Rheumatoid arthritis (RA) is a type of chronic debilitating inflammatory arthritis that usually affects small joints of hands and feet. If not treated adequately, RA may cause severe pain and joint damage leading to permanent joint deformity.

How common is RA
Worldwide, the prevalence of RA is estimated to be 0.24% of the population (Global Burden of Disease 2010 Study). In US and European countries, RA has a higher prevalence (0.5%- 1.0% of the population). In South-east Asia, the prevalence of RA was reported to be 0.40% (J Glob Health 2015). RA is found twice as common in women compared with men and more commonly found between 30-50 years old.

What causes RA
RA is an autoimmune disease. To date, the exact cause of RA is not able to be identified. Researchers believe the occurrence of RA is multifactorial. A positive family history, genetic factor, smoking, obesity, physical inactivity, age and female sex have been reported to increase the risk of RA.

Presentations and symptoms of RA
Commonly, RA patient will experience stiffness of hands/ feet or affected joints for more than an hour during early mornings. Joint pain and swelling are common. Joints involvement are usually symmetrical on both sides and joint distributions are polyarticular in nature. Apart from joint symptoms, patient may suffer from dry eye, dry mouth, lethargy, weight loss, nodules on skin, lung fibrosis or skin ulcer.

Diagnosis and investigations
Diagnosis of RA is made based on patient’s history, physical examination, blood and imaging tests. Physical examination may reveal boggy joint swelling and joint tenderness on palpation. Patient may have deformities such as radial/ ulnar deviation of the wrist, wrist subluxation, ‘boutonniere deformity’ (hyperextension of the distal inter-phalangeal joint and flexion of the proximal inter-phalangeal joint), or ‘swan-neck’ deformity (hyperextension of the proximal inter-phalangeal joint and flexion of the distal inter-phalangeal joint).

Blood test for specific autoantibodies associated with RA are rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA). A positive RF or ACPA may indicate a more severe/ aggressive disease. Inflammatory markers such as erythrocyte sedimentation rate (ESR) or c-reactive protein (CRP) may be elevated in active disease.

Imaging such as x-ray and ultrasonography of the affected joints may help to detect joint inflammation or erosion on the bones. Musculoskeletal ultrasound is widely used in rheumatology outpatient clinic as a diagnostic tool because ultrasound is more sensitive to detect early arthritis. Ultrasound is a non expensive, non-invasive safe procedure that does not use radiation when compared to other imaging modalities.

Differential diagnoses of RA
Other than RA, the differential diagnoses of chronic inflammatory polyarthritis are: –
– Gouty arthritis- polyarticular
– Psoriatic arthropathy
– Generalized erosive osteoarthritis
– Arthritis related to connective tissue disease such as systemic lupus erythematosus (SLE)

Treatment
Treatment of RA should be initiated as soon as the diagnosis of RA to preserve joint function and prevent joint deformity. The mainstay treatment of RA is disease modifying anti-rheumatic drugs (DMARDs). Example of commonly used conventional DMARDs are methotrexate, leflunomide, sulfasalazine and hydroxychloroquine. Biologic therapy or small molecule targeted therapy are also an option to treat severe RA whom have failed conventional DMARDs. Non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids may be used as an add-on therapy to reduce joint inflammation.

Non-pharmacological treatment is also important as part of RA treatment. Physiotherapy or occupational therapy may help in maintaining joint activity, strength and joint protection.

Complication of RA
Untreated RA may cause severe disabling joint deformity. Apart from joint complication, RA may cause premature cardiovascular disease, lung fibrosis, osteopenia or osteoporosis, dry eyes and mouth, increased risk of cancer such as lymphoma.

What should I do if suspected to have RA
If you have symptoms of arthritis, please consult your doctor. If investigations and further management are required, referral to Rheumatologist is warranted.

Dr Lim Chong Hong is a Consultant Rheumatologist & Physician in Loh Guan Lye Specialists Centre, Penang. He has vast experience in diagnosing and treating various rheumatic diseases/connective tissue diseases such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, gout, degenerative joint diseases and systemic lupus erythematosus (SLE).

by Chng Tian Ying,
Head Sports Trainer – RMIT University

When it comes to the management and rehabilitation of soft tissue injuries, there is much complexity involved. What is a soft tissue injury? Soft tissue injuries commonly involve sudden trauma or overuse to muscles, ligaments, or tendons. These injuries often occur during sports and exercise activities but can also be sustained in a situation such as from a misstep when walking, and in many more different scenarios. 

The most common traditional first aid protocols for soft tissue injuries were the mnemonics R.I.C.E. (Rest, Ice, Compression, Elevation), P.R.I.C.E. (Protection, Rest, Ice, Compression, Elevation) or P.O.L.I.C.E. (Protection, Optimal Loading, Ice, Compression, Elevation). 

These methods highlight the acute management of soft tissue injuries but do not cover the sub-acute and chronic stages of these injuries. In 2019, Blaise Dubois and Jean-Francois Esculier proposed a new protocol: P.E.A.C.E and L.O.V.E. 

The PEACE and LOVE protocol is a new comprehensive guide that covers all stages of injury. It also emphasises the importance of patient education and the biopsychosocial model. 

