Episode 4 - Understanding psoriatic arthritis

(upbeat music) - Hello, I'm Dr. Kira Kelly and you are very welcome to Beyond Expectations. So, let's talk psoriasis. This is a four-part series where we're looking at all things to do with psoriasis and psoriatic arthritis. And we're gonna be trying to share with you the important and practical information that you need as somebody living with one of those conditions. Today, this is our final episode and we're talking today about psoriatic arthritis, which is a condition that affects about 30% of people who have psoriasis. And I am delighted to be joined by Aiman Bern, who is a Dublin-based guard and an Irish parapsychless who is living with psoriatic arthritis. I'm joined by Gronia O'Leary, who is the chief executive of arthritis, Ireland, Professor Doug Veal, who is consultant rheumatologist at St. Vincent's University Hospital and Professor of Medicine at UCD. You're all very welcome and delighted to have you here today. And psoriatic arthritis, it's one of those things that is quite hard, despite being relatively common among people who have psoriasis. It's relatively difficult to diagnose and people tend to get a diagnosis a reasonably long time after their symptoms present. I'd like to kind of get into that. But before we do, could I ask you Doug, will you just as opposed to explain to people what exactly it is? Sure, so it's a form of inflammatory arthritis. So the joints become inflamed, the back often becomes inflamed in patients who have psoriasis. As you said, I think 30% of patients with psoriasis. So that in my calculation would say about 30,000 people in Ireland would suffer from psoriatic arthritis. And it's not just in arthritis, because it affects the, obviously, the skin psoriasis, the nails, it also can affect the areas where the muscles and the tendons actually attach to the joints. So these areas, like the Achilles tendon inserts into the heel, so these areas which can become very inflamed. And then the fingers and the toes can also become inflamed throughout there if you're like the holes of finger or toe can become inflamed. So it has lots of different presentations, which adds to the complexity of the disease. And also why sometimes patients are reluctant to attend a doctor or even maybe will attend the wrong type of specialist and therefore the diagnosis doesn't get made because all of these areas don't seem to be ticked together. By wrong type of specialist do you mean that they go off and see an orthopedic person or a neurosurgeon or something totally different? - Yes, yes, yes, yeah, a pain specialist on orthopedic surgeon. And thankfully a lot of our colleagues now will refer those patients into us or into the dermatologist and the dermatologist and the rheumatologist are referring much more readily to each other as well. So I think that the time to the delay to diagnosis has certainly come down in the last 10 years. - And Amy, you're obviously living with the condition and you were only diagnosed I think 2019, which is relatively recently. How did it present for you? What were you experiencing? - Pain, I had predominantly back pain, lower back pain and it was something at the time Doug touched on it there. I had seen pain specialists. I got faster joint injections. I was taking anti-inflammatories and I think that had been going on for years without really understanding. I just thought I had back pain. Nobody really explained to me that, maybe I could have had a arthritis and it was only now in retrospect that I was dealing with a whole lot of our host of pains and those things, I mean since my diagnosis, those I don't have any of the other pains. I sometimes have a low level of back pain but I don't get the same flare ups that I would have had. I don't have the same kind of fatigue and illnesses that I would have, you know. - Was fatigue a big part of it? - Yeah, yeah. Now I, so I worked my shifts and I would have always just assumed that's why I had symptoms of fatigue and at the same time I always looked at my colleagues who didn't suffer the same sort of levels of fatigue and I just put it down to being a bad sleeper which arguably I am but that fatigue is gone now and so I know that it was all apparent at the same time. - So you were putting it all down to the job in your life, you were kind of making explanations in your head for this thing. - Absolutely. - Did you ever heard of Sariatograd? - Never, no, no. My brother, my brother had Sariatosis. I knew what Sariatosis was but I just thought it was a skin condition and. - And you didn't have Sariatosis? - I don't think so. My parents don't think so. I think I had a touch of exam which possibly was Sariatosis when I was growing up. I never would have had to be treated for it. I never would have had to, you know. - So you didn't think of yourself as somebody? - No, no, no, no. It really surprised me. - And does that add to the complications that are around diagnosis? Because we kind of, oh, 30% of people. - Yes. - But then you have people who don't even have the Sariatosis or aren't aware that they have Sariatosis? - So there's two things I guess I'd say that you could have the arthritis before you have the Sariatosis although it's not the most common way in which the disease presents. But also, we do see patients there and that's recognized in the sort of classification criteria that