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SARA LOMAX-REESE: Right now I want to welcome Dr. Donee Patterson, from Einstein Department of medicine to be our co-host for today.
DONEE PATTERSON, MD: Thank you; thank you for having me.
LOMAX-REESE: Thank you. And Dr. Richard Grant who is our special guest to share some really powerful information about arthritis. Welcome, Dr. Grant.
RICHARD GRANT, MD: Thank you very much.
PATTERSON: Sara, I should say Dr. Grant is one of our new members to Einstein; highly recruited from Cleveland and he is an orthopedic surgeon at our hospital.
LOMAX-REESE: OK, fantastic. Let’s dive right in; Dr. Donee, why don’t you set it up for us because I know living with pain which has kind of becoming the general theme for today’s program can be absolutely debilitating; not just physically but mentally and emotionally. It can actually wreak havoc on just you but your entire family as well.
PATTERSON: Exactly. I picked this topic for us to talk about today for several reasons. First of all, a lot of people don’t understand that there are many, many types of arthritis and they need to know that so they can discuss that with their doctor and go to the right place for follow up and treatment. Osteoarthritis is a particular type of disorder where the cartilage between each joint gets worn down and it’s often known as a disease where it is worn down because of wear and tear; so overuse, or trauma to that joint can wear that nice, slick cartilage between the joint to protect the joint. Whereas rheumatoid arthritis is more an inflammatory disorder where your body is attacking its joints and it really does present differently and it’s a whole different speciality. Since we have our orthopedist here today we are pretty much going to focus on rheumatoid arthritis but I wanted people to understand that there is differences. There is gouty arthritis, there is psoriatic arthritis, so for people who have psoriasis so there is many different types but we are going to focus on the most common type, which is osteoarthritis. It affects over 20 million people.
LOMAX-REESE: So you mentioned rheumatoid and osteoarthritis. Let me ask you Dr. Grant, what do you see in your work in terms of any kind of disparities around race or gender around arthritis?
GRANT: The greatest disparity that I find in dealing with the patient population that I’ve been seeing since about 1986 or so, 1988, usually in our African American community, the disparity is in knowledge about what to do about it. If you look at our population, there are a lot of advances in osteoarthrosis and the care of osteoarthrosis that just hasn’t been applied to our community for whatever reasons; even to the most sophisticated application of joint replacement and there is a huge disparity in the treatment of osteoarthrosis especially when osteoarthrosis is severe enough that the primary physicians refer patients to us for orthopedic care. A lot of the patients that I see are actually shocked when they come into my office and say oh, I didn’t realize that you were a surgeon and I look at them and say well you know the sign says orthopedic surgery. So we are sort of the court of last resorts, a lot of what we do has to do with African American patients and minority patients who are coming to us along with other patients because everything else has failed. When I am talking to my patients about rheumatoid arthritis and I try to get them to understand what the definition of rheumatoid arthritis versus osteoarthrosis is, I start with the concept of saying well you lost the gristle in your knee and you are walking bone on bone, then you have severe osteoarthrosis and medications are not going to help at this point, injections are not going to help at this point, usually they have been tried, physical therapy is not helpful and usually they are at the point where they may or may not need a joint replacement. First of all, that is not the first thing we suggest but a lot of times we will go back and do some of the same things that their primary care physician has done in order to try to get them to relieve the pain.
LOMAX-REESE: And what are some of those things that may be happening before they get to the need for a replacement?
GRANT: Well there are a lot of things going on usually by the time the patient sees us. We have patients who come in with angular deformities. When I was a kid we used to talk about people being either knocked knee or bow legged and you will see that a lot in our community where it will go to the extreme as age progresses. If there is an angular deformity, we try to deform that by getting an x-ray survey and then we will try injections. Steroid injections can work but you can only give them every three months. If you give them more frequently than every three months it will cause bone destruction. We will sometimes use bracing, although a brace is very, very difficult to help the knee in terms of what it needs because a brace can't handle 3-5 times body weight but most people don't realize that if you walk up a stair and you weight 200 pounds your knee is seeing 600 pounds. There are very few braces that can handle 600 pounds and often in my practice I will see patients who have body weight 300-400 pounds. There is no brace in the world that is really going to help that. What we will try to do sometimes is say to the patient is listen, why don't you lose some weight because if you lose 10 pounds your knee is going to see 30 pounds less every time you take a step. That is a very, very difficult thing to do in the United States, especially given the way our diets are progressing and the way of keeping us very heavy. The first things we suggest is exercise then we suggest something like talking to a nutritionist. We don't usually recommend bariatric surgery. The reason why we don't recommend bariatric surgery is because bariatric surgery is very difficult for a lot of patients and can cause problems with micro-nutrition deficiencies and it's a difficult process for people to go through.
