worse outcome if the doctor waits until all of the American College of Rheumatology criteria are met.
Most health care professionals as well as their patients prefer to have the condition treated as early as possible to prevent bone erosion - even if the American College of Rheumatology criteria are not yet met.
The American College of Rheumatology criteria are useful for categorizing established rheumatoid arthritis, especially when studying the causes, distribution, and control of the disease in populations (epidemiology).

Distinguishing rheumatoid arthritis from other medical conditions

At the time of diagnosis rheumatoid arthritis needs to be distinguished from other possible conditions which may have similar signs and symptoms. These include:
  • Gout and pseudogout (crystal induced arthritis) - this usually involves specific joints. It can be distinguished from rheumatoid arthritis by aspirating joint fluid.
  • Osteoarthritis - blood tests and X-rays of the affected joints can help distinguish this condition.
  • SLE (systemic lupus erythematosis) - specific clinical symptoms and blood tests (antibodies against double-stranded DNA) can distinguish this condition from rheumatoid arthritis.
  • A specific type of psoriatic arthritis - can be distinguished from rheumatoid arthritis by checking nail changes and skin symptoms.
  • Lyme disease - can be distinguished from rheumatoid arthritis with blood tests in endemic areas.
  • Reactive arthritis (used to be known as Reiter’s disease) - usually linked with urethritis, conjunctivitis, iritis, painless mouth ulcers and keratoderma blennorrhagica. The arthritis is not symmetrical and usually involves the heel, sacroiliac joints, as well as the large joints of the leg. In cases of rheumatoid arthritis joints are symmetrically involved (e.g. both knees, both hands, etc).
  • Ankylosing spondylitis - involves the spine and generally affects men. However, several joints may be affected symmetrically, as with rheumatoid arthritis.
The following rarer (non-rheumatoid arthritis) conditions may cause joint pains:
  • Sarcoidosis
  • Amyloidosis
  • Whipple’s disease
  • Acute rheumatic fever
  • Gonococcal arthritis

Rheumatoid Arthritis

What Are The Causes Of Rheumatoid Arthritis?

The smooth lining of the membranes (thin layer of cells) that surround our joints is called the synovium. A flexible joint is lined by a synovial membrane. The synovium produces a clear substance - synovial fluid - which lubricates and nourishes the cartilage and bones inside the joint capsule.
When the immune system attacks the synovium, rheumatoid arthritis may occur. Antibodies attack the synovium, leaving it sore and inflamed - the synovium becomes thicker and may eventually invade and destroy cartilage (the stretchy connective tissue between bones) and bone inside the joint. The joint is held together by tendons (tissue that connects bone to muscle) and ligaments (tissue that connects bone and cartilage). These tendons and ligaments weaken and stretch, and the joint eventually loses its shape and configuration. The joint may eventually be completely destroyed.
Nobody really knows what starts off this process. Experts say some people are genetically predisposed to environmental factors that may trigger rheumatoid arthritis, such as some bacteria or viruses. However, this is a theory which has not been proven.

Rheumatoid arthritis is an autoimmune condition

An autoimmune condition is an illness that develops when the body tissues are attacked by the immune system. The immune system is a sophisticated system within our bodies, designed to seek out and destroy undesirable invaders, such as infectious agents. A person with an autoimmune disease has unusual antibodies in their blood that attack their own (good) body tissues.
In the case of rheumatoid arthritis, the immune system sends antibodies to the lining of the joints (the synovium) - they attack the tissue surrounding the joint, instead of harmful bacteria or viruses.

Next Page: Diagnosing Rheumatoid Arthritis >

Rheumatoid Arthritis

What Are The Risk Factors For Rheumatoid Arthritis?

A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2.
The following risk factors may raise the risk of developing rheumatoid arthritis:
  • Gender - according to The Mayo Clinic, USA, the disease is two to three times more common in women than in men. Experts believe this may be due to the effects of estrogen - a female hormone - which might be a factor in the development of the disease. However, this is still a theory.
  • Age - although rheumatoid arthritis may develop at any age, it is more like to begin in people aged between 40 and 60 years.
  • Genetics - people who have a close family member with rheumatoid arthritis may have a higher risk of developing it themselves. Experts say that the disease itself is not inherited, but rather the predisposition to develop it.
  • Smoking - regular smokers have a significantly higher risk of developing rheumatoid arthritis. Smoking makes the outlook for the disease worse.

Rheumatoid Arthritis

What Are The Signs And Symptoms Of Rheumatoid Arthritis?