doctors use for Sariatosis. Now that if you have a family history of Sariatosis then that is an additional factor which we take into account to make the diagnosis. - And is it different for, you know, particularly for people maybe one of the great things about this series is it is hard to get to see a consultant and it is hard to get kind of information. But is it the case that Sariatosis is different to other arthritis for people who are kind of going, what do I actually have? And why was it affecting me? Is it different to other types? - Yes, it is different. And I think it's because it's got all these different facets of these different clinical features. And of course, one patient with Sariatogathritis may have a completely different set of features. Their disease is very different to perhaps, you know, the next person who has Sariatogathritis. And so for that reason, you know, everybody's very different and people present with different symptoms. - Yeah, and Gronia, I'm sure people who come to arthritis are looking for information. This is one of the types of arthritis that they have. What do you say to people? What should they be looking out for or what kind of thing should they be aware of if they're having symptoms? - Well, I think first of all, it's kind of joining the dots on those symptoms. I mean, Doug's dog and I may have described you kind of the myriad of symptoms that people can have. And particularly with Sariatogathritis, what we find is that, you know, it can be quite a very different experience to, for example, rheumatoid arthritis, which would be more common. And probably people may have a bit more of an understanding of what that is. So generally, people are having kind of different symptoms. It's kind of, you know, pain in different parts of the body. And Doug even mentioned the things like the nail changes that you wouldn't always think of. When people, when they hear the word arthritis, you know, they think of joint problems and they think of pain. And pain is that number one symptom still. However, kind of that unexplained fatigue as well that I'm in talked about, I mean, people would say to us that sometimes they can handle the pain, but actually that overwhelming fatigue that unless you've ever experienced it can be just one of those things that's really, really hard to manage. Because, you know, your normal activities, your daily activities of living can just come to a halt and can just be really, really difficult and undertake. So I suppose people wouldn't necessarily think that was arthritis. - No. - That's part of the problem, isn't it? - No, I think when people sometimes hear it then that this form of arthritis is an partial immune disease. And when you think about what an partial immune disease is, it's something, you know, that's not quite working in your immune system. So, you know, I think then it becomes, people can understand us a little bit better. - Was it helpful to you, Aiman, to have a diagnosis so that you could actually explain what, because obviously it was interfering with your life. As you say, you were tired all the time. You had pain. You were attending different types of specialists. So you were obviously looking for a solution because it must have been impacting you. Was it helpful to kind of go, oh, I'm not just a hyperchondrip. I'm not somebody who, all my colleagues are tired, but for some reason I cope with it less well than other people. Was it a kind of a helpful thing to actually be told, no, this is what you have and this is what we're going to do? - Yeah, for me, it answered a lot of questions. And even now it's still, it was even just listening to some, I never considered my nails before. And I would never mention that. And now what I think back, I did have, like, defamation of my nails. Or like, I remember going to see my consultant and he asked me, you know, how am I feet? Nice and my feet are fine. And they weren't fine at all. My feet were actually really painful when I realized when he stood his thumb and my foot. Like, you know, so you were kind of minimizing to yourself what you were experiencing. - And, you know, it's still even now, like if I don't stay on top of my mobility, for example, you know, I really tighten up, like, and I-- - Stiffness. - Yeah, and those are things that I try not to let happen anymore, whereas before, you know, I would have gone through phases of inactivity or, you know, maybe easing off a little bit too much. So you're self-managing your condition 'cause you know what you have. - So much better. - I'm like, yeah, I know what sleep means to me now, more than I would have before. Everyone knows where it's supposed to sleep, and get a good night's sleep, and rest, and recover. But I know now if I don't stay on top of that, that I'm probably asking for a flare-up, or I'm asking for pain. And it's enough for me to go, well, it's not worth it, like, you know, whereas before I wouldn't have known, I was even down there, and I had a flare-up, that happened, and it was because I was inactive. - It's not an insult, but you were a young man as well, and I don't necessarily think that that group paid huge amounts of attention to their health. - You know, I think you're not still a young man, right? (laughing) - I think it's okay, it's okay, it's okay. - It's okay, we've been carly young man from before. It's, I think you get away