It outlines some of the important side effects of methotrexate but also puts them in perspective based on my many years using the drug as a rheumatologist.

This is my first attempt at providing medical information using youtube.

I’d be interested in what people genuinely think of the information posted.

Is it too detailed?

Isn’t it detailed enough?

Are there other topics you’d like to see covered? Please let me know.

These results apply to a special and limited section of the population and may not be applicable outside of the setting of a private rheumatology outpatient clinic and should be interpreted in this light.

We surveyed all patients presenting to the outpatient clinic of two rheumatologists (Dr. Adrian Gibbs and Dr. Ronan Kavanagh) over a one week period. 124 patients completed the survey.

The patients surveyed are that bit older than the general population (Median 57 yrs vs 34.8% nationally), more likely to be female (2/3 are women vs 50% in the general population) a bit more affluent than average (there is some data to suggest that internet usage is higher in those with higher incomes).

Even allowing for the fact that our patient population is higher than that in the general population, the results of this survey show that mobile phone, texting and internet usage is high amongst patients attending our clinic.

Here’s a summary of the results.

• 96% of our patients have a mobile phone
• 84% are able to send and receive text messages
• 72% of our patients have internet access
• 70% of our patients who do not have internet access indicated that they a family member who accessed it on their behalf
• 41% of our patients are on Facebook and 18% on Linkedin and only 5.3% have Twitter accounts
• 83% of our patients send or receive emails daily or a few times a week
• 79% have researched a product or service online
• 83% have looked online for information about a specific disease
• 70% have looked online for information about medical treatment or procedure.
• 59% have looked online for information regarding health insurance
• 56% of those with a Facebook account post updates daily or a few times a week and 44% post rarely of never post.
• 88% of those who had visited the Arthritis Ireland Website indicated that they thought it was either good or excellent
• None of our patients have ever posted an online review of a doctor and only 2.5% have posted a review of a hospital online.

The majority of our patients have a mobile phone. Whereas 84% of patients indicated that they are able to receive AND send messages, it is possible that had we asked the question in two parts, there would have been greater percentage of patients who knew how to receive / read text messages.

The internet usage in our patients is very similar to that in the general population. 72% of our patients use the internet and 69% of Irish households have internet access. Only 41% of patients who use the internet indicated that they have a Facebook account compared with the 69% of Irish internet users (or 45.3% of the Irish population). This probably reflects the older average age of our patients. Also of those who have a Facebook account 25% rarely post and 20% never post messages (figures are similar for Linkedin users with 51% posting daily or a few times a week).

Many of our patients have researched a product or service online and most have looked online for information about a specific disease,treatment or procedure but very few patients have looked at doctor or hospital ratings websites and none of them have rated their doctor in an online ratings site.  Irish internet users, it would seem, are internet ‘Lurkers’ and like to watch rather than post updates or comments.

Overall, the results of this survey suggest a high proportion of our patients will be in a position to avail of an online booking system when put in place. Whereas we have had a text reminder service for all outpatient appointments for the last few years, until now we did not know what percentage of our patients might be able to avail of it. We are now going to extend this to annual recall appointments and where possible send  dual reminders by text and email.

Summary graphs appear below

The Orgasmatron in action

The Climatron, as it was referred to in media reports of the time, was used by Professor Joseph Hollander, a Philadelphia based rheumatologist to determine the effects of the weather elements on the symptoms of arthritis patients. The device was basically a hotel room sized chamber (with room service) which was designed to comfortably house two patients for periods of two to four weeks. Using a system of valves and dials, it was possible to adjust the temperature, humidity, rate of air flow, barometric pressure within the chamber.

The Climatron in action (with Prof Hollander)

In his experiments, a small group of largely ‘weather sensitive’ arthritis patients, were recruited to come and stay in the Climatron. A number of times a day they completed a diary documenting various aspects of their health including assessments relating to their joint symptoms. They were also examined by a doctor and had their joints assessed. None of the subjects were aware that the main focus of the research was their joint symptoms and were not informed about changes being made to the weather variables within the chamber.