A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.
Rheumatoid arthritis is a long-term disease - a chronic disease. Symptoms can come and go and each patient is affected differently. While some patents may have long periods of remission, when the rheumatoid arthritis is inactive and few or no symptoms are felt, others may have virtually constant symptoms for long periods.
A patient with sudden onset rheumatoid arthritis may go to bed healthy one night and wake up the next morning in a great deal of pain; possibly unable to get out of bed.
In most cases rheumatoid arthritis begins insidiously. Signs and symptoms develop slowly over a period of weeks or months. The patient may initially experience stiffness in at least one joint; often accompanied by pain when trying to move the affected area. There may be tenderness in the joint. First symptoms are usually felt in the small joints, such as the ones in the fingers and toes.
How many joints are affected varies considerably. However, in nearly all cases the process eventually affects at least five joints at the same time. Unlike systemic lupus or gout, rheumatoid arthritis is an additive polyarthritis - more joints are affected as time passes.
Usually both sides of the body are affected, for example, both knees or both hands.
The most commonly affected joints are:
  • The proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints of the hands (middle and base joints of the finger)
  • The wrists, especially the ulnar-styloid articulation
  • The shoulders
  • Elbows
  • Knees
  • Ankles
  • Metatarsophalangeal (MTP) joints (in the toes)
Note: The distal interphalangeal (DIP) joints are not usually affected (top joint of the finger)
The spine is never affected, except the atlanto-axial articulation in late disease. Morning stiffness - morning stiffness is a hallmark symptom of rheumatoid arthritis, especially if it lasts more than an hour. Experts say that the duration of morning stiffness is usually a good indication of the inflammatory activity of the disease. Although patients with other forms of arthritis may have early morning joint stiffness, they tend not to last for more than an hour.
There may be stiffness after long periods of inactivity, which tends to last longer than in cases of degenerative arthritis.
Joint pain and swelling - the lining of the affected joint becomes inflamed - the skin over the joint becomes warm, red and swollen. The area is painful and tender to the touch.

Anemia - according to The National Health Service (NHS), UK, approximately 80% of patients with rheumatoid arthritis are anemic - there is a low number of red blood cells; the blood is unable to carry enough oxygen.
Loss of appetite/Weight loss - a significant number of patients may experience loss of appetite, and subsequent weight loss.
The patient may have red and puffy hands.
The following non-specific systemic flu-like symptoms may be felt weeks to months before other symptoms appear:
  • Fatigue (tiredness)
  • Malaise
  • Depression
  • Fever - usually low grade (37° - 38°C; 99° - 100°F). Experts say that a higher fever often indicates an infectious cause (another illness).
The symptoms of rheumatoid arthritis tend to be intermittent (sporadic); they come and go. Sometimes the patient will have a flare-up - the symptoms will be more intense and severe.
Although flare-ups can occur at any time, they tend to be more painful in the morning, when the patient wakes up. As the day progresses symptoms will start to ease.
Rheumatoid arthritis is a systemic illness (one that affects the entire body)
Multiple organs in the body can be affected, including:
  • Inflammation in the lungs - this usually causes no symptoms. If the patient develops shortness of breath medications may be prescribed to reduce inflammation in the lungs.
  • Inflammation of the membrane around the lungs (pleura)
  • Inflammation of the pericardium - a double-walled sac that contains the heart and the roots of the great blood vessels.
  • Inflammation of the tough white outer coat over the eyeball (sclera) - affects about 5% of patients. Symptoms may include red, painful and possibly dry eyes.
  • Nodular lesions - about 1 in every 4 rheumatoid arthritis patients develops lumps under the skin - rheumatoid nodules. They tend to occur on the skin over the elbows and forearms. They may be painful, but not usually.
  • Inflammation of the tear glands
  • Inflammation of the salivary glands
  • Inflammation of the cricoarytenoid joint - this is a joint in the larynx (voice box). When it is inflamed it can cause hoarseness.


Rheumatoid Arthritis

All About Rheumatoid Arthritis

 What is Rheumatoid Arthritis? Rheumatoid Arthritis Diagnosis
Signs of Rheumatoid Arthritis Treatment for Rheumatoid Arthritis
Rheumatoid Arthritis Risk Factors Rheumatoid Arthritis Complications
Causes of Rheumatoid Arthritis


What Is Rheumatoid Arthritis?