with it more than two, and I would not get away with it now, but if I had the same knowledge now that I had years ago, I wouldn't try and get away with it, you know? - And on that note, the managing it, and particularly managing the flares, people often look for triggers, or maybe are aware of triggers. How should somebody out there watching this today who has this condition? How should they manage their flares, and what should they be wary of in terms of triggers? - Yeah, so I think when you're having a flare, or essentially what we mean is that the disease is active, and there's inflammation, your immune system is activated, and it's actually affecting your whole body. Now the fatigue is a feature, the stiffness is a feature, and you can see then increase in pain in the joints and lack of sleep, and all of these other factors, which are sort of secondary, in a sense, to the inflammation. So what we'd say is you should rest if your joints are inflamed. If you're taking regular exercise, perhaps just dial it back a little bit, you know, reduce your amount of exercise, certainly weight-bearing exercise, so walking or running is not to be advised during a flare. And so just take it a little bit easier, rest up a little bit, and actually take painkillers. When you have pain, people are very reluctant to take painkillers a lot of the time, and you hear it, they get worried about addiction, and various other factors. But if you have pain, we say take painkiller, take an anti-inflammatory if you need it. Now thankfully, the medications we have for controlling the disease and reducing flares are really much, much better now than they were 20 years ago. - And would you echo that, growing you, that when people come to you, pain medication is part of the treatment plan for arthritis, and very often people do need to take painkillers, and sometimes it's not taking the strongest to painkillers either. But I suppose it's that thing about treating pain early, that if you get on top of pain, before it gets too bad, you'll have a better outcome, and be able to resume your normal activities, whereas it can be harder to get on top of pain when it gets really bad. So that's one of the messages we would always give to people. - So get in there, don't wait till your pain is more severe. - We've touched on treatments, and treatments have really improved. Obviously there's a sort of a spectrum of treatment. Would you like to kind of outline where people might start and where they might end up in terms of treatment? - Yes, so commonly, I guess, because the psoriasis will, in most cases, the psoriasis will be present before the arthritis, people will start with topical treatments, or creams, and lotions, and potions. And then there's tablet treatments, which have been around for a long time, and some of them are very effective for some people. And now, the more recent, in the last 20 years, a lot of the injection type treatments have really been a game changer, essentially. They have changed so that they both control the inflammation. They reduce a lot of the symptoms, but importantly, they also prevent damage to the joints. And as a rheumatologist, we're always really looking at that sort of prevention of future damage. And we do still tend to start with the tablet treatments first, and then move on to the injections. But occasionally, in very severe cases, we might combine the tablets and the injections at the same time from the beginning, to particularly in a younger person, to try and prevent that damage. - And are you now, I presume, probably, like everything else, and medicine initially, the injectables would have been kind of kept back a little bit and sort of held in reserve. - Are we quicker to use those now? Are we quicker to progress, and if you go on a tablet of some kind, and you're not getting huge benefit or huge impact, you just kind of go, "Oh, do you know what? "Okay, it's time to move on." Are we seeing people progress through the types of treatment a little bit more quickly now than we used to? - I think we are, and one of the challenges, I think, from medicine, is trying to, can we identify those patients who are going to be at most risk of their disease progressing and damage occurring? So if we can identify those people at a really early stage, then we can say, "Yeah, these are the patients "who really do need early intervention "with the injectable treatments, "and they don't need a delay in trying other treatments." - Was that your experience of treatment that you started with one thing and was, like, moved from A to B to C? - So I was kind of already taken anti-inflammatories and painkillers, I guess, self-treatant. That was just the treatment of a pain. - I think you're not impacting on your symptoms. - I found, once I had flared up, it didn't really make any difference. And we had, when I was initially diagnosed, it was, I was given anti-inflammatories also, it was a different type, and they did help, but then I found, again, I had a high pressure week, it was race week, and I could do nothing. I had physiotherapy every day, on hand, I had painkillers, I had anti-inflammatories, and it just made no difference. - It was like your body wasn't working? - It just, that was it, like, it decided, you know, that I was gonna be in pain that week regardless. - Very hard. - Yeah, yeah, I, from me, because I had already