When individual weather variables were adjusted in the Climatron, none of the subjects  noted any difference in their joint symptoms. However when an attempt to reproduce the weather conditions of imminent stormy weather (simultaneous increase of humidity and reduction in atmospheric pressure) the effect on symptom worsening was significant in 7/8 of the rheumatoid patients and in 4/4 of the osteoarthritis patients. When this experiment was completed a number of times, those who noted a worsening did so about 3/4 of the time.

This was one of the first scientific attempts to correlate arthritis symptoms and the weather. Whereas the results are tantalizing, its hard, in view of the small numbers of patients studied, to draw any firm conclusions.

Arguments for there being a link

The strongest suggestion that arthritis symptoms are affected by weather is from patient surveys. About 2/3 patients in some studies state that their pain is worsened by certain weather changes. Some report how their joints help them predict the imminent arrival of wet weather, some note a dramatic improvement in their pain while on holidays in the sun (only to deteriorate on their arrival home ) and some even notice a worsening of their symptoms during heat waves. Whereas surveys are interesting, they don’t necessarily prove the link.

However, there are also some semi-plausable mechanisms as to how weather might affect joint symptoms; We know that joints  contain pressure receptors (baro-receptors) for example. Couldn’t changes in atmospheric pressure therefore be detected within joints ? The problem is that the sorts of barometric pressure changes seen with weather fluctuations are small and only of the sort of magnitude that might be experienced going up and down in a lift or on an airplane journey. It is also true that the physical properties of  tendons and cartilage can be altered by temperature changes but again, this has only been shown in laboratory experiments using extremes of temperature not usually seen in the environment . There’s even some evidence that levels of inflammatory proteins (cytokines) have been shown to decrease in patients undergoing hot spa therapy with inflammatory arthritis and of course heat (or cold) applied directly to joints also seems to help some patients too.

Some patients feel can predict weather changes in their joints

What’s surprising therefore is how prospective scientific studies over the years have failed to show a consistent relationship between various weather variables and arthritis symptoms.

This is at least partly due to the fact that these studies are difficult to do. If the weather were a new drug and researchers were trying to determine its effectiveness in the treatment of arthritis, we would be obliged to ‘blind’ both the patients AND their assessors to their weather treatment (a wet day, dry day etc). Its hard to be ‘blind’ to the weather. Unless you spend all of your time indoors – but then you are not being exposed to the weather changes (other than barometric pressure) either. People also wear clothes most of the time, which alter the humidity and temperature around joints and which could ‘blunt’ any effect that external factors might have.

Other investigators point to the difficult confounding role of psychological factors. Where someone with arthritis holds a belief, for example, that damp cold weather worsens their symptoms, they are psychologically more likely to place emphasis on information that reinforces this idea. They might be more likely therefore to remember those days where their joints were bad AND where the weather was damp and cold but not place emphasis on days where the weather was damp and cold and their joints were good. It has also been suggested that bad weather causes patients to feel depressed or to become inactive – both factors which have been shown to worsen pain.

What’s the bottom line:

Although the data is confusing, I tend to believe my patients when they tell me there joints are effected by the weather. This is true for some patients but not for all.

In my opinion, and despite and firm to data to back it up, I believe the following;

1. That arthritis is not caused by cold or damp weather. There is no evidence whatsoever that this is the case.

2. Where weather has an effect on arthritis,  it is solely on the symptoms of the disease and has no effect on disease progression or structural damage.

3. The effect of weather on arthritis symptoms varies from patient; as a rule I would have said that most patients prefer dry warm weather to cold damp weather. Patients with poorly controlled rheumatoid arthritis can occasionally flare when its very hot.

4. The better controlled a patients disease, the less they will notice fluctuations with weather changes. This is particularly true of patients with inflammatory arthritis (eg rheumatoid arthritis, psoriatic arthritis).