Rheumatoid arthritis, sometimes referred to as rheumatoid disease, is a chronic (long lasting), progressive and disabling autoimmune disease that causes inflammation (swelling) and pain in the joints, the tissue around the joints, and other organs in the human body. Rheumatoid arthritis usually affects the joints in the hands and feet first, but any joint may become affected. Patients with rheumatoid arthritis commonly have stiff joints and feel generally unwell and tired.
Rheumatoid arthritis is an autoimmune disease. Our immune system is a complex organization of cells and antibodies designed to seek out and destroy organisms and substances which harm us, such as infections. When our immune system starts attacking our own bodies, mistaking body tissues for foreign invaders, we have an autoimmune disease.
Individuals with an autoimmune disease have antibodies in their blood which target their own body tissues, resulting in inflammation. The immune system of a patient with rheumatoid arthritis attacks the lining of the joints, causing them to swell (become inflamed). As opposed to the wear-and-tear damage which occurs with osteoarthritis, rheumatoid arthritis affects the lining of the joints, resulting in painful swelling that can lead to bone erosion and joint deformity. Eventually the affected joints may become permanently damaged.
Rheumatoid arthritis is referred to as a systemic illness. Systemic means it affects the entire body; in the case of rheumatoid arthritis, multiple organs in the body can be affected. The patient may also have fevers and experience fatigue. Rheumatoid arthritis may also produce diffuse (spreading) inflammation in the lungs, the membrane around the lungs (pleura), pericardium (a double-walled sac that contains the heart and the roots of the great blood vessels) and the tough white outer coat over the eyeball (sclera); it can produce nodular lesions, most commonly in subcutaneous tissue under the skin.
Patients with rheumatoid arthritis have a significantly higher risk of having a heart attack, compared to other people.
  • According to The National Health Service (NHS), UK, about 350,000 British people are affected by rheumatoid arthritis.
  • According to the National Rheumatoid Arthritis Society (UK) rheumatoid arthritis affects 0.8% of the UK population.
  • According to The Mayo Clinic, USA, the disease is two to three times more common in women than in men.
  • Although people of any age may be affected, rheumatoid arthritis is much more common after the age of 40. According to the National Rheumatoid Arthritis Society (UK), approximately 12,000 children under 16 years of age have a juvenile form of the disease.
  • According to the John Hopkins Arthritis Center, USA:
    • Approximately 1% to 2% of the world’s population is affected by the disease.
    • Prevalence increases with age, approaching 5% in women over 55 years of age.
    • Annual average incidence is 70 in every 100,000 in the USA.
    • It is 4 times more common in smokers than non-smokers.
Rheumatoid arthritis is much more common that MS (multiple sclerosis) or leukemia. However, awareness of the disease’s effects and severity are more restricted to patients, their caregivers and their relatives because it is not well publicized.
Rheumatoid arthritis symptoms generally come and go. On some occasions symptoms may be mild, while on others they may be severe and extremely painful. A patient has a ”flare up” when symptoms are bad. It is impossible to know when a flare up may come.
Rheumatoid arthritis can be a very painful condition, leading to considerable loss of functioning and mobility. Diagnosis is made chiefly as a result of identifying signs and symptoms, as well as rheumatoid factor blood tests and X-rays. Diagnosis and the long-term management of the disease is generally carried out by a rheumatologist; a specialist in rheumatology.
Although the disease has no cure, early diagnosis and prompt subsequent treatment of symptoms may slow the progression down, as well as making the patient more comfortable.
According to Medilexicon's medical dictionary:
Rheumatoid arthritis is “a generalized disease, occurring more often in women, which primarily affects connective tissue; arthritis is the dominant clinical manifestation, involving many joints, especially those of the hands and feet, accompanied by thickening of articular soft tissue, with extension of synovial tissue over articular cartilages, which become eroded; the course is variable but often is chronic and progressive, leading to deformities and disability.”

Next Page: Signs of Rheumatoid Arthritis >



Non-allergic Rhinitis

What Is Non-allergic Rhinitis? What Causes Non-allergic Rhinitis?

When a person has rhinitis the inside of their nose becomes inflamed (swells), causing cold-like symptoms, such as itchiness, blocked nose, runny nose and sneezing. Rhinitis can be caused by an allergy (allergic rhinitis) or something else (non-allergic rhinitis). This article is about non-allergic rhinitis. The symptoms of non-allergic and allergic rhinitis are similar, but the causes are different.

Some individuals with non-allergic rhinitis often find they have a runny nose that does not seem to get better, while others find that symptoms keep recurring. The blood vessels inside the nose expand, causing the lining of the nose to swell. This stimulates the mucus glands in the nose, causing it to become congested and "drippy".

According to The Mayo Clinic, USA, and the National Health Service (NHS), UK, both children and adults are similarly affected by non-allergic rhinitis. Women tend to be more susceptible to nasal congestion during menstruation and pregnancy.