been diagnosed and I'd been given, you know, this medication from me, I thought, well, that's it, I'm good to go now. And that was my fourth experience of going, oh, actually, I'm not good to go here. And we had a chat when I came back, and that was it, I was put on the biologics. - Okay, and was that a game-changer for you? - Complete, yeah. Now, we took a while, but it is and was, like, absolutely, yeah. Like, I can't explain the difference. I don't have flare-ups. I don't have flare-ups anymore. So, if I have, you know, pains and, you know, mobility restrictions, I think it's something that maybe is already existing, they're not gonna go away, but I don't have that extreme debilitating flare-up anymore. - Yeah, that's just not anymore, yeah, yeah. - It stops me doing things, it stops me, you know, training or it stops me exercising right before. - And I'm really glad you mentioned exercise, 'cause obviously, you're a parapsychless, and I had to ask you before we started, 'cause what exactly is a parapsychless? So, you're on a tandem bike with somebody who's visually impaired, and so that one of you can see, and then you both cycle. So, you're, like, it sounds a fabulous thing. - Is that exercise? It's obviously dog-mentioned weight-bearing exercise, like running and walking can be a problem. Is that exercise working really well for you in terms of, obviously, it gives you exercise, but it's not causing you problems? - I guess I'm on the very extreme end of that, you know, it's good to, you know. - You were the totally wrong person to get this right. - Exactly, that's what I was like. - I am, and I think, like it's great, people should walk, and swim, and so, but nobody should do what I'm doing, because not of your, not of your trying to. - So, but all the advice, but not this and not your trying to, like, control and manage your assistance. - Yeah, I was, I listened when you said earlier on, but, you know, it should, like, reduce the low bearing, but I never had the opportunity, because you can slow down, you can't ease off. But I find now that, even now, if I take a time off, you know, two weeks, three weeks, everything creeps back in, and yeah, even so, exercise, exercise is part of the treatment, isn't it? - Oh, absolutely. - In terms of mobility and stability. - Yeah, for all forms of arthritis, I think, you know. It's important that the muscles stay strong, because the muscles really support the joints, and if you, and part of the inflammation often will reduce muscle strength, and people lose muscle bulk, actually, when they have a lot of inflammation. So, yeah, so it's important that you, you know, the type of exercise is important, so we do think either swimming in a pool, or walking in a pool, or cycling, you know, non-weight bearing is better, because it takes the strain out of the joints, while you can actually still build up the muscles. - Okay, so I'm doing something you like. This must be something you hear all the trends on it. - Yes, it's one of the, I mean, you know, there's probably, you know, if you look at it from a, in terms of, you know, non-pharmacological approaches to dealing with and managing arthritis, there's two things, one is exercise, and the other with weight management, and they go hand in hand, and, of course, many people are, you know, recommended to, you know, become more physically active, but that's really difficult, too, and look, we hear this all of the time. If you're in pain, sometimes the thing that you feel, least likely to, feel like doing, is exercising, and also, it's also, it almost feels like the wrong thing to do, because you feel maybe exercise gonna cause more pain. So, I mean, one of the things we encourage people to do is start where you're at, because obviously people, we encounter all types of people, with all types of diagnosis, and, as Amon said, you know, he's at the extreme end of the support, he's living with psoriatic arthritis, equally we would get people coming to us with psoriatic arthritis who've never exercised in their life, and now they're being, you know, recommended or encouraged to exercise. It's a kind of a vicious circle here, isn't it? Like, you're saying, keep your weight down, but they're in pain when they exercise, and so, most of us when we're in pain with something, that's the, people will say to you, that's the body telling me to avoid it. And so, you can kind of understand why people are going, I don't know how to manage my weight if I can't exercise, but if I exercise them in pain, you know, and they, it creates a kind of a problem, yeah. I think the first thing is to make a plan to start, you know, to kind of start where you're at, so if you're not physically active, you know, one of the things we would always encourage people to do is, you know, link in with their either consultant or their GP to have that initial discussion, and perhaps even seek the support of a chartered physiotherapist about where to start. I mean, one of the things is always to start with something that you might actually like doing. So, if you've never gone to a gym in your life, it's unlikely that that might be the successful journey for you to be engaging in physical activity, but maybe if you are able to, you know, start with the gentle walk or, you know, we would have lots of people who can't just say that, even exoscent gentle exercise and movement in