 Hi, I'm Dr. Sunil Kini, Consultant and Orthopedic Surgeon and at Manipal Hospital, Old Airport Road, Bangalore, with special interest in joint replacement, arthroscopy and trauma. I'm here to answer a few questions which I put forward, specifically on arthritis. I have a few recent questions which I'm going to go through first and then try to answer them. Any further questions live are always welcome at any point of time and I'll take it one by one. The first question asked by Neetu, at what are the major symptoms which I should be looking for to detect arthritis? All kinds of arthritis are various types which I'm going through. The symptoms specifically start with the pain. So pain is the number one indication for which someone comes to me as a chief complaint. So this pain initially is very much localized to one of the joints. The pain initially in the early stages is only when you walk and climb activities such as climbing stairs and very rarely at rest. So rest pain always indicates that the pain is much more significant. Along with pain, other chief complaints are swelling in the joint which can either be reactive as in old age or osteoarthritis or such as inflammatory arthritis. Other complaints could be restricted range of motion, especially getting the need to bend beyond a certain degree. And also stiffness of the knee which can also be another chief complaint. So these are some of the complaints with which an arthritis patient comes with and which much alert the patient to in the scenario. Second question by Havarsha. So what are the major types of arthritis a person is likely to go through? The few basic categories into which arthritis can be classified. Number one, the commonest is osteoarthritis or also called age related arthritis which is more so seen in the older population. Usually you've seen earlier at age 60 or more but nowadays with the dietary changes and with the wear and tear we see arthritis even in patients as young as 40 to 45 years of age. Apart from osteoarthritis the other commonest cause of arthritis is what is called as inflammatory arthritis. This corresponds to a few spectrum of conditions. The first among this common is what is called as rheumatoid arthritis which again is an autoimmune condition which affects the joints. So the autoimmune system which in the body attacks the host itself. Apart from inflammatory arthritis, rheumatoid arthritis, there are some other types of arthritis called as psoriatic arthritis. Gouty arthritis which is related to high levels of uric acid crystal deposition in the joint. There are also some kind of arthritis which are bacterial arthritis or viral arthritis. So bacterial arthritis is usually called as septic arthritis and this is usually an emergency so someone septic arthritis has to seek emergency help. So these are the common kind of arthritis we usually come across. Next question by Priyanka. Are there any natural cure for arthritis which I can do from home? Yeah, there are few natural remedies which we prescribe for all kind of arthritis. It's not a cure exactly but what we can say that it's one of the kind where you can do some remedies to halt the progression of arthritis. First of all among them is weight reduction. We all know that obesity or increased BMI, body mass index is one of the commonest reasons for which arthritis has come across. So dietary changes in form of low fat fatty diet or reducing saturated fatty acids or also diet exercising is a major component of preventing wear and tear or arthritis. So these are the common natural remedies which we can come across to prevent the disease progression. And next part is can arthritis be cured for life or has it to be continuously taken care of in the very end? Some kind of arthritis such as viral bacterial arthritis can be completely cured. Number one, some kind of arthritis may be inflammatory arthritis such as rheumatoid, psoriatic or gouty arthritis can actually go into something called as a remission. So these arthritis usually have a peak every say every three or six months after which the disease goes into a complete heart or what we call as a remission. So even these kind of arthritis can be very well taken care of if they take intervention at an early stage, take care of by exercising weight reduction, stop smoking and also take the medicines which the doctor recommends on a timely basis. Some kind of arthritis as osteoarthritis sadly can only be kind of taken care of in the sense it cannot be allowed to get to a greater stage. But there is no complete treatment for osteoarthritis. You can only heart the disease progression by methods mentioned above. Next question from Ayush, apart from joint surgery or painkillers, how can I get rid of knee arthritis? So as I described about these are all natural remedies which you can do weight reduction, exercising, keeping yourself fit, include less of saturated fatty acids in your diet, include more of antioxidants in the form of vitamin C. And by other methods as described above. Next question by Binu Babu, hi how to control treatment for the gouty arthritis? Please let us know the food items which need to be avoided. So again we must remember that gouty arthritis is a form of crystal induced arthritis which we normally call at level of uric acid in the body. Uric acid is normally excreted in the urine but