PATTERSON: So let me just go way back. You had asked about some disparities, well we know that in our African American community, obesity is a major concern. Obesity affects the joints in many different realms. For example, the hormones itself related to obesity, they actually can cause some inflammation that can actually damage the joints and also as Dr. Grant eluded to, people don't realize that for every three pounds that you gain, that there are six pounds of weight added to your knees and to your hips. Even just modest amounts of weight loss can actually help your joints. Obesity and prevention, we know that prevention of diet and appetite using different kinds of fresh fruits and vegetables that aren't always accessible in urban areas, those types of things are very important to joint help and staying healthy.
LOMAX-REESE: Well let's talk a little bit about prevention because you just said, Dr. Grant, that exercise is one of the first thing to aid in weight loss and everything, but you also said that exercise, if you are overweight, can put additional trauma, or create trauma, on your joints. What are the appropriate kinds of exercises for people who are overweight that is not going to add more damage to the joints. I see very overweight people out on the drive, jogging on the regular, and I'm like wow, that looks painful and I'm just wondering, what are your recommendations for that?
GRANT: I would agree with you because if you are saying the doctor says exercise, my knees are bad and this is a dilemma that I face all the time when patients are saying this, doctor I can't exercise and do core exercises or running exercises because if I walk too far it hurts too much. I encourage patients though, if you walk, I say listen, take a watch, go 15 minutes in one direction and 15 minutes back in the other direction. You've got 30 minutes of exercise and you are back at the point where you started. But if your left knee is hurting when you are doing your exercise, use a cane on the right side, not on the left side but the right side, because on the side opposite that will reduce the weight bearing forces across the knee by 30%. The cane has been around since biblical times; it is just physics; it is a counter lever arm. The other thing I suggest is that if they can, use a treadmill. Don't put it on elevation but use the treadmill. It is the consistent of exercise at lease every other day if you are able to do that you will lose weight and you are going to strengthen the muscles. The muscles are like springs on either side of the knee or the joint that is affected. If you strengthen those muscles, you reduce the weight bearing forces across your knee also. We have some patients who will say listen if there is a program locally6 at your YMCA try to get into water acrobatics because you will be able to get into the pool; you will be more buoyant; your joints will not hurt as much and you can work your core exercise; it won't be as painful. If your doctor has given you medication, take the medication just before you exercise. You will be able to get that 30 minutes in and that can be helpful in terms of helping them develop a program that is going to be effective, even if they are overweight.
LOMAX-REESE: That is dr. Richard Grant and he is an orthopedic surgeon at Einstein and we are also talking to Dr. Donee Patterson from the Einstein Department of Medicine and we are talking about arthritis today and we know that fortunately our population is becoming older and older but the quality of life is a question and I'm curious, are there.…what do people need to be doing at 30, 40, 50 to make sure that their able to be pain free and healthy and their joints are going to be in good stead when they are 60,70, 80?
PATTERSON: I know that it just seems so easy just to keep talking about weight loss and we talk about that often. But prevention from even gaining an extra 8-10 pounds in a year; I've seen people who come back to me that I haven't seen for a year and they have gained 8-12 pounds within that year. As a lot of people know, trying to get weight off is even harder than just preventing it from being on, so really increase your fruits and vegetables, make that be half your plate; decrease your carbs and the empty calories and just think about foods that are rich in vitamin C, they have good joint health which fruit that are rich in beta carotene, they are good for the joints. Encourage our daughters, our sisters, our nieces to make sure they are eating diets high in calciums so that they can get calcium and vitamin D in their diet so that their bones are stronger when they are 30. I talk to 18, 19, 20 year olds all the time and they never think about being 40; they never think about being 45 or 50, but if they do the work now with the fruits and vegetables that have all those antioxidants and cancer fighting chemicals and anti-inflammatories, it really does pay off in the future.
LOMAX-REESE: I'm curious about… I've seen supplements that are for joint health and bone health and those kinds of things. Dr. Grant, do those have any value?