their local swimming pool or walking in their pool, like I, we have a great, I have a great person who, you know, her feet are really badly damaged by her arthritis, but actually, she wears quite a supportive pair of old runners in the pool and she will engage in physical activity. The buoyancy helps take someone to the waist. Yeah, exactly. So, it's finding those things that, that person might find something you like. I just start small. We used to say when I was in general practice that movement is medicine. Yes, so you sort of have to see it as part of the, it's part of your treatment. Yeah, the lexicon of things that you use because it's important to both of you and all three of you, maybe, is diet part of this? Do we have to look at diet as well? People certainly have in their heads that certain foods trigger things and whether that's true or not. Along with the exercise, diet is probably one of the other questions or areas that we get a lot of questions about. Look, I think so many books and art because it's been written over many decades about the role of diet and the role of food in the management of arthritis. I mean, I don't speak to, you know, the different foods and the myths around some of that. But in general, what we would encourage people to adopt as a healthy, you know, a healthy, well-balanced diet because, you know, so not a fat diet. It's not a fat diet, you know, you know, learning, so learning about what a healthy diet is, if you don't, if you haven't, if you feel you haven't been following a healthy diet. There's no one diet that's going to, it's not going to solve your arthritis, it's not going to cure you. But it is about feeding your body while you're particularly when you're newly diagnosed and you're, you know, you're engaging in your treatment, eating healthy is part of that. You know, you need to feed your bodies that you're able to deal with the challenge just that this disease is supporting your whole body. Yes, but I know dog eye have had patients swear to me that tomatoes kick a flare up or yeast is another one people have said to me many, many times. Is there truth in those things? There's very, it's very hard to get evidence, scientific evidence, and you know, the researchers will say, you know, there's no evidence in the literature or nobody can really pin down tomatoes or citrus fruits, or. Is it possible that on an individual basis, these are triggers that we need to have? Yeah, and I often say to patients, I say, look, you know, if you find something that triggers off your arthritis, I had a lovely patient actually, gentleman who attended me for many, many years, and he used to come in and say, "If I have one square chocolate," he said, "I'm in agony." And he said, "I know that it's going to set off my arthritis, but you know, I love chocolate." So, yeah, swing is random, yeah. Yeah, exactly, so, but you know, so that's the sort of thing. And I say to patients, look, if you identify something in your diet, that is going to trigger your arthritis, then you just avoid it as much as you can, you know? But there's nothing you can generalize, and it's one of the most common questions I get is about diet. So, in the same way, symptoms are relatively individual, potentially, I'm not trying to be sort of, you know, flaky on us, but potentially triggers could be individual too, so if somebody does recognize that's alcohol, or whatever it might be, is an issue for them, then they should. Moving it on a little bit, the conversation in general, growing up, somebody who has psoriatic arthritis, particularly if they have the skin manifestations and the stiffness and the pain, like we've touched on it, it can be very difficult in terms of taking exercise, very difficult, maybe in terms of your fatigue, going to work, and stuff, but it also has an impact on things like personal relationships, your marriage, or maybe if you aren't married, dating and things like that. Do you have advice for people who maybe feel a bit low, I suppose, about the fact that they are dealing with this, and it's impacting on them, and maybe that impact is quite far-reaching? Yeah, I mean, I think it's one of the really important aspects of your arthritis. I mean, I think a lot of the focus tends to be on the physical manifestations, you know, in terms of the pain, but it is very much, you know, a disease that impacts our身 at an emotional level as well, and a mental health, you know? So, and often the things that people can really struggle with, it does bring change into a person's life, and not only into that individual's life, but to their loved ones, you know, around them as well. If they're lucky to have loved ones, if you haven't started down in the path with their loved ones, yes, having a chronic disease often makes you feel, well, that's me ruled out of the mix for that kind of thing now. That's the thing. I mean, I think we always, you know, what I would always encourage people to do is, first of all, you know, if you are, you know, in terms of close family and friends, is to open up communication channels. So, you know, not to be afraid to speak about how it is impacting you. So, to have that kind of open, so if you are in a relationship, you know, if you have a family, you know, to really, I suppose, because they need to be educated too, about how it's impacting you, but also how they can help. And even if