5. Emigrating for a better life with your arthritis is probably not a good idea. If an improvement is noted on moving to another country it is quite often temporary. Uprooting yourself from the support network of your family and friends isn’t a good idea and then there’s the stress of moving to another culture, negotiating another health system etc.

6. As with all things that you can’t control its probably better not to stress about it too much. You can’t control the weather…

Sun going down on Galway bay.

I know this because amongst them are some of my younger patients in my practice, many of whom are afflicted with conditions like rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. Whereas many of them are doing well on treatment, and seem quite up-beat and excited to be considering the idea of a few years away, there are some downsides to consider. This is particularly true for those who are on biologic treatments for their arthritis.

Biologic therapies are a group of modern, hi tech and effective treatments for certain types of arthritis. They are also very expensive. The annual cost in this country for a patient treated with once of these drugs ranges from €15,000 to €20,000.

Although many gripe about the state of the Irish health service, one of the things it does very well is provide funding for these drugs. At present (although likely to change) there are very few restrictions on a Irish rheumatologist’s ability to prescribe biologic therapies for arthritis.

Every Irish citizen is entitled to have the costs of  subcutaneous biologics (e.g. Enbrel, humira, Simponi, Cimzia) covered (subject to shortfall)  through a fund known as the ‘HiTech scheme’.  This is usually subject to maximum shortfall per family of €132 per month and about a third of the Irish population who have a medical card (those over the age of 70yrs and those below a certain income) which entitles them to (almost) free medical care where they have to pay 50c per month per item on their prescription. The centrally funded Hi Tech scheme (which is ring fenced from other health service costs),  does not cover the costs of the Intravenous biologic drugs (e.g. Remicade, Roactemra and Orencia). These are usually funded through local hospital budget (much to the chagrin of public hospital administrators). Those with private health insurance have the costs of intravenous drugs and related infusion costs met by their insurer (a bit less than 50% of the Irish population carry health insurance).

For those patients who are considering changing jurisdiction  there are always two considerations when it comes to getting continued access to your regular arthritis medication.

1. The first is that a change in country means a change in rheumatologist. Where your new rheumatologist will effectively be the gate keeper to access treatments, your ability to get access to these drugs depends wholly on your new rheumatologist agreeing that biologic therapy is appropriate for you. Whereas consensus for patients with more severe forms of arthritis is unlikely to differ, there are often grey areas where opinions may vary. The decision making process however is more likely to be informed by local funding issues.

2.Funding for biologic therapies is much more restricted in other countries. For example, in Australia, access to biologic therapies for anklosing spondylitis is restricted to patients with a certain grade of severity of AS on Xray whereas in Ireland it is wholly at the discretion of the treating rheumatologist.

3. Even where you have Irish private health insurance, it will usually only cover you for emergency treatment abroad for a certain period.

What is the best advice for those thinking about emigrating who are on treatment?

1. Be aware that you may not automatically entitled to access to biologic treatments abroad. The HiTech scheme in Ireland only covers the cost of drugs of patients living here.

2. If you are thinking about emigrating, discuss it with your rheumatologist before making any firm decision. He/She may be able to recommend a rheumatologist and initiate contact for you.

3. Firmly establish the funding guidelines and restrictions on prescribing of these drugs in your target country and ask your rheumatologist for advice. I have included links to the UK (NICE) guidelines (for Rheumatoid arthritis Ankylosing Spondylitis Psoriatic arthritis , Australian Medicare guidelines (Rheumatoid arthritis , Ankylosing Spondylitis, Psoriatic arthritis) and Canadian guidelines. US regulations are much more complicated. I think it would be fair to say that having health insurance in the US would be imperative and that you would need to establish from the target insurer what their coverage guidelines are. Get it in writing!

If you are a patient in a country other than Ireland who has guidance you’d like to offer to foreign patients thinking of emigrating you your country, please add a comment.