According to Medilexicon's medical dictionary:

    Rhinitis is " Inflammation of the nasal mucous membrane."
The English medical word rhinitis comes from the Greek word rhinos meaning "nose" and the Greek suffix (word ending) itis meaning "inflammation".

There are different types of non-allergic rhinitis:
  • Infectious rhinitis - also known as viral rhinitis. This is caused by an infection, e.g. the common cold or flu.
  • Vasomotor rhinitis - the blood vessels in the nose are too sensitive, leading to inflammation. There is abnormal nerve (neuronal) control of the blood vessels in the nose, resulting in inflammation.
  • Atrophic rhinitis - the membranes inside the nose become thinner and harder, causing the nasal passages to widen and become drier. Crusts form inside the nose, some of them foul smelling. The patient can lose his/her sense of smell. This type of rhinitis may be a complication of nose surgery or an infection.
  • Other causes - some people may develop non-allergic rhinitis after taking certain medications, such as beta blockers, aspirin or the overuse of nasal decongestants (rhinitis medicamentosa). Sometimes pregnancy, puberty or an over-active thyroid gland can cause rhinitis (due to a hormonal imbalance). Eating spicy foods can cause rhinitis in some people (this is not allergic rhinitis because it is not caused by an immune system response).

What are the signs and symptoms of non-allergic rhinitis?

A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.
The signs and symptoms of infectious rhinitis, vasomotor rhinitis and rhinitis medicamentosa are similar, and they include:
  • Sneezing
  • A blocked nose
  • A runny nose
  • Nasal pressure
  • Nasal pain
  • Postnasal drip - phlegm (mucus) in the throat
The signs and symptoms of atrophic rhinitis include:
  • Crusting inside the nose
  • Crusts produce a foul smell
  • The nose may bleed when the patient tries to remove the crust
  • Anosmia - loss of the sense of smell
Individuals with non-allergic rhinitis do not generally have itchy nose, eyes or throat (allergic rhinitis symptoms).

What are the risk factors for non-allergic rhinitis?

A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2. Risk factors for non-allergic rhinitis include:
  • Irritants - people who are exposed to tobacco smoke, smog, exhaust fumes, and some other irritants are more likely to develop non-allergic rhinitis. People who work in environments with irritants, such as airplane fuel, jet exhaust, solvents, and some other substances have a higher risk.
  • Overuse or prolonged use of nasal sprays and drops - people who use OTC (over-the-counter, no prescription required) decongestant drops or sprays for longer than a few days have a significantly higher risk of developing severe nasal congestion.
  • Gender - females tend to be more susceptible to nasal congestion during menstruation and pregnancy.
  • Some health conditions - individuals with lupus, cystic fibrosis, some hormonal disorders and asthma are more likely to develop non-allergic rhinitis, compared to other people.

What are the causes of non-allergic rhinitis?

Viral rhinitis - the lining of the nose and throat become inflamed when a virus attacks the area. Inflammation triggers the production of more mucus, which in turn leads to sneezing and a runny nose.

Vasomotor rhinitis - blood vessels inside the nose should contract and expand, thus helping to control the flow of mucus. If the blood vessels are oversensitive they can dilate when exposed to several kinds of environmental triggers, leading to congestion and too much mucus. Triggers include chemical irritants, perfumes, paint fumes, smoke, changes in humidity, a drop in temperature, consumption of alcohol, spicy foods and mental stress.

Atrophic rhinitis - atrophic rhinitis can occur if the turbinate tissue becomes damaged. The turbinate tissue refers to three ridges of bone that are covered by a layer of tissue inside the nose. Surgery is a common cause of turbinate tissue damage - if air flow is obstructed it is sometimes necessary to surgically remove turbinate tissue. Infection can damage turbinate tissue (more common in India, China and Egypt. Very rare in Western Europe and the Americas).

Turbinate tissue helps keep the inside of the nose moist, it protects against bacteria, helps regulate air pressure of the oxygen we breathe in, and contains nerve endings that give us our sense of smell. If some turbinate tissue is lost, the inside of the nose becomes dry, crusty and much more vulnerable to infection.

While some people need to lose a significant amount of turbinate tissue for atrophic rhinitis to develop, others need only lose a small amount.

Rhinitis medicamentosa - caused by over-use of nasal decongestants. In some cases it can be caused by cocaine use. Nasal decongestants reduce the swelling of the blood vessels inside the nose. If the patient uses nasal decongestants for more than five to seven days non-stop the lining inside the nose can start to become inflamed again - even after whatever caused the symptoms, such as a cold, has gone. If the patient carries on using decongestants to try to reduce the swelling, it will probably make the swelling worse (rebound congestion).