you're not in a relationship, you know, in terms of your family, and even it can be things like work colleagues, you know, to actually, you know, to encourage people to express what is actually how they're experiencing their symptoms, their disease. And people often in a person's circle want to help, but they don't know how. So, sometimes when you're the person living with a condition, you need to be the person saying, this is how you can help me. Yeah, that's fair. And would that resonate with you? I don't want to ask you too many personal personal questions. But you know what I mean, that kind of impact, nevermind, just on you taking part in exercise or on your career or whatever. But on intimate relationships, some personal relationships, if you're in pain and tired all the time, or maybe a bit irritable, or maybe sometimes people are even a bit low, or their confidence is effective, those types of things. I think looking back, I have more of those moments than I knew, like, you know, like, whereas, like, just felt that my wit and were kind of just downtroddened, like, why am I just in pain, you know? And you've taken your pain killers, you've done everything you're supposed to do, exercise, and, you know, and I'm eating well and still in pain. It's very hard to accept that, you know? And looking back, I just got on with it and I thought, she's just no like a. And if you talk to some people, without the diagnosis, and you say, I have a bad back, you know? And that's it, and people are just kind of. Sometimes don't realize what that is, you know? He just has a bad back, but. It's actually really unfair, because you're there with pain in your feet and pain in your back and everything, and minimizing it and trying to get on and trying to ignore it, and other people maybe looking and thinking, "Oh, I have a bad back too, and I'm not exaggerating." Like, you're nearly categorized as being dramatic when you're actually underplaying it all the time. I think I only, maybe some of my family members would have, you know, seen me, like, struggling to get ill bed, like, you know, not able to put socks on or, like, being in such pain that, you know, you're hobbling and limping and stuff. That's really important, because I try to just kind of be seen. Unless it's really having a severe impact on your mobility. Yeah. And I think that's one of the things about psoriasis, and arthritis and psoriasis, that I would say, it's often a double whammy, because patients who have got bad psoriasis, they have, you know, almost a double dose of that sort of, you know, anxiety and, you know, maybe depression or low mood associated, so they feel they look bad because they're psoriasis, but they also feel bad on the inside because they can't move. So they're getting almost a double dose. And so the confidence thing must be a feature, and the stress. And stress, of course, sometimes flares these things up. Yeah, stress, so it is a kind of a trigger for a lot of people. Can I ask you, lasty, because I know we have questions from, like, viewers, and we want to put them to you. But lasty, just in terms of fertility and pregnancy, and young women who might be experiencing this, is there anything special that they should know, Doug? Absolutely. So, well, the first thing they should do is we've started a clinic about seven years ago in the National Maternity Hospital in Hollis Street for young women because obviously inflammatory arthritis and sorry, I think arthritis is no exception, affects predominantly younger women in their reproductive years. So a lot of people who suffer from arthritis are planning a family or in the midst of having a family. So, yeah, and the most important thing I would say is get the disease under control, so treat the disease and get it under control, reduce the activity of the inflammation before you actually plan your family. And planning is important. So before you conceive, get the disease under control as much as possible. Flares are not as common as we used to think during pregnancy. It's usually after the pregnancy that actually a flare is maybe more likely to happen. And the other thing is that a lot of the newer treatments are very safe. Now, during pregnancy, so we would advise most women who have inflammatory arthritis to actually continue on their treatment because if the mum is healthy and well during pregnancy, then we're likely to have a healthy, well, baby. So guys, we did ask some people who are living with psoriatic arthritis what they would like to ask you as experts on this. So we have some questions from people and I'm going to put you on the spot a little bit now and make you prove your expertise. But first question here, my grandmother had arthritis which caused her fingers to be misshapen and twisted. Does psoriatic arthritis cause that? And a lot of people will be familiar with those big knuckles and those sort of lateral deviations of fingers and things. Is that the case? It can, yes. And you know, not so much nowadays because the treatments do prevent the damage. And so if you get on the treatment early enough, you can prevent a lot of that if you like disability and that deformity that occurs. So we don't see it as much nowadays, but it certainly can happen. So it's one of the reasons why we say to people, you know, do get in there and get to see. The impact of hands, never mind misshapen hands, but