Arthritis/ Trigger finger/ Dequervain’s disease

WRIST ARTHRITIS/ TRIGGER FINGER/ DEQUERVAIN’S DISEASE

Wrist Joint arthritis is usually accompanied with pain and stiffness affecting the flexibility of the affected joint. Wrist is composed of numerous small joints and inflammation and pain in these joints are symptoms of wrist arthritis. Wrist arthritis damages the cartilages surrounding the small joints, leading to ligamentous instability causing pain during movement of the joint. Wrist arthritis causes pain, stiffness, swelling, limited range of motion and clicking or cracking sound on movement.

Trigger finger is a condition developed due to the inflammation of the tendon sheath in the fingers causing pain, tenderness and limiting the finger movements. The affected tendon sheath usually develops a nodular swelling which makes it difficult for the tendon to slide under fibrous pulley near the base of the finger; thus making it hard to straighten the finger from the  bended position. This causes stiffness, tenderness and a popping or clicking sensation while moving the finger.

De Quervain's tenosynovitis is an inflammatory condition affecting the tendons which move the thumb finger causing pain in the base of the thumb with difficulty and a sticking sensation when trying to move the thumb. The tendons are lubricated by the synovial fluid from the protective sheath. Inflammation to the tendon affects the lubrication resulting in thickening, and swelling of the tendons in the thumb. The doctor examines these conditions by applying pressure on the affected area, pushing the thumb into the hand and may order imaging tests to understand the cause and severity of the condition.

Conventional treatment for wrist arthritis includes NSAIDS pain medications, Disease Modifying Anti-Rheumatoid Drugs and in later stage, Wrist Arthrodesis or fusion surgery. Conventional treatments for tendon disorders are usually NSAIDS, Steroid injection and Soft tissue release Surgery to regain the gliding movement of the tendon. Medications are prescribed to reduce pain and swelling followed by physical therapy to stretch and strengthen the affected area.

Alternative treatment method at Daystar Clinic, Alappuzha & Beth Yehudah Arthritis Center, Pullad

1) Platelet Rich Plasma in Osteoarthritis of Wrist joint : Platelet Rich Plasma prolotherapy is the recent trend in treating various joint conditions and is designed to stimulate repair of chronically inflamed synovium, partially torn/damaged ligaments in the affected joint and to reduce swelling and pain caused by the condition. PRP therapy uses only PRP, whereas PRP Prolotherapy is a combination treatment where PRP is injected into the joint and dextrose prolotherapy is given to the ligaments and soft tissue attachments around the joint. This treatment may help a patient who does not want surgery and helps to overcome the disease condition with minimally invasive injection techniques. The treatment method stimulates the natural immune repair mechanisms of the body and delivers the building block essential to build and repair damaged tissues.

How does PRP work? Blood components are of four major types - plasma, platelets, white blood cells and red blood cells. Platelets assist in clotting and are also the “first-responders” of the body post injury; helping repair an injured region and in building up of new tissue and thereby promoting the healing process. Once platelets contact collagen in damaged tissues, the platelets release various biological growth factors (Table 1 as given below) to promote healing in soft tissues locally. Activated platelets commonly release the following growth factors:

Table 1: Various biological growth factors released by PRP when activated

PRP injection delivers a high concentration of autologous (patient’s own) platelets to the Wrist joint, where Osteoarthritis is present. Platelets present in the blood are the first responders to an injured area and helps build up new soft tissues. Introducing high concentration of platelets directly into the joint using PRP injection stimulates the healing process and faster recovery from the joint condition.

Patient Benefits of PRP Prolotherapy

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• For those who wish to avoid if not delay Wrist Surgery.
• Significantly reduces the symptoms associated with Secondary Osteoarthritis
• Reduced risk of adverse events
• Assists in repair and tightening of ligaments improving joint stability.
• Safe and effective treatment method
• Assists healing and recovery

2) Prolotherapy for Osteoarthritis of Wrist: Prolotherapy is a natural and cost effective alternative method to surgery. Prolotherapy is an almost painless injection technique under local anesthesia where very thin needles are used to inject high concentrations of dextrose solution (sugar similar to glucose) in to loose and damaged ligaments, tendon and muscle attachments around the osteoarthritic joint. Prolotherapy works by increasing the glucose concentration in the fluid outside the cells. This results in movement of fluid from inside the cells through the cell membrane to the outside of the cells thereby shrinking the cells and causing temporary cell damage (hyperosmolar damage). As the cells are temporarily damaged, they release many biosignals to the body which results in stimulation of the local immune system of the body to accelerate the inflammatory process locally resulting in increased local blood circulation, fibroblast (fibrous cell) proliferation, ligament regeneration, tightening and repair. Prolotherapy is an effective non surgical treatment method used successfully in osteoarthritis/ degenerative joint disease conditions. This treatment method has the ability to strengthen the existing intact, but weakened, ligamentous and tendinous structures in the joint. Along with the treatment technique, it is important to perform series of movement and muscle strengthening exercises to strengthen the already weakened muscles due to osteoarthritis joint condition.