Only two types of arthritis to consider. That shouldn’t be too hard to do now should it? Here’s some of blood tests that help us do it;

Inflammation blood tests (ESR, CRP)

The results from these two readily available and relatively inexpensive blood tests are probably the first tests any rheumatologist looks for on a patient are the ESR (‘sed rate’) and CRP. These two complementary blood tests help us differentiate between patients with active inflammatory arthritis (eg rheumatoid, psoriatic, reactive arthritis, undifferentiated inflammatory arthritis, ankylosing spondylitis) and those with degenerative joint problem or with other causes of their pain. Although they can be become elevated in conditions other than arthritis (infections and malignancies for example) I tend look on them as measuring the ‘temperature’ of any inflammatory process. The higher above the normal range they are, the more intense the inflammation present. In certain disease states (eg rheumatoid arthritis), very high levels can help us identify patients at higher risk of damage. The closer to the normal range they are, the less likely a patient it to have an inflammatory process. These tests are also used to help monitor the activity of inflammatory arthritis and its response to treatment (one of the ways we know treatment is working is that the CRP / ESR falls during treatment) These tests are not infallible by any means. For a list of pitfalls in their use see below under specific conditions.

Disease Markers (RF, CCP, ANF/ANA)

Once a doctor suspects a patient has inflammatory arthritis, these disease specific tests are used to determine which type of inflammatory arthritis (or other connective tissue disease) they have. Examples of these tests would be Rheumatoid Factor (RF), CCP antibody and Anti Nuclear antibodies (ANA/ANF).

The majority of rheumatoid arthritis will have a positive rheumatoid factor test (‘seropositive’) or a positive CCP antibody (CCP positive). Rheumatoid factors can also occur in some other conditions (eg SLE, Sjogren’s syndrome) but CCP antibodies are usually only present in patients with rheumatoid arthritis. The presence either of these antibodies can help identify patients who are at greater risk of more severe forms of rheumatoid.

There is also some evidence that these antibodies can be present for many years in people before they develop rheumatoid arthritis so be positive in patients without symptoms. The ANF* is usually positive in SLE but can be positive in patients with rheumatoid arthritis. Confused yet?

*Further discussion of the use of Antinuclear antibodies is beyond the scope of this piece

Osteoarthritis

This is the commonest form or arthritis and a condition where ALL of these blood tests listed above should be normal. That means normal ESR, CRP, RF and CCP antibodies unless there’s another condition present alongside the osteoarthritis.

Rheumatoid arthritis

The ESR or CRP may also be normal in patients newly presenting with rheumatoid arthritis. In a large study of RA patients from Finland and US, between 45-47% of patients had a normal ESR, 44-58% had normal CRP at presentation. BOTH were normal in 33% and 42% of patients**. When a rheumatoid factor test was included, 14-15% of patients had no abnormalities in all 3 tests.

Remember that only 70-80% of patients will have a positive rheumatoid factor or CCP antibody (and one can be positive whether the other is negative so we tend to do both) and even greater percentages of pts will have negative antibodies (‘seronegative arthritis’) early on. Having negative antibodies does not therefore exclude rheumatoid arthritis.

It is also well describedthat inflammation can be visible in the joints using MRI ultrasound scans in patients with known rheumatoid arthritis in the absence of inflammation clinically or on blood tests.

Psoriatic arthritis

Many patients with psoriatic arthritis (approximtely 50%) will have either normal or near normal ESR and or CRP levels. Patients with Psoriatic arthritis will usually have negative rheumatoid factors and CCP antibodies and Antinuclear factors.

Ankylosing Spondylitis / Undifferentiated spondyloarthritis

Ankylosing Spondylitis is a form of inflammatory arthritis (largely affecting the spine). Whereas abnormal CRP and ESR can be very helpful in making a diagnosis of AS in certain patients with back pain, these tests will only be abnormal in about 50% of patients. The rheumatoid factor, CCP antibodies and ANA should be negative in this group of patients.