when the levels get to such a high that it is beyond the capacity of the kidney to excrete it then it gets deposited in various joints. Commonest being the great toe, knee and then the shoulder joint which you commonly see. So this is because of increased breakdown of protein in the body. And gouty arthritis present itself by severe joint pain occurring on one fine day which is excruciating and which usually requires doctor consult. For gouty arthritis the treatment is mainly based on a combination of both medications for the acute attack and the chronic period thereafter and also to start on some dietary modifications. Coming first two dietary modifications this mainly includes avoid food items which are increased source of purins. So this mainly includes avoiding fatty foods and foods rich in red which are rich in those especially red meat to be avoided. All kinds of alcohol also should be avoided in these conditions. Some kinds of fish such as sardines or mackerel also has to be avoided in these cases. Sea shell food again has to be avoided and the treatment are in various forms and that has to be taken after a doctor consult. Next question by Geetika. Hi, how to differentiate between the symptoms of arthritis and rheumatoid arthritis. What is the treatment plan for both? That's a very good question. I think there are some very important points I would like to highlight here. So when she says arthritis it's mainly osteoarthritis we are talking of and the difference between osteoarthritis and rheumatoid arthritis. Rheumatoid arthritis generally involves people in their younger age say probably as early as 20 years to as earlier as elder as probably 40 to 50 years. Whereas osteoarthritis is mainly seen in the older population number one. Rheumatoid arthritis pain is usually has something called relapses and remission. So one fine day you have pain lasting for say 2-3 months then the disease goes into remission. It will be absolutely fine and again the kind of pain flares off. Whereas osteoarthritis pain is usually slow in onset and then usually increases over a period of time after which it only goes higher up. So there is no disease-free period what we call in osteoarthritis unlike the rheumatoid arthritis. Rheumatoid arthritis has a more strong congenital or hereditary cost compared to osteoarthritis which is mainly wear and tear related to your usage of joint and also due to your increased BMI. Apart from that common symptoms are pain which restricts your motion. That's common in both OA and rheumatoid arthritis. Stiffness of joints is common in both conditions although more in rheumatoid. Swelling of joints is seen in both although more common in rheumatoid arthritis. Treatment is entirely different. So treatment for osteoarthritis is basically depending on physiotherapies, knee strengthening exercises or hip strengthening exercises. Diet modification or reducing your BMI. Whereas those rheumatoid arthritis is mainly based on what we call as DMA-ARDs or disease modifying anti-rheumatic drugs. So any concern with rheumatoid must always be seen by a rheumatologist rather than orthopedic surgeon being the first line of treatment. So they will prescribe you on any of these DMA-ARDs depending on some of the blood tests which they may do to ascertain whether the levels are safe or not. And also nowadays they have something called as monoclonal antibodies which although are expensive is like a wonder drug for patients rheumatoid arthritis. So any kind or any person suffering from rheumatoid arthritis, the number one person you must be going to is a rheumatologist in the initial stages. Of course when the damage is done beyond control then an orthopedic surgeon comes into picture for the surgical part. Next question by Babu Beg. So he has a couple of questions. First is what are bone spurs, first part. So bone spurs are nothing but extension of osteophytes or bony plugs at joints. Usually what we all have is pristine joints and we don't have any extensions. But when there is arthritis the body tries to limit itself by cornering themselves and creating more bone on the edges where it is not required. So bone spurs are radiological picture what we refer to when we see these kind of osteophytes or bony extensions near the joint. Next question is what is the most important thing a person suffering from arthritis should keep in mind? The most important thing is to seek treatment early so that you know what are the do's and don'ts. And then to maintain a healthy lifestyle as I say reduce the BMI, reduce and have good eating habits, exercise, stop smoking. And treat, seek medications in early stage because especially arthritis such as inflammatory arthritis, if you seek treatment at an early age then you can prevent the progression of the joint damage at a later stage. Next question by Sanita. Is arthritis an effect of prolonged use of steroid? Yes, it could be that steroid itself can lead to arthritis. More so arthritis, you know that steroids are prescribed to reduce the inflammation in the first instance. But prolonged use of steroid can indirectly cause something called as AVN or Urvascular Necrosis where in the part of the joint the bone loses its blood supply and then collapses. So this is most commonly seen in joints such as the hip joint but also which is the weight bearing joint but also