GRANT: They do to the people who invented them. We have not been able to figure out why something like over the counter chondroitin sulfate and glycosamine works. We have not been able to figure out how you can take a pill, get it to digest itself in the GI tract which is fulled with acid and then get it to distribute itself to the joint. Patients come to us often saying wow my knee feels so much better that I have been on glycosamine or chondroitin sulfate or some form of that. We are not really sure why that works for some patients and why it doesn't work for others. The unfortunately thing, however, is when we see patients who come to the orthopedic department and they might need a knee replacement, when we go and delve into their history, we also find that some other members of their family have had arthritis to the point where they need joint replacement. So another thing to factor in to the whole process of thinking about osteoarthritis, end stage osteoarthrosis, is that sometimes it runs in families. It never hurts for patients to be able to exercise, to strengthen their muscles, to stay at ideal body weight. All of those things can help them manage arthritis even if they have a family tendency to develop arthritis.
LOMAX-REESE: I wanted to see if you could talk a little bit about rheumatoid arthritis because I know that as you said Dr. Donee that is more of an autoimmune…is it more of an autoimmune disorder?
LOMAX-REESE: So is that more genetically…your predisposed genetically?
PATTERSON: Yes, you are more predisposed genetically for rheumatoid arthritis d some of the other arthritis's like gout and psoriasis as well. It doesn't mean that 100% you have to have family history, but it does run in families and there is also a genetic component to rheumatoid arthritis so there is a juvenile rheumatoid arthritis that children younger than 16 get at very early ages. The difference here is because your immune system is attacking your joints, it tends to be bilateral, so on both sides and it tends to be both joints, not that you can't have both joints affected in osteoarthritis but it is usually not at the same time. Then, because it is your immune system, people tend to feel fatigued, they may have low grade fever because it is a chemical that is circulating in their body and often that chemical can be picked up on blood work which is different from osteoarthritics. You don't follow blood work for osteoarthritis; it is just basically by history and examining the patient that you would understand that. Rheumatoid arthritis is a very different entity and because it is an inflammatory we often treat the pain very similarly initially with anti-inflammatories but then later on there are some more advanced treatments for it.
LOMAX-REESE: we are talking with Dr. Donee Patterson and Dr. Richard Grant, both from Einstein and they will be with you when we come back. I have to step out for a moment. I'm going to be on an interview on Huffington Post, which I am very excited about, but they are going to continue the conversation about arthritis, osteoarthritis, rheumatoid arthritis and I will be back later.
PATTERSON: Hi this is Dr. Donee Patterson and I'm joined with Dr. Richard Grant, who is one of our established orthopedic surgeons and we are here to answer some questions about osteoarthritis. As we were discussing before Sara left, there is a big difference between osteoarthritis and rheumatoid arthritis and people should know that there are different specialists that address both issues, but if you are having problems with your joints, stiffness or pain in your joints, I encourage you to talk to your primary care doctor. I want to ask you a question Dr. Grant, a lot of my patients come and say I need an MRI, they think that is the very first thing that should get tested by MRI and that is not really the case. Can you explain to people what they see on an x-ray and when x-rays will be ordered?
GRANT: Usually patients will come to orthopedic surgeon after they have seen their primary care physician and that is probably the order that it should happen because the primary care physician really knows the patient well and there may be something going on that needs to be dealt with outside the realm of primary care, either internal medicine or family practice and a lot of times we will have patients come to us via a gynecologist or ob-gyn or former pediatrician. But be that as it may, the x-ray is done; say for instance the patient comes in with a complaint of severe knee pain, severe hip pain. It lets us see what the joint is doing. Is the joint aligned properly? Is there cartilage left? Is there a deformity? Is there a fracture that might be missed? So these things are very important in terms of screening.
PATTERSON: Sure. A lot of people, they go out and they plan sports and they may not be conditioned to play sports. What do you say about that the stretching before sports and what do you say to your kids that are in sports?
GRANT: I say that stretching is important. I'm the last person to stretch when I go out and exercise. My wife corrects me on that, it's terrible. I think it is very good because it helps to allow the joints to be more limber, it keeps you disciplined and focused and it helps you avoid an injury because a lot of injuries occur when we exceed our capabilities, like the we warriors, you have to be very, very careful. So I think stretching is essential; I just need to do a better job of doing it myself.
PATTERSON: Yes, we all could do a better job. Let's go back to diet for a little bit, because I want to emphasize to people which foods to include in their diet. Foods rich in vitamin C, vitamin D, and beta carotene, those foods rich in vitamine C might be like bell peppers, lots of different colors and tomatoes and grapefruit, raspberries, strawberries, but do you find that when people are taking supplements or anti-inflammatories that that can be it for them? That they don't have to go any further than that?