Palindromic Rheumatism

Palindromic Rheumatism describes a syndrome where there are recurrent episodes of pain swelling warmth and stiffness of joints. The symptoms can have onset over hours and last days – weeks, before subsiding. However episodes of recurrence form a pattern, with symptom free periods between attacks lasting for weeks to months and some of these patients will go on to develop rheumatoid arthritis. It is not unusual for these patients to have normal inflammatory indices (especially between attacks, when they are well) and approximately 50%will have negative Rheumatoid factor and CCP antibodies.]

Conclusions

Making a diagnosis of inflammatory arthritis in patients is usually straightforward but there are some pitfalls to catch the unwary. Whereas the tests can be unreliable in some settings, with the right history and clinical examination in the hands of an experienced rheumatologist, it is possible to make a diagnosis of inflammatory arthritis and offer effective treatment even where the labs don’t quite fit the picture.

A typical blogging rheumatologist

I’m on the list too but then you know that because you’re on my blog reading this…..

http://bjcconnectedcare.com/ by Dr. Irwin Lim, Sydney, Australia
http://rheumatologe.blogspot.com/ by Dr. Lothar M. Kirsch, Meerbusch,
Germany
http://www.arthritissupportboard.com by Dr. Shashank Akerkar, Mumbai
India
http://www.carvica1.blogspot.com/ by Dr. Carlo V Caballero,
Barranquilla, Colombia
http://paulsufka.com/ by Dr. Paul Sufka, Minnesota, USA.

The Doctors’ Rheum by Dr. Julie Levengood Worcester, MA, USA
http://blogs.medscape.com/brunooliveira by Dr. Bruno Oliveira,
Billings, Montana, USA

http://larhumato.com/ by Dr. Francis Berenbaum, Paris, France

There was a time, in recent memory, when it was possible to skim the entire book of abstracts for the meeting during the transatlantic flight to the US (with plenty of time left over for a nap and the in-flight movie). This year,  a few hours on the flight and a further couple of hours in my hotel room only got me half way through  abstracts presented on DAY ONE by the time day two came along. At that point I simply gave up.

Thankfully, the organizers of the meeting are aware that most delegates will be unable to digest all of the research presented in this way and organise nice, succinct 30min – 1 hour reviews on everything they think we should know about. There’s also plenary sessions where the pick of the best scientific abstracts are presented and discussed by people who know what they’re talking about. Whereas these updates are presented by smart, eloquent speakers with nice slides and data, no single attendee will recall everything that was said at each presentation. This year there were over 400 such sessions. I didn’t get to all of them.

Of course the Annual Scientific Meeting isn’t all about what goes on in the lecture rooms. Even the most diligent of attendee sees the meeting as time to catch up with old friends and colleagues in a non-work environment, keep on gossip, and even do some sight seeing. Although these social opportunities may act in some ways as a distraction to the core meeting, I find that a lot of the important work of the meeting take place precisely in this environment; many of the ‘juicy morsels’ of clinical information are exchanged between colleagues at breakfast buffets, on shuttle buses and even in the Jacuzzi’s, bars and restaurants of the convention hotels.

Given that it is often these brief informal information swaps that I find so potent and informative, I wondered about using Twitter to replicate this sort of information exchange. Twitter is a free online social networking service that enables its users to send and read text-based posts of up to 140 characters (about 20 words), informally known as “tweets”. The format of its short textual summaries closely mimics (to my mind) the short verbal exchanges which help communicate so much information in so little time.

I used a laptop (excellent free Wifi access is essential) to post my tweets and to follow the activity of other tweeters at the conference. For each presentation I attended, I ‘posted’ a number salient, take home points about the presentation with links, where possible, to the source material / speaker.

To be certain of exposure of me tweets wider audience than my relatively limited number of ‘followers’, I also posted my Tweets to a ‘discussion group’ (or ‘Hashtag’ = #ACR2011) for the meeting and also to discussion groups for specific disease (e.g. #rheumatoid #rheum #autoimmune #osteoarthritis). This way, anyone who was interested on following the proceedings of the meeting could see my comments and those of any delegate posting in this way. It was also possible for non attendees to post questions to this on-going meeting discussion which could be replied to by any delegate or observer.