can be seen in the knee as well as the ankle or the shoulder for that matter of fact. So and this collapse or AVN can lead to something called as a secondary arthritis which then leads treatment. So yes it can lead to a form of arthritis steroid use can lead to form of arthritis. Next question by Avinash. Is having arthritis also a sign and symptom of having a heart disease? It can be. Not the routine form of osteoarthritis or so but some kind of arthritis such as rheumatoid arthritis in early stages can start as rheumatic fever. So it all starts as a form of an infection here, tonsillitis, sore throat, which can be an attack of a streptococcal infection. So these kind of infections over a period of time recurrent attacks if not treated with antibiotics or prevention can secondly cause a spectrum of disease what we call as rheumatic fever. And rheumatic fever then can involve the heart and cause condition causes called as endocarditis. And a spectrum of extension of that could be the joint infection which we call as rheumatoid arthritis. So indirectly it could be a form of alertness to having a heart disease especially if it is something to do with rheumatoid arthritis. Next question by Anish. Hi, I'm 23 and I've been diagnosed with osteoarthritis. I feel devastated. What are some of the tips that could help? This is quite a rare scenario 23 having osteoarthritis. It could be arthritis due to any other cause. So again I'm not sure what joint you're referring to whether it's the hip or the knee. At a young age it's usually the hips that are affected. And these arthritis are often a cause of pain in the younger individuals only if it is a part of a disease spectrum. So some of the conditions which can affect people in their 20s. I've operated hip joints at the age of 21. In someone you say what is called as ankylosing spondylitis. Ankylosing spondylitis is another form of autoimmune conditions wherein people in their 20s are affected and all the joints are fused and those are people that need early attention. And some other kind of childhood disorders such as hip displace or dysplastic hip or something called as Perthys disease or a slipped femoral head. A subtle form of it can start in childhood and then progress thereafter and by the time they're 30s or 30s they can already have osteoarthritis. So in your case it depends on what stage of arthritis. If it's early stage and obviously it can be cut with arthritis of the joint then you may need surgical intervention to prevent worsening of the disease and pain. So please consult your orthopedic surgeon and make sure you get the right treatment. A second part of his treatment is is there any hope to repair cartilage destroyed by osteoarthritis. Again a very interesting question and something which is a form or as a hot debate topic when we go to conferences in our scenario. So if there's a localized kind of cartilage destruction or early stage of cartilage destruction which is very much localized area of 1 centimeter, 2 centimeter square then it can be treated by various methods. We have got conditions or we have got treatment modalities such as cartilage transfer where when we take a piece of cartilage from the healthy part or the non-weight bearing involved part of the joint from the other knee save me for example and then transfer it. So this can only happen if it's limited to a specific small area and to a limited depth. We can also in early stages we can also do something called as a drilling technique wherein we drill small hole through the defect and then we hope that the fluid ingress from within the cavity can come and fill it up. Although it is not the normal cartilage or the synovial highland cartilage what we describe it is replaced by something was a fibrous cartilage which is often good enough. But in osteoarthritis what happens is it's a very large area that is affected at the same time. So in those conditions it is not possible to do any kind of cartilage repair therapy. So as indicated there's only for localized cartilage loss that cartilage therapies can be advocated. Next question by Diwali. What are the most efficient ways to treat hip joint arthritis? Number one, is it doable to lift weights with the diagnosis of osteoarthritis? The most efficient ways is obviously to prevent arthritis prevention as I stated and reinforce again having a good healthy lifestyle, dietary modifications, excessive regime, low BMI, stop smoking. All this can help prevent osteoarthritis. Again once you have osteoarthritis then we ask patients to restrict some of the activities such as squatting, sitting cross-legged, climbing stairs especially related to the knee and the weight clearing joints. Second part is is it okay to lift weights? You can lift moderate weights depending on what kind of arthritis you are in. Exercise we must remember also involves other kinds of regimen not only weight lifting also involves stretching and strengthening exercises and this is what is most helpful than actual weight lifting. So any patient with arthritis you always ask to stretch, go to your physiotherapy under supervision do some stretching strengthening exercises so that the weight is taken less by the joint and more by the muscular skeletal part of it. Next question by Nisha. Is chronic tonsillitis a cause of arthritis? Yes as I said if it's all starts with