Patient Benefits of Prolotherapy

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• Avoid if not delay Wrist Surgery
• Significantly reduce the symptoms associated with Osteoarthritis of Wrist joint in most patients.
• Reduced risk of adverse events
• Repairs and tightens ligaments improving joint stability.
• Safe and effective treatment method
• Assists in healing and recovery

Neural & Soft Tissue Infilteration Therapy (NESTIT)

Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT):  Steroid tablets and injections of the group Corticosteroids, (which are very different from Anabolic steroids misused by some athletes) have been repeatedly proven medically for the last 70 years in the successful treatment of inflammatory conditions due to its potent anti-inflammatory effect. Though corticosteroids are very effective in reducing inflammation, they carry numerous potential side effects, which are undesirable. To circumvent this problem, and in order to utilize the potent anti-inflammatory effects of steroid injections, at the same time taking appropriate measures to considerably lower its side-effects, Dr Tejaz Koshy John in 2010 while working as an Orthopaedician in his private clinic in Guyana, South America developed NESTIT. NESTIT stands for (Juxta) Neural and Soft Tissue Infilteration Therapy. It consists of injecting small amounts of diluted anti inflammatory steroid solution indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb. It is preferably given for those patients who have Rheumatoid Arthritis, Inflammatory Arthritis, Synovitis, Inflammatory Low Back Pain, Spondyloarthropathy & Nerve and Nerve root irritation. It is not a substitute for DMARDS (Disease modifying anti rheumatoid drugs), however when given with low dose DMARDS, in Dr Tejaz John’s clinical experience it may result in significant reduction of local inflammation, pain and improvement of joint function in most cases, also indirectly reducing side effects of high dose DMARDS.

NESTIT involves 

1. Administeration of low dose local steroid via infilterative type of injection technique rather than giving oral steroids (as cumulative daily dosage of oral steroids over a 6 week period could exceed the dose of local steroid injection by almost 5 to 10 times) or conventional single injection into joints directly.
2. Reduce the dosage of Steroid given via injection and the use of a sliding scale according to patient’s body weight and height to regulate dosage. A 40 kg woman of 4 feet 9 inches should not receive the same dosage as a 100 kg male of 6 feet height.
3. Dilute the low dose steroid injection upto 80% with sterile water and local anesthetic.
4. Administer relatively insoluble low dose steroid via multiple infilterations locally in inflamed tissues in very small amounts indirectly near (juxta) nerve CCPs- (chronic constricting points) in the lower back/ hip/ neck/ shoulder regions as per requirement, in order to reduce juxtaneural and perineural inflammation, as well as in certain soft tissue sites including but not limited to trigger points (painful muscle “knots”)/ myofascial syndrome and/or enthesitis (inflammation of soft tissue-bone junctions) and/or sites of nerve inflammation (neuritis/ radiculitis) and/or bursitis (inflammation of fluid filled cushions called bursa) and/or additional sites causing pain referrals (referred pain) to distant sites; in order to obtain a reduction in inflammation and pain in the concerned joint/ region/ limb.
5. Identification of high risk patients and risk stratification to reduce possibility of side effects, for eg. Patients suffering from serious heart & liver conditions tuberculosis, infections, significant osteoporosis, immuno-compromised patients, menstrual irregularities, already having Cushing’s syndrome, ongoing significant hair loss etc.
6. Regular monitoring of body weight and physical appearance for early detection of Cushingoid features, if it occurs (rarely), to delay/ avoid further injections.
7. Control of High Blood Pressure and Diabetes prior to giving injections.
8. Doing skin sensitivity tests to rule out allergic reactions to the drugs.
9. Explaining possibilities of common & rare side effects to the patient and taking precautions regarding other common side effects wherever possible.
10. Opting for/ Shifting to regenerative treatments like Platelet Rich Plasma and Dextrose Prolotherapy wherever there is secondary degenerative disease / soft tissue damage, once the severe inflammation subsides.

In Dr Tejaz John’s clinical experience, the patient benefits of Low Dose Steroid Infilteration/ Neural & Soft Tissue Infilteration Therapy (NESTIT) treatment are:

• Minimally invasive treatment method
• Almost painless injection technique using very thin needles under local anesthesia
• Avoid if not delay Surgery in Inflammatory conditions of the Wrist.
• Significantly reduces the symptoms associated with Inflammation in cases of Arthritis of Wrist/ Trigger Finger/ DeQuervain’s Disease..
• Reduced risk of adverse events compared to oral steroid tablets which are taken daily, due lower dosage (very low steroid dosage compared to cumulative oral steroids over 6 week period).
• Reduced risk of side effects/ adverse effects due to prior risk stratification and identification of high risk patients vs. low risk patients by doing precautionary steps and tests prior to giving injection.
• Reduced incidence of post-injection pain due to highly diluted steroid solution.
• Reduces joint stiffness.
• More effective treatment method in inflammatory joint diseases.
• Faster recovery.
• NESTIT treatment usually results in significant, effective, progressive improvement of wrist pain, function and reduction of stiffness if given in series.

At Beth Yehuwdah Arthritis Centre, Pullad & Daystar Clinic, Alappuzha we provide a variety of options for patients suffering from Wrist Arthritis/ Trigger finger/ Dequervain’s disease. To know more about treatment plans and cost, contact us/ book an appointment now.