Current research has shown that an individual’s experience of pain is influenced by the complex interactions between their biological, psychological, and social factors; Thus, it is essential that they receive equal attention to optimise the individual’s recovery process. 

This protocol is split into two parts. PEACE is used as immediate care in the acute stage (1-3 days) after injury, and LOVE as ongoing management in the subsequent phases of injury. 

In the past, movement and exercise after injury have been frowned upon because of the fear of re-injury, but recent research has suggested that introducing easy and gentle movement during the early stages of injury can be beneficial. It can help with blood flow, joint mobilisation, and decreased fear to get back into activity later. It has been suggested that movement is safe as long as it does not exceed a 4/10 pain, does not worsen the existing condition, and is not done excessively. 

You may be wondering why ice has not been suggested in this protocol as one familiar scene that has been seen repeatedly, especially in the sporting community, is the use of ice during the early stages of a soft tissue injury. 

The PEACE and LOVE protocol holds a controversial opinion towards the use of ice. Despite ice being widely used, there is no high-quality evidence to back up the efficacy of it. It has been suggested that although it can help relief pain, it could also potentially disrupt the inflammatory process and delay healing, as inflammation is the body’s natural response to heal and repair damaged tissue. The avoidance of anti-inflammatories is also suggested for a similar reason. 

With the continual advancement of research comes new knowledge; therefore, leading to the constant evolvement of treatment and rehabilitation strategies. This article is a brief introduction to the PEACE and LOVE protocol, and more details can be found online. 

With that being said, if you do experience a soft tissue injury in future, don’t forget to treat them with PEACE and LOVE!

by Dr Hayden Pooke,
Chairman of the Sports Chiropractic Council Malaysia (SCCM)

The formation of Malaysia’s National Chiropractic Sports Council (NCSC), the Sports Chiropractic Council Malaysia (SCCM) was announced by the Association of Chiropractic Malaysia (ACM) at the beginning of 2020 and it was officially recognised by the International Federation of Sports Chiropractic (FICS) in 2021.

According to the SCCM Chairman and Sports Chiropractor, Dr Hayden Pooke, the SCCM’s membership increased from 13 to 47 members in 2021 and he hopes that the trend continues as the Malaysian Sporting Sector begins to open up and travel restrictions are reduced.

Before the Covid 19 national lockdown, the SCCM was involved in their first ever event in the Zurich PGAM Junior Invitational Tournament in 2020, invited by the Professional Golf Association of Malaysia.

Despite ongoing challenges from Covid-19, the SCCM is currently collaborating with Malaysian Sports Associations and plans to provide Sports Chiropractic care for athletes at as many events as possible in 2022.

SCCM is also poised to conduct, with FICS, their first International Certificate in Sports Chiropractic (ICSC) “hands-on” seminar in the third quarter of 2022 in Malaysia. The SCCM is also proud to announce that one of their student members Kong Hong Lian was awarded one of the FICS Student Scholarships for 2022, a first for any Malaysian Chiropractic Student.

Apart from producing world class Sports Chiropractors by completing the FICS highly acclaimed ICSC and giving its members the opportunity to represent FICS Sports Chiropractic delegations at international sports events treating world class athletes, SCCM also pledges to do everything it takes to bring Sports Chiropractic treatment to the local Malaysian sporting scene, servicing and educating athletes at all levels of competition.

by Dr Tan Boon Cheong – MBBS (MU), MS Ortho (MU)

I believe some of us have come across stem cells treatment in certain diseases. In orthopaedic, stem cells have been used to treat osteoarthritis, for example knee osteoarthritis, etc. Much has been said and heard about stem cells treatment but I believe the knowledge of the general population on stem cells treatment is still superficial. Thus, it is better for everyone to learn a little more about it.

Stem cells are undifferentiated cells with the ability and potential to self-renew and proliferate, producing more differentiated or specialised cells in the process. Stem cells can be obtained from several sources; they have several types, namely embryonic stem cells, perinatal stem cells, induced pluripotent stem cells, adult stem cells(Mesenchymal, hematopoietic and epithelial) and immune stem cells.

With the advancement and research development of stem cells technology, stem cells therapy has been able to expand its therapeutic function. Stem cells have been used as a cell source to reconstruct or rebuild living tissue. In the field of immunotherapy, stem cells have been used as an immune modulator for autoimmune diseases. Furthermore, it can also act as progenitor cells for immunotherapy, allowing the development of cellular technology for anti-cancer, anti-virus and enhancement of body immune system. Because of its potential to self-renew and proliferate, stem cells is also used as a therapeutic agent for degenerative diseases related to aging and frailty, and it has been developed into drugs for treatment of chronic and resilient illnesses. With recent advancements, stem cells therapy has been introduced into the treatment of autism and it has shown promising results.

After several decades and continuous research, stem cells therapy will become a game changer for the future in medicine. The capabilities of stem cells are growing everyday although there are still many obstacles to overcome. It is undeniable that stem cells play a huge role in regenerative medicine and transplantology, but because the technology that produces stem cells is expensive, only few could afford it. With the establishment of more regulated stem cells laboratories, I believe stem cells therapy could be more affordable to everyone that requires it.