GRANT: I wish at the grade school level and at the high school level we did a better job of teaching nutrition. We need to know a lot more about what our food intake involves. I think our diet is a little too heavy in fats, too heavy in meat and meat products, which should be limited and very, very carbohydrate intensive, which leads to obesity. In a lot of schools they don't have recess, they don't have organized sports, kids aren't burning off those calories. I think we need to reeducate ourselves as far as nutrition is concerned. Things that are good for us for good joint health, as you say, does involve vitamin C but one of the biggest recommendations we have now is some supplementation with vitamin D in the long term because more often than not a lot of the patients who come to me, even those who require surgery eventually, are very low in serum vitamin D and they don't know it because it hasn't been tested.
PATTERSON: Sure, I think t hat is very important as well. I want our listeners to recognize that we have a primary care doctor here so often I am the first gateway to treatment and then we have an orthopedic surgeon here and we definitely are not saying that surgery is what everyone needs but there are definitely cases where surgery has helped many people. Can you talk about that?
GRANT: Sure. I was just looking up an interesting fact today. In a lot of communities, there are families who have never had an individual who has had a joint replacement, especially in the African American community. This is one of the things that there are not a lot of orthopedic surgeons who are African American in the United States but sometimes when we do get together we talk about the disparity, the application of this particular procedure. This is an operation that has been around since 1960 and it is just now beginning to be utilized on a reasonable basis in the African American community. That has a lot to do with lack of recommendation in the past and we are seeing that changing as individuals are developing more knowledge about what is happening as far as what is available to them when they can no longer walk. When they come to us, they are at the point sort of the court of last resorts and they have tried everything else and they say what about this knee operation I've been hearing about? A lot of our patients are learning about knee operations and hip operations on televisions. Some of that information is factual; some of that information has a lot of hyperbole in it so a good portion of what we do has a lot to do with educating the patient about what their options are by the time they are referred to us by their primary care physician.
PATTERSON: I think we have a caller, is that right, from Gerald from North Philly? All right, if there is anyone who has questions for us, they can call us at5 215-634-8065. We have a few minutes left here with Dr. Grant, talking about osteoarthritis. That number again is 215-634-8065, and I'm Dr. Donee here with Dr. Richard Grant. So, Dr. Grant, I know that you mentioned bracing and I have some people who think that when they put on those spandex braces, that it does give them support. What do you think about that?
GRANT: I think that there is a very good basis for that and it has a lot to do with the whole concept of laying on of hands. A lot of what we do is reassurance and if a brace is reassuring, even if you buy it from the local drug store, I have no objection. I just have had patients get into trouble when they take the brace and they wear it all day and they fall asleep with it on. If you fall asleep with a brace on your knee, it can cause some problems and injury to the skin so I try to warn them to be careful. I will also have patients who come in and they put multiple ace wraps around their knee and their favorite tiger balm or the equivalent and I say well that's fine if you are doing that during the day but please take the ace wrap off at night. I don't have any objections to a brace; it's just that you can't expect the brace to do what your knee can't do.
PATTERSON: I don't really like ace wraps because they don't give even compression and people end up cutting off their circulation. If we do use a brace I like to use the braces that give even compression. So very quickly, we are almost out of time, for acute injuries, for someone who acutely injured themselves, what should they do? Is it ice, heat? I think people are confused.
GRANT: Ice is good for swelling. About 20 minutes at a time, don't keep it on longer than that. Use frozen peas applied directly to the knee. As far as pain relief, you can apply warm compress, make sure that the warm compress is not going to give any problems with the skin. Be very, very careful because if a warm compress is kept on the skin for longer than 15-20 minutes it can cause skin changes and burns so you have to be very, very careful with the application of those.
PATTERSON: Again, what are your final thoughts for this half hour segment? We've talked a lot and I hope that people learned a lot about osteoarthritis and the difference between osteoarthrosis and rheumatoid arthritis. Do you have some final thoughts for our listeners?
GRANT: I think the major thing is to prevent arthritis be sure that if you have a joint injury that you have an x-ray and the doctor examines you because you can develop what is called post traumatic arthritis that can be missed until several years later. For those of us who are anticipating entering into the 4th and 5th decade, you may want to get a radiograph or an x-ray of your knee if your knee is painful, chronically, you should know what is going on with your knee. Don't ignore it. If you do need arthritis surgery make sure that you have a good conversation with your orthopedic surgeon about what the alternatives are before you sign up for surgery.
PATTERSON: I am going to jump in with last thoughts as well. I am going to ask people to try to prevent injury to their joints whether it is your riding hard on their bike or doing tricks, or trampoline falls. Really remember your joints and try to protect them and if you are having a problem make sure you talk to your primary care doctor and try, try, try to keep the weight off instead of trying to just lose weight. Try to keep some of that weight off by staying active.