rheumatic fever what I said as chronic tonsillitis in childhood untreated or not taking proper antibiotics this can go forward to tonsillitis and then they can cause rheumatic fever and as a spectrum of this this can later involve the joints in probably say 20s or in the late 30s. Next question by Mudit. Is there any diet plan that can ease arthritis pain? That's the first part. Yes as I said diet do influence number one diets which have low source of saturated fatty acids. Diets which actually increase source of omega fatty acids theoretically reduced joint pain that involves you know cod liver oil fish is a good source of omega fatty acids and weight reduction. Next question by Siddhar. How does body weight influence arthritis? Obviously people with increased body mass has over ease or constantly overloading their joints so obviously they take more weight on their joints and then the cartilage where accelerates and then the joint where starts. So body weight is known to directly influence arthritis so any BMI more than 40 what we call as morbid obesity is directly or proportional to the sequence and the speed which the arthritis can catch up in these people. Next question by Ajati. My brother has rheumatoid arthritis one of the best ways to prevent it. So early treatment is what is most important. If you have not seen your rheumatologist I think it is high time that you see one because treatment effect as early as six weeks after starting of symptoms can actually go a long way in preventing permanent damage because once your joints are permanently damaged then there's no way out. It's only surgery which can actually show the way. So early rheumatoid arthritis say if you have pain restriction of motion, stiffness, swelling this is the time you need to have an early consult and start on medications. Apart from that I say dietary modifications does help low fat diet, decrease saturated fatty acids. Diets which are increasing antioxidants and vitamin C, cherries, berries and a lot of fruits can actually help lower the symptoms of arthritis because they actually prevent the immune system from misfiring against your own body. Next question by Bisu. So what is the type of arthritis most commonly found in the older age group and can it be cured completely? And how much would it approximately cost? I presume for surgery. So type of arthritis most common in the older age is almost always osteoarthritis or age rate arthritis which is most commonly related to wear and tear of the joints. Can it be cured completely? Sadly it cannot be cured completely but you can hard to prevent progression of arthritis through various methods that have been reinforcing. One is dietary changes, exercising certain activities which you should not be doing so that deep squatting costs like stairs to a large extent. How much would it cost? Again when you go to a stage of arthritis so we recommend arthritis only when pain interferes with the activities of daily living. When you say daily living cannot do stairs, cannot go out for shopping cannot sit on the chair, pain from rising of the chair, rest pain. These are all activities of daily living. So anything which comes restricts all these activities along with an X-ray evidence of say grade 4 arthritis. Grade 4 arthritis is bone on bone. So we all patients with arthritis we take weight weight X-rays and make sure to stage them. So if they are in stage 4 where it's already bone on bone with the clinical with the clinical science and symptoms of arthritis then we recommend the surgery. In such case again it depends on what implants we are using. So this range can be varied depending on the implants which you use whether it's imported or something from the local market. So again I think you must consult your local orthopedic surgeon to seek further notice on what would approximately be the cost of surgery in these cases. Second part of arthritis question is, hi doctor my relative got knee surgery 2 months back. Just wanted to know if he can go for another surgery on the other knee now. So this is quite a hot debate of bilateral knee replacement. So both knee replacements whether it can be done in the same sitting whether it can be done in two sittings and what must be the spacing between two surgeries. Most commonly all knee replacements or joint replacements are done stage that means one knee followed by the other. So very rare scenario we operate. I have operated on both knees and both hips together on certain conditions which is out of the norm. Say where the joints are totally gone in a young patient say enclosing spondylitis where both joints are fused and where one surgery or one doing one joint will not help in these cases. So doing two joints may help or would help in terms of the surgery early recovery, physiotherapy, pain relief and stressing over the other joint. So if a young patient with both joints badly involved with a good cardiac reserve which we see where which is seen by the cartilage is no respiratory issues those conditions very rare exceptional scenario we can do a bilateral knee replacement that is both knees in the same scenario. Otherwise most of the other cases it is always always a stage procedure one knee probably followed by the other. So spacing again we say probably six weeks to three months is the safe period for the body to recover for the