Tweeting from the meeting was a really invigorating experience. The process of funneling of a large amount of information into its distilled essence required a high level of attention to the presentations (much like reading a book for a book-club – knowing you’re going to have to discuss the content later). It made me more tenacious in my pursuit of an understanding of the topic in situations where I might have otherwise allow jet lag or other meeting distractions get the better of me. There’s an implied level of responsibility when communicating information in this way, that demands that you get it right. As a result, I got a lot more from the presentations than I usually do. My Tweets from the meeting have also acted as short aide memoir to the whole proceedings.

The feedback from the my tweeting efforts was very rewarding.  I received live comments and questions from rheumatologists in other countries and from many patients. A graph of the influence of all tweeters at the meeting was posted online so I could see the range of people my tweets were influencing . While I was attending a lecture on one topic there colleagues tweeting information from other sessions so I was able to be in two places simultaneously.

I would throroughly recommend getting familiar with Twitter in anticipation of your next big conference. The more you tweet, the more you’ll learn and the more rapidly you will disseminate information to other rheumatologists. Although the Twitter experience hardly replicates the bonhomie, fun and immersive atmosphere of actually attending a conference, using it will add to your experience of the conference whether you’re in Washington DC or in Galway for #ACR2012.

Thanks to all my Twitter buddies at #ACR2011 @_connectedcare @rheumepi @brianreid @carvicab @rawarrior @drakerkar @rheumatologe @psufka @socialmediashan and @dsymons

Hand osteoarthritis

Modern treatments for RA are now very effective at reducing symptoms of the disease and are also capable of dramatically slowing its progression. The treatments are so good in fact, that it has made us all realize how poor we still are at treating OA. It is ironic therefore, that I find myself 20 years later, contemplating that some of my OA patients might fair better if they had RA. If recent media reports are to be believed, help may be on the way for OA sufferers in the form of a nutritional supplement. Sound familiar? Read on….

Osteoarthritis

Treatments for OA

Just when you thought it was safe to back in the water

Chondroitin Sulphate – New trial published

A recent publication in the Sept 2011 edition of the Arthritis and Rheumatism journal has confirmed that Chondroitin Sulphate, another fish derived dietary supplement is safe and is more effective than placebo treatment in the treatment of some symptoms of osteoarthritis of the hand.  The study suggests that patients who have hand OA and who take 800mg of pharmaceutical grade Chondroitin Sulphate every day for 3 months, have pain scores which are  significantly better than those who have taken placebo tablets. Pain scores in the treatment group improved by an average of 8.8 (on a scale ranging from 0 to 100) more than in those those taking placebo treated patients. Despite the apparent small improvement in pain scores, the requirement for additional pain relief in the form of paracetamol / acetaminophen was unchanged in the Chondroitin sulphate taking patients.

There was also a statistically significant improvement in hand function (patients could do more with their hands) amounting to 3 points on a 30 point scale and they loosened out more quickly in the morning (by about 4 mins) compared to those on placebo. These benefits only occurred  in those who have been taking the drug for 3 months. The study didn’t report what happened patients after the 6 month protocol ended so its not clear whether any of the benefit was sustained.

Does is work?

The reported improvement in arthritis pain in the Chondroitin Sulphate treated patients was small. Whatever the small improvements in these outcome measures, there is no evidence from this study that chondroitin sulphate had any effect on the metabolism of cartilage.

Low expectations

It is a measure of the low expectations that we have for the treatment of OA that a study like this would have been published at all. Most studies of the effectiveness of a new treatment in RA, for example, would demand an improvement of at least 20% in a number of outcome measures and most rheumatologists wouldn’t be happy with response rates of at least 50 – 70% or complete remission. We have along way to go before we achieve anything near this OA. OA is likely to derive from disease processes in a number of structures within joints, and perhaps its naiive to expect that a drug directed at one component like cartilage might have an effect on all of the others.