How is non-allergic rhinitis diagnosed?

Viral rhinitis - the signs and symptoms of an infection, as may be observed in a cold or flu, help a doctor diagnose viral rhinitis.

Vasomotor rhinitis - as this type of rhinitis has similar symptoms to allergic rhinitis, diagnosis is not so easy. There is no single test that can diagnose vasomotor rhinitis. Doctors use a system known as diagnosis through exclusion to be able to eventually make a diagnosis. All other potential rhinitis causes may have to be checked, including allergens, such as animal fur or pollen. This will include some allergy tests:
  • Skin prick test - drops of diluted foods are placed on the patient's arm. The skin is then pierced through the drop, thus introducing the food into the system. If there is itching, redness or swelling, the indication is most likely a positive reaction. Experts say that negative results are 95% accurate, while positive results are 55% accurate.
  • Blood test - the aim is to measure how much IgE (Immunoglobulin E) antibody there is in the blood. IgE is produced by the immune system in response to a suspected allergen.
  • Patch test - a tiny amount of suspected allergen is added to metal discs which are then taped to the patient's skin. They remain there for up to two days. The health care professional then inspects the skin to see whether there has been a reaction. The test is generally done in hospital.
If the patient is found not have any allergic reactions, the doctor will probably diagnose vasomotor rhinitis.

Atrophic rhinitis - signs and symptoms, such as nasal crusting, widening of the passages in the nose, a foul smell, and the patient's loss of his/her sense of smell indicate that the patient has atrophic rhinitis.
    CT (computerized tomography) scan - the CT scanner uses digital geometry processing to generate a 3-dimensional (3-D) image of the inside of an object. The 3-D image is made after many 2-dimensional (2-D) X-ray images are taken around a single axis of rotation - in other words, many pictures of the same area are taken from many angles and then placed together to produce a 3-D image. Doctors may use a CT scan to confirm diagnosis and check for changes in the nasal cavities.
Rhinitis medicamentosa - the doctor will ask the patient whether they have been using decongestant nasal sprays, and how long for. The patient needs to answer honestly. The doctor is interested in making a diagnosis, and will not judge or criticize the patient.

Ruling out a sinus problem - the doctor may want to determine whether the patient might have a deviated septum or nasal polyps. Either a nasal endoscopy or CT scan may be ordered.

What are the treatment options for non-allergic rhinitis?

Viral rhinitis - as the infection that caused the rhinitis usually goes away on its own, medical treatment for the rhinitis is not usually required. Nasal decongestants may help reduces swelling and blocked nose - it is important not to overuse as this may eventually make the congestion worse, leading to rhinitis medicamentosa. People taking MAOI (monoamine oxidase inhibitor) antidepressants should not take nasal decongestants.

Vasomotor rhinitis - an individual who has been diagnosed needs to try to avoid exposure to the environmental triggers that are causing vasomotor rhinitis. Corticosteroid nasal sprays may help reduce inflammation and congestion. If the patient does not respond, the doctor may try:
  • Antihistamine nasal sprays - even though these are more commonly prescribed for patients with allergies, they sometimes help patients with vasomotor rhinitis.
  • Anticholinergics nasal sprays - this medication helps widen the airways, which helps breathing. They also reduce the production of mucus.
  • Sodium cromiglicate - reduces the production of mucus as well as inflammation. In most cases the medication is inhaled.
Atrophic rhinitis - nasal irrigation is most commonly recommended. A saline solution is inserted into the nasal cavities with the use of a syringe. Nasal irrigation is effective in treating crusting and dryness. If there is an infection - often the case if there is a foul smell - the patient will be prescribed an antibiotic.

The following surgical procedures are sometimes used to treat atrophic rhinitis:
  • Young's operation - the nasal cavity is closed, usually for about nine months, after which it is reopened. This allows it to heal with a much lower risk of infection.
  • Nasal narrowing - grafted bone or cartilage, and sometimes Teflon or silicon is used to narrow the affected nasal cavity. If the cavity is narrower crusting is less likely to occur.
Rhinitis medicamentosa - the patient needs to stop using the nasal decongestant spray. Some may find this difficult, especially if they have been using them for a long time. The following may help:

  • Do not use the spray on the good nostril (or less congested one). The good nostril will eventually open up - then stop using it on the other nostril.
  • There are some types of antihistamine, especially the older ones, that cause drowsiness and help the patient sleep. When taking them be careful not to drive or operate heavy machinery.
  • Use a saline solution to naturally lubricate your nose. 


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