Jews with Mysterious Pain: Psoriasis?
by Michael J. Colin, MD

There are many times when pain seems to develop for no specific reason.  Most people have had pain in different parts of their bodies from injuries or spontaneously lasting days or weeks.  We always seem to try to find a reason or precipitating factor to explain pain. “I must have lifted a heavy suitcase or worked out too long or tripped and hurt my ankle.”  Sometimes the pain is in joints and other times it is in areas much more difficult to identify specifically as to location.  We only know that it hurts in the fingers or elbows or shoulders or the outer part of the hips.  Sometimes the areas of pain are associated with swelling either related to an injury or perhaps not related to injury at all. The swelling may come and go. If pain persists people see their physician. Not all pains have a definite cause.  Pain can occur for no good reason and be associated with joints with or without swelling.  Frequently the pain feels like it is in the muscles or near the joints or is worse with movements. The origin and the cause of these pains can be mysterious and difficult to diagnose. The following story may serve as an example of a patient with mysterious pain.

“I am 49 year old male and have been very active all my life doing sports and going to the gym. I do not go frequently though and always do cardiovascular exercise and some floor exercise and occasional do weights.  I have played tennis for years but now do so infrequently.  Ten years ago I was diagnosed with tennis elbow but in my opposite non-dominant arm. I had to have an injection. It took a while but I got better. Then, three years ago I developed heel pain and pain around the right ankle. All the X-rays and blood tests were negative and the orthopedist diagnosed plantar fasciitis. It still hasn’t gone away. Last year my left shoulder started to hurt for no reason, no fall, no injury or heavy weight lifting at the gym.  The orthopedist said I now had rotator cuff injury. An MRI revealed tendinitis.  He sent me for physical therapy with some relief. It still hurts. Just last month my left ankle started to swell on and off.  I have trouble walking.  My grandparents were born in Russia and in Germany. My grandmother on mother’s side had arthritis and took medication.  My mother has a skin rash on her elbows. I am Jewish as are my relatives.  So what’s wrong with me?” 

This a typical and far too often unrecognized story of a person developing what is most consistent with Psoriatic Arthritis (PsA) and tendinitis. In the past, years ago it was considered rheumatoid arthritis associated with psoriasis. However, it is now being diagnosed more and more frequently as psoriatic arthritis with enthesopathy or enthesitis.  Rheumatologists have developed more clinical tools and more suspicion when the story told above is related during a visit.   These pains are separated by time and anatomy and may occur together but usually are seen at different times historically.  That makes the diagnosis more difficult. But how can this be psoriatic arthritis if there is no psoriasis?  And how is this related to “Jews with Mysterious Pain”?

There is a significant hereditary component to psoriasis. The genes associated with psoriasis and psoriatic arthritis are quite common in the Jewish population and in areas where Jews lived centuries ago in central, northern and eastern Europe.  Non-Jewish people from these areas also have a significant number of these genes and development of the same conditions is also quite common.  Immigration over the centuries has enabled these genes to travel all over the world but they are more prominent in certain areas. Having a mother or a father with psoriasis is one of the criteria for diagnosis of psoriatic arthritis. The patient above did not have psoriasis but his mother did.  Tendinitis or enthesopathy or enthesitis are common in this condition.  They come and go and are sometimes very difficult to identify and diagnose. They involve the tendons and ligaments. The enthesis is the attachment point of a tendon and its muscle to the bone. The enthesis acts like a mini joint in many ways. It contains the tendon and bone, fibrocartilage and a bursa lined with synovium which makes fluid to bathe the enthesis or attachment point. It is this area which can become inflamed and result in pain and swelling. It can be a cause of Achilles tendinitis or plantar fasciitis.  It could be in the shoulder or the elbow and cause rotator cuff pain or tennis elbow. It is the reason why all the different pains in the story above are related even though the symptoms were years apart and anatomically not close to one another.