Better than nothing?

Although Chondroitin sulphate may be a little better than taking nothing at all, I would be surprised if many rheumatologists will be routinely recommending it to their OA patients. It is unlikely that any scepticism within in the rheumatology community will prevent the inevitable marketing push from nutriceutical companies promoting this product on the basis of these largely disappointing results.

Fortunately there are many options available that make this disease more bearable for people but the search for a treatment to halt its progress continues.

These pictures, taken by Francesco Carrozini  makes it obvious to this rheumatologist, that Keith has well established osteoarthritis (OA) of his fingers. 

Most of us who live long enough will get OA in some shape or form and it is by far the commonest form of arthritis.

The particular type of OA that causes the swelling in the distal finger joints is known as ‘nodal OA’  - so called after the hard and bony ‘node’ like swelling it causes in affected joints. Nodal OA can be very painful at the outset (as the bony swellings enlarge) but it is not uncommon for the pain to ease up a bit once the joint stiffens up and no longer moves properly. Its easy though to see how OA of the fingers could cause significant problems for any player.

Anyone who’s even tried to learn a few basic guitar chords will realize how much force and dexterity are required in the fingers of the fret hand to play an F barre chord – simultaneously firmly holding and index finger across all six strings and at the same time getting the middle ring and little fingers to hold three other strings.

Don't try this at home folks

All guitarists (soloists in particular) need a high degree of dexterity to allow their fingers to move quickly around the fretboard with precision and considerable strength. And that’s just the left hand! In addition to the difficulties caused by pain and stiffness of the joints, the enlarged bony nodes can get in the way and make unwanted contact with guitar strings.

Although there has been some speculation in the media that his playing may have contributed to the development of his arthritis, there’s no evidence that playing any instrument wears joints out quickly. Musicians get arthritis, just like the rest of us.

Playing related pain is very common in guitarists though and occurs in between 70% and 80% of them.  Most problems relate to the fret hand and wrist (i.e. the left for most players), low back and neck. Guitarists also suffer from shoulder impingement, tennis elbow, wrist tendonitis, carpal tunnel syndrome, finger tenosynovitis / trigger finger and non specific forearm pain. The symptoms relate primarily to the postures adopted playing the guitar, supporting a heavy instrument, moving heavy amplifiers and equipment, long hours of practicing without breaks, increasing practice time to quickly after a lay-off and lack of aerobic fitness. Stress, sleep disturbance and depression will also influence how these performers experience pain and how they present.

Over the years Keith Richards has also made changes to his playing technique which might have made it easier for him to perform as he gets older. In the late 60′s he started using a form of guitar tuning called ‘open tuning’ (which allows a more economical use of the fretboard compared to standard tuning) and started using a 5 string guitar (a standard guitar has 6 strings). On describing this adaptation, he says;  ’there’s a million places you don’t have to put your fingers. The notes are there already’.

Keith Richards’ continued ability to perform in one the most  hardworking bands in the world is likely to relate to far more than changing his guitar tuning or to his legendary physical constitution. For Keith Richards and for most musicians, giving up music is simply not an option. His observations about the addictive qualities of music and performing give us an insight into the addictive qualities of creating and performing music;  ’a far bigger drug than smack. I could kick smack. I couldn’t kick music. One note leads to another, and then you never know quite what’s going to come next, and you don’t want to. It’s like walking on a beautiful tightrope.’

Health care providers encountering musicians need to be as persistent and as creative as the people we’re caring for in finding solutions to keep them playing. Remember that losing the ability to play music is for many musicians, akin to losing part of themselves.

PS. It has of course occurred to me that by drawing attention to Keith Richards in this way, that I might offend him in some way. Bearing in mind his propensity to throw knives at people who have upset him in the past, I include a link to the Keith Richards Merchandise site to take the edge off his ire. His autobiography, Life, is excellent too.