knee joint to recover and also the body reserves to recover. So at least six weeks or three months is ideal to space the two surgeries. Next question by Babu, can physical therapy help arthritis pain? It definitely helps. So physiotherapy is the number one recommendation rather than medications for any patient staging from say one to or even three arthritis grading. So while early arthritis physiotherapy is the treatment modality. How pain can be normalized for a 90-year-old woman? So again the treatment modality doesn't change. So in her old abilities of physiotherapy assesses what mobility or what strength a 90-year-old would have and depending on that he or she would chalk out a treatment regimen which mainly includes strengthening exercises in the early stages. So if it's a late state device whether depends whether patient is a good candidate for surgery in terms of medical conditions. It has to be assessed by a team of doctors and then only a treatment modality in terms of surgery can be advocated. Third part of this question is how is psoriatic arthritis diagnosed? It's diagnosed by a clinical as well as combination of serological blood investigations. So once a patient is diagnosed with psoriatic arthritis he or she would have given treatment regimen including an acute regimen to get rid of the acute pain and then a chronic regimen to decrease the uric acid levels in the body. Next question by Gul Hassan. What causes arthritis pain? Why is it so variable? So arthritis pain as I described again there are a lot many causes of arthritis pain. It depends on what the etiology is. The pain can be severe. It can be subtle to start with and then become severe. It is so variable because it depends on what the cause is. If it is age related arthritis it is slow goes on building over a bit of 5-10 years. It really becomes bad so much that even the activities of daily living becomes difficult. In inflammatory arthritis the pain is again okay. You have pain less free period for 3 months then you have flare ups for 3 months then it comes down so it's like a plateau it's like an ups and downs. That's why it's so variable depending on what the condition is. Next question by Hamid Sheikh. How does rheumatoid arthritis affect people's lives? So rheumatoid arthritis sadly affects people in the young 20s-30s. This is age wherein physiologically very active unlike in the 60s. So it is definitely a condition which is bothersome, requires early address. That's why I said early treatment with medications and an exercise safe regimen saving the first 2 or 3 months of suspected rheumatoid arthritis once your diagnosed can actually work miracles. So perhaps in patients who are as normal as the other population once they seek early treatment. But if you don't seek treatment early say you come up for 10-20 years then you have you are in the stage of what is called as a burnout stage. By the time the joints are always invariably involved the joints are destroyed, destructed and not often salvageable. That's when it becomes a pain as it is probably the only alternative that is left. Next question by Gul Hassan. Why do joints make popping and cracking noises? So I assume this is a question is in the scenario of background arthritis. In the scene of arthritis what we call as popping and cracking noises is what we refer to as crepitus or the crackling of the joint. So this usually happens in advanced arthritis say grade 3 or grade 4 when the two bones are no more apart. So usually there is a joint there is a joint space where we have something as a sign of fluid. So both the joints of either end are at an approximate distance of 4 to 5 millimeters from each other. So once the fluid dries up then the joints come closer to each other and then finally they sit on each other and start rubbing. So when two joints rub each other that gives rise to what is called as a popping, cracking noises or crepitus what is called. So that usually indicates that this is an advanced case of arthritis. Next question by Valsala defense between rheumatoid and rheumatic arthritis. More often it's an exchange scenario. It's the same. Rheumatoid arthritis is a spectrum of condition. When you say rheumatoid it's usually localized to the joints more often. Rheumatic arthritis involves other systemic conditions along with that involves the heart, lungs where in the autoimmune condition is spread out to involve systemic involvement. Next question by TESFA. So what is the most effective medication for rheumatoid arthritis? So medications for rheumatoid arthritis have a different subclass. The first line of treatment would obviously be this is modifying anti- rheumatic drugs which involves many drugs such as could be steroids, could be hydroxychloroquine, sulphasalazine and also nowadays we have something called as MF alpha blockers or tumor necrosis factor. These are all monoclonal antibodies which act much faster and much effective in clearing the disease progress. The only adverse effect is the down line of cases is quite expensive therapy. So these are the common medications which are prescribed for rheumatoid arthritis. The best person to answer probably would be rheumatologist. Shoaib Sheik asks, could I really have arthritis? I am 20 and what is the age where arthritis can start happening? Well this is a very hypothetical question to start