hands that don't function properly. That is a disability. That's actually incredibly difficult for people. Does heat help the condition? I love this. Should I go on sun holidays more often? I had a very famous patient who gave an interview to the paper and said, I advised him to go to Spain, but I didn't. It varies again. That's an individual thing. Some people find that heat helps. Some find that heat actually makes them worse and they're better and it's at a cooler climate. So it's a very individual thing. Did you ever notice him in any of those things? I don't think so, no. I don't think so. Like I could be the middle of winter, the middle of summer, and I would have the flare as we're doing. Yeah, it never made a difference to me. I think the other thing is that people, when there are a way, when you think about when you go to Spain, for example, on a holiday, you're on a holiday. So you're not doing your normal activities and you're also probably more relaxed in your on a holiday. No stress, despite even, you know, you take the weather out. So, you know, that has an impact. Amazing, all the complex interactions. And my toes have become swollen with it. And my toenails are very brittle. Will medication, will going on treatment fix that? Yes, the medication is very effective at reducing the swelling of the toes and also improving the nail quality. So a lot of people think they've got a fungus, a fungal infection of the nails, because that's the commonest cause of that sort of discoloration that you see of the nails. But in fact, a lot of the time it's due to psoriasis. I was told, in addition to seeing a rheumatologist, I should also see a pain specialist to manage my psoriatric arthritis. Is that always necessary, or sometimes necessary? Sometimes necessary. We would say, you know, if the pain is due to the inflammation and the inflammation is treated with the correct treatment, then the pain will disappear. As in, I think Aiman mentioned that his pain almost totally disappeared with the treatment that he went on. But I guess it depends, you know, not all pains are due to psoriatric arthritis. And could it be that if damage was already done to joints and there was pain that wasn't due to acute inflammation that was still ongoing, that's not going to necessarily respond? That's right, it may be due to the damage that's so curried or accrued, yeah. You obviously dodged that polish, which is a good tool. Believe it or not, I've only had an injection in my wrist maybe a year and a half ago. So I think, like, what you've just said there, and touched on, the damage was already done. The toy still has wrist problems. I think won't be, you know, is now a pain level. Something I have to deal with. Sorry to hear that. My arthritis means I find it difficult to walk far or fast. This must be the classic conundrum for people with all forms of arthritis. How can I avoid waking when mobility is my challenge? I grew on you. Sometimes, you know, basically, to start small. So, you know, short walks. Walking isn't the only way or the only form of exercise as well. So maybe if walking is difficult to do other forms, so the swimming, cycling, non-weight bearing. A lot of people tell us as well, you know, even going to your pool and walking in the pool because, or even doing gentle exercise in the pool. Because, obviously, the washer gives you takes a bit of the weight off the joints. So that can be a really good way, and certainly, that's something that people would report to us. That's how it would echo that. Absolutely. And even, actually, I would say, you know, start off with just, you know, stretching exercises. You know, by starting at the very beginning, start with stretching or something in a mild yoga or Pilates, just to actually get into the experience. And then move on to. I think it's probably fair to say as well that diet plays a role in Sephiras that I know as a GP, I had this very conversation multiple times of people. And we used to say, look, people in wheelchairs can lose weight. If you exercise dietary control and a lot of outweight losses, maybe 70% diet, 30% exercise. So no one ever wants to kind of exercise the portion control and all those things, I think that's fair to say, but sometimes that has to be. Looked at the biggest factor in weight loss. It's actually what you eat. Yeah, and how much you eat. Yeah. And if you aren't very mobile, you may not require as much as you'd like, shall we say, and that's good for people to. Is swimming a good exercise? Yes. Full stop. If you swim now, there's lots of people who don't swim. Although I think I have to the lockdown. Yeah, I've had some people as well come to us and one of the things they would say is that where they went to their class and maybe a lot of us, I'd be one of those. I call myself a bit of an Irish swimmer where I learned, and at my stroke, couldn't be great. So a lot of people have gone and maybe just got some advice on their. and Irish swimmer, I like that I think. Their technique. I too. Which helps them. Which helps them to be able to swim for exercise and also ensure that, you know, for example, they're not. Yeah, just correct in the technique, basically. But you don't have to swim in there. I call aerobics. Lots of people really get. You know, because the heat of the water as well as the buoyancy. Yeah, taking the weight of them. The other thing is, you know, with aqua aerobics, is you're often in a class and so there's other people. Yeah, nice socializing. And there may be other arthritis sufferers. And I know a lot of. And just I'm glad you mentioned it, because if you are going to a pool, and you have maybe. some people do quite dramatic skin manifestations of psoriasis, that can be an issue for people, because people are self-conscious. Yeah, and a lot of people would mention that. That they wouldn't want to, you know, they've never been to a pool because of psoriasis. Yeah. On kind remarks. Yeah, and it's very important. I think that, you know, we often say this to patients with psoriasis. It's not infectious, you know, it's not an infectious disease. You know, so people can't catch psoriasis from somebody with psoriasis. So it's really important. I've been told that massage helps the pain. Is that correct? It seems counter-intuitive. I suppose that somebody's saying that they're stiff and they don't know that they want to be touched, but does it help? Yeah, I think massage can help, certainly. And I mean, I wouldn't be saying to do it all the time, where, you know, go down that road only. Yeah. But certainly, if you have painful muscles and painful joints, it certainly can help you. Diagnosis with psoriasis. I'm wondering if it's something that could be passed to my children. There is quite a significant genetic element in psoriasis. It's less so in psoriasis, so that the gene is stronger for psoriasis than it is for the arthritis. But it's not often directly transmitted. I suppose I mean, you said your brother had psoriasis. Yeah, it was one of the factors in getting lost. One of the familial things. And onto our final quick fire round with all the pressures on you, Doug. But myth-busting, because there are a lot of myths and misunderstandings and stuff. So only in older people are arthritis. Only in older people? Absolutely not. Yeah, we've seen kids as the youngest two months, babies as the youngest two months can get arthritis. It's very harsh. Is she as an inevitability as we age? No. No, there are lots of people who age without arthritis. I look forward to that. Exercise, I think we've knocked this one on the head already, but people do think this exercise is bad for arthritis? No, exercise is good. And there's more arthritis in Ireland. I've heard people say this a lot because of our bad weather. Yeah, I think that's a real myth, actually. My grandmother used to tell me that in. It was rheumatism. The rheumatic conditions flare up in the cold. No, none of that. Nuclecracking, I tell this to my children. Just to stop them doing it because it's horrible. Nuclecracking causes arthritis. No. I'm still going to tell them. There's nothing you can do to help arthritis. Absolutely not. There's so many things you can do. There's things that people can do to help themselves, but there's also lots of people out there. Doctors, nurses, physiotherapists, occupational therapists, who can actually help? It only impacts the joints. Absolutely not. And all arthritis is the same. No, there's 200 different types of arthritis, and they all vary in many ways. This is why you have to be a professor to understand all of this. Yeah, and well, it's the importance of seeing a doctor and I think getting a right diagnosis and I think gaming touched on this earlier, the correct diagnosis, it does help you manage your arthritis yourself. And osteoarthritis is the same as inflammatory arthritis. No, osteoarthritis is the most common form of arthritis, but it's very different from. It's the kind of the wear and tear arthritis, isn't it? That's right, that's what we often say wear and tear. Everyone with psoriaccharthritis has the same symptoms. No, no. I love how infastic you are. No, I thought we covered this earlier. You know what I'm saying? And you can cure it with a diet. No. Sadly, no. There is a test, a single test to diagnose it. Yeah, unfortunately not. And that's one of the reasons why there's such a delay, often in making the diagnosis. Not only because different patients will present with different features, but also there is no single test. There's no blood test that you can do quickly that sort of says, "Oh, this is it." And that's why it's difficult if patients don't have psoriasis or they have the arthritis before they develop the psoriasis. It can be a tricky diagnosis to make. Look, my sincere thanks to you, Amin, to Gronia and to Doug for joining us today. And we hope that was informative and engaging for you. And thank you for joining us. This is our fourth and final episode in the series, Beyond Expectations, so let's talk psoriasis. We hope it was useful and informative for you out there. Listening, we'd love to keep the conversation going online using the hashtag, so let's talk psoriasis, PSO is how we spelled so. I'm Dr. Keri Kelly and we're delighted to have you on board for this series and all the series is continued to be available online. The views, information, or opinions expressed during the So Let's Talk psoriasis podcast and video series are solely those of the individuals involved and do not represent those of Johnson Science's Ireland UC. The primary purpose of this series is to educate and inform and it's not a substitute for a professional diagnosis or treatment. This series is supported by funding from Johnson Science's Ireland UC.