with. Anybody could have arthritis. So what you should be I mean 20, 30, 40 age is not a criteria. So as I said younger patients are 20 usually have inflammatory arthritis or crystal arthritis induced arthritis and or arthritis which is congenital hereditary and which is progressed through in the first decade of the second decade. So you should be worried only if you have constant pain which is usually not traumatic or not infective or metabolic. So if you have constant pain say for a prolonged period of time say 3 or 4 weeks associated with the restricted movement, joint pain, joint stiffness then you need to see a doctor who would obviously start off with an x-ray if needed and some blood test to make sure you don't have the other form of arthritis which can be treated. So there is no age limit which is barred from having any kind of arthritis. Next question by Rabiya Wajahad. I have knee arthritis what are the three things I should take care from my end? Well it again depends on what stage of arthritis I assume it's early arthritis. So if it's early arthritis the first treatment modality is dietary and exercise modification. So dietary modifications in the sense I already imposed low saturated healthy diet, more fruits, decreased blood BMI, quit smoking and good exercise regime number two wherein you need to keep your knees fit, avoid activities of increased contact stress such as sitting cross-link and climbing a lot of stairs if it's in the advanced process. And third seek the help of a physiotherapist who is going to chocolate and exercise regime for you and after that you need to do those exercises which mainly involves quads strengthening the crutches of something in front of the knee, VMOS strengthening, hamstrings strengthening, stretching exercises which can actually go a long way to delay the progression of arthritis. Next question by Vandana. Hello sir can you please tell me what's the role of genetics in rheumatoid arthritis? So rheumatoid arthritis as I previously said is an inflammatory disorder which is autoimmune. So there's a large role of genetics in that it's known to run in families. When we say genetics it's actually the autoimmune system. We all have an immune system which actually warps off any attack from the external environment say bacteria, viruses. But in these cases the patients rheumatoid arthritis, the immune system fails to recognize your own cells from the foreign cells. So it starts attacking your own body so it's a very early stage at which arthritis or the disease progress starts and then rapidly progresses. So genetics has a role in rheumatoid arthritis patients. Next question by Rohit. I'm 20 and my joint sound whenever I move them is any problem. So sounds can be normal. So we all can have crackling sounds but you should be alerted to any sound only when it's associated with any other symptoms such as A pain, 2 restriction of motion, 3 swelling of the knee or a force difference of the joints or any other joint environment. So if any of these conditions are running parallel with your cracking sound then it needs to address it otherwise purely a harmless sound should not be taken seriously. Next question by Chirag has got 2-3 questions running side by side. He asks does swelling and pain implies one is suffering from arthritis? Not always but it could be. So pain swelling if it's not a traumatic cause could be one of the early symptoms of the signs of arthritis. So if it's prolonged say more than 2 weeks and if it's persistent and not okay on medication that's when you need to seek treatment because it could be an early sign of arthritis. Second question, Parox question, does weight maybe the cause of arthritis? Absolutely. Weight bearing joints in these cases weight is an often cause and symptom of arthritis. So any patients with increased BMI more than 35, more than 40 which we call morbid obesity, a high risk of developing weight bearing joint arthritis. So that must be taken care of. Third part is numbness of the body part related to arthritis. Numbness may not be directly related to arthritis of the weight bearing joint but some kind of arthritis in holding the spine say lumbar spondylosis or arthritis of the joint of the back. So let me say lumbar canal is where in the nerves can be compressed and you may have what is called a shooting pain down the leg or sciatica. So that's the difference. In this cases you must visit your orthopedic surgeon or a spine surgeon to make sure he examines you, look for the cause of numbness and then do X-rays and MR scans if needed. Next question by Apoor. Can a person whose age is 60 to 70 with an arthritis problem do exercises to remove the bone disorder? So obviously I assume that he's asking whether there's a cure to something called an osteoarthritis. As I said there's no absolute cure but you can prevent the progression of the disease. So exercises is an absolute must for any patient with any grade of arthritis whether it's pre or post even after surgery he has to do physiotherapy to make sure that the joints remain in active condition. So yes they don't remove the bone disorder but they definitely prevent in helping prevention or the progression of the disease. Next question by Apoor. What is the best natural treatment for severe chronic lower back pain and knee arthritis? It is quite interesting and to note that many of the people who come with knee and hip problems or ankle problems always have some coexisting lower back pain. This may not be to the fact that they are directly related or separate conditions but people who have hip and knee pain have an altered gait so you walk in a different direction and that's the reason you strain the joint above. So they usually have a strain of the lower back but they can also have in the older age people where people with knee or hip osteoarthritis can also have something like lumbar spondylosis or lumbar canastinosis with numbness of the legs. So it's very important that any patient with knee and hip problem also has to be looked for any associated spine issues and if both are existent then we must do investigations to treat and manage both the conditions which are coexisting. Next question is from Vandana. What is the best treatment of arthritis and are there any medical advancements in this field? Surprising to note that the advancement of arthritis is quite drastic and quite progressive. So best treatment of arthritis again depends on what stage. As I said if it's early stage arthritis then obviously physiotherapy and diet exercise modification can help to a certain extent but if it's advance case of arthritis where it's bone on bone, grade 4 arthritis then it may require surgical intervention. A medical advancements keep happening all the time so far in the surgical scenario. Earlier people were quite scared to go ahead with arthritis even in their most advanced conditions because the joints which were initially placed used to last probably say only for 10 to 12 years but nowadays with the recent advances in the ortho biologics what we call the implant manufacturing they've got plastics without metals which can last for 20 to 25 years. So people no longer have to, who is a surgical, people who are surgical candidates no longer have to wait say for you know to suffer till the age of 60 or 70 to undergo surgery because even patients who have symptoms in early 40s, 50s can get joints done if indicated because the longevity of the implant has drastically improved and so has the function. Next question by Asir, can you cure post-traumatic arthritis? It again depends on what stage it is. So any kind of trauma to the joints can cause an early cartilage injury which can progress and then cause bone collapse and then arthritis. So if it's post-traumatic arthritis in the early stage again it can be managed conservatively but more often than not this may require surgical intervention of any sort. Next question by Rohit, will having arthritis in the past have any long term effects on me? So if it's arthritis which has been cured say viral arthritis or bacterial arthritis they often don't have any long term effects. They just have what is called as lapses and remissions. Obviously arthritis is a post-traumatic arthritis and inflammatory arthritis is a continuous form of arthritis so they may have long term sequelae. So it's best to know what kind of arthritis you are suffering from and then seek appropriate treatment accordingly. Next question is from Gautam, so what is the best natural treatment for severe chronic low back pain and knee? So natural treatment is a treatment arrangement of exercises. So anyone who comes to me say for knee pain or low back pain say with low back pain we advocate exercises, low back strengthening exercises so more of us we exercise all our upper and lower limbs but we hardly take care of our back. Most of the people who come to me with back pain have a background of an IT scenario wherein they have to sit and work in front of computers for the posture. Two wheeler riding in this kind of roads can obviously damage your back as well. So exercise regime meets the first line of treatment Physiotherapies was the first line of treatment for chronic low back pain allowing some kind of early treatments such as say IFT or SWT or ultrasonics which may advocate knee pain again exercise regime includes your knee strengthening quadriceps strengthening hamstrings and strengthening stretching exercises and offloading exercises for your knee. Tina asks how did you get over inflammatory arthritis? As I said the best treatment for that is early intervention. You see cure doctor early, see your doctor rheumatologist early or an orthopedic surgeon early so that the treatment can be started. So once the treatment starts you can prevent what is called as flare ups. Although there is no permanent cure there is what is called as you can prevent the flare ups of surgery so that they can go into what is called as remissions or a pain free period and once you get good treatment that this duration of pain free period can be increased so that they can have as near normal life as possible. Next question by Christian Recently I had my knee operated after an accident. What are the chances of developing arthritis, contracting arthritis. So again it depends on what kind of surgery you have had. So was it an articular injury, in the sense was it the fracture involved the joint and how bad the arthritis was when it was a single fragment when it was commuted to 3-4 pieces and how well it was operated and how good is the restoration of the joint. So when we operate on any trauma which involves the joint or what we call as articular injury it is very important to reconstruct the articular part, say with implants what we use plates, nails, whatever. So once we have adequately restored the joint, say within 2 millimeters of normal then the chance of developing arthritis are quite less. But if you don't restore your natural joint in the most normal way possible then it's very likely that the arthritis can rapidly progress even after a period of 5 or 10 years. I've had people wherein the initial injury was so bad with a lot of fragments or in the case wherein the procedure was not done initially properly, the joint was not properly restored and they've come in as early as 3-5 years after an operation with arthritis. So in such cases it may be insulgible. So you have to, it depends on what stage of arthritis and what kind of surgery was done to answer your question. Next question by Valsala. Have asthma and take steroids. Valsala was recently diagnosed with arthritis as well. I was not allowed to take arthritis medication as I'm taking steroids for asthma. Please suggest some natural remedies to cure arthritis. So that's what, this is often a pro and cons sequence. So steroids is a main stage of asthma treatment and that cannot be stopped. Long term steroid intake can cause what I call as herb acetyl and necrosis and then eat away your bone and then can cause secondary arthritis. So you must discuss with your physician, see what dose of steroids you need for maintenance. If it's a low dose, then it's well and good. From our side, an orthopedic point of view, natural remedies include exercises of good weight, good regime and fit regime, decrease your weight, decrease your BMI and certain activity modification as I previously mentioned. Next question by Arvind. Is it true that a damaged joint hurts more when you list it? Well, that's a good question. So damaged joint with pain is what we call as rest pain. So if there's rest pain that means it's a very serious condition. It means it's an advanced form of arthritis. So initially when you have a joint pain, it doesn't beat any kind of etiology or cause. It's usually only on moving the joint. So like climbing stairs, running a few steps here and there. But later as the disease progresses and the pain is more severe, then you have something called as a rest pain. You have pain at night. You have pain which is actually waking you up from sleep. Certain kind of infective arthritis such as tubercular arthritis that may involve the hip or knee can cause what is called as a rest pain. So when you rest, your muscles relax and then the joint surfaces come close to each other and then they start rubbed when you move about and then it causes severe pain. So rest pain is an indicator of most often they're not advanced arthritis. Next question by Vinayat. Do ice treatments often cause the joints to swell leading to arthritis? Absolutely not. Ice treatment is a form of rice therapy what we advocate for ligament injuries and spades. So ice is often known to decrease the inflammation in the joints and not so often increase it. So ice treatment should not cause this acute pain to actually swell. So the answer to that is no. Are there some more questions coming? There's one by Misha she asks what are the major types of arthritis and what are the most common? For someone who is joining late I would like to this was my first question and I would like to reiterate so that you are aware what are the common causes of arthritis. So most often the first important cause of arthritis is age-related or what we call osteoarthritis. The second important cause of arthritis is inflammatory arthritis which involves rheumatoid arthritis gouty arthritis which is often sub catarized crystal induced arthritis, psoriatic arthritis, ankylosing spondylitis and some kind of inflammatory bowel diseases which involves the bowel and then can cause arthritis. Other form of arthritis is infective arthritis, bacterial arthritis including viral arthritis TB is very common in the country, tuberculosis arthritis another kind of arthritis which could be common is crystal induced arthritis what is called as gouty arthritis. So these are the few kind of arthritis we look at and the most common ones. This can involve variable age groups say from the very young as in inflammatory causes to the age population which is age related which is osteoarthritis. They all present usually in a similar manner except that the intensity of pain may be different. So we all have to investigate, you must see orthopedic surgeon as soon as pain say prolongs beyond 2 weeks your doctor will investigate, you will do some x-rays, examine your joint foremost and do some blood investigations and then ascertain what kind of arthritis and then treat accordingly. The other questions we so I think that's the end of it and thanks for having so many good questions, so many mind boggling questions. I hope I have answered them to your satisfaction. It may not be possible that it may be a whole bunch list or bucket list of answers but this is often the iceberg so if you have any problems related to joint pain in any age group anything which is persistent say beyond 2 weeks and not better on any of the medications or natural remedies which have been advocated then I think you must see your local orthopedic surgeon or rheumatologist for further treatment. Thanks for spending time. Thank you.