Moreover, blood tests are frequently negative except for possible elevated inflammation markers. There is no specific test for psoriatic arthritis in the blood.  An MRI may be helpful to diagnose the tendinitis and fluid around the tendon or detect swelling in a joint and perhaps bone inflammation called bone marrow edema or inflammation in the soft tissue. Ultrasound can also detect local inflammation around tendons and the entheses.  X-rays are usually negative unless disease is more advanced but can show calcifications in tendons and bone spurs. These findings are non-specific but are suggestive of the pattern seen in PsA.  However, when taken in context of years or months or pain in multiple locations and having tendintis or fasciitis and arthritis these findings can help confirm the diagnosis.

That is why these symptoms can cause “mysterious pains” and frequently go undiagnosed for many months or years before treatment is started. There needs to be a high level of suspicion when patients describe a history of these “mysterious pains.”  The most appropriate physician to make the diagnosis is a rheumatologist because they are trained in evaluating all types of pain syndromes involving joints, spine, tendons, skin and bones.  A physician with a high index of suspicion may refer you to the appropriate physician.  Orthopedists are frequently sent people with pains in various places.  They can make diagnosis of arthritis or tendinitis but do not really treat the more complicated features of psoriatic arthritis with the more advanced treatment options that may be required for control of the disease.

Psoriasis is an autoimmune disease of the skin. Of importance is the fact that many patients with psoriatic arthritis do not have psoriasis.  About 15-20% of patients have arthritis that precedes the psoriasis. Some of these people will develop psoriasis years later and some never will get the skin involvement. A parent with psoriasis in a criterion for the diagnosis of an offspring with arthritis and no psoriasis visible at the time. About 5% to 42% of patients with psoriasis will develop the aches and pains of arthritis or enthesitis in their future.
If you or someone you know develops this type of mysterious pain it would be advisable to see a physician and possibly a rheumatologist.  Now there are many medications to treat this type of arthritis which were not available years ago.  We have pills and injectable medications which can make an enormous difference in controlling the disease and preventing joint and tendon damage, and most of all improve the quality of life.

Mysterious pains now have an explanation and can be diagnosed and treated. 

Michael J. Colin M.D. FACR
Associate Clinical Professor of Medicine, NYU Langone Medical Center New York
Attending Physician Lenox Hill Hospital Northwell Health New York
Email: mjcolinmd@aol.com
References:
Harrison’s Rheumatology, Anthony S. Fauci and Carol A. Langford. 4th Edition, 2017
National Psoriasis Foundation Website
Int J Health Sci2010 Jan 4 (10:23-29 Hani A. AlShoballi et al)

Plant Your Way to Happiness
by Gary Smith

This may be a little overstated but getting outside and trying gardening can not only be invigorating, but provide exercise, fun, mild relaxation and something productive. Planting Herbs, fresh vegetables, including tomatoes and some fruits can be an exhilarating experience. It will help you appreciate eating healthy.  Making your own is particularly special.
 
From a more physical nature, gardening increases blood flow, works different muscles and helps to lower stress.  Since 2011 gardening has been growing with almost 74% of households doing some gardening according to a National Gardening Survey. A study done by the Oxford Brookes University in the UK found that elderly people that did at least 6 months of gardening had better grip strength.  A Kansas State University survey of people 63 to 86 who gardened and wore heart monitors found them to have increased heart rates and enjoying some of the health benefits mentioned above.
 
May is a good month to plant collard greens, spinach, peppers, peas and more. In June-tomatoes can be planted.
 
What is really interesting is that FJMC Foundation for Jewish Life provides grants for new creative and innovative programs at the men’s club / synagogue level.  Four years ago I applied for a grant for our synagogue to be able to start a garden.  It was to be tied to pre-B’nai and B’nai mitzvah kids to learn how to take care of the land.  As part of the religious school experience they and their families have learned how to garden in the image of our ancestors.
 
Growing flowers also adds so much to our health. It increases relaxation, increases memory and provides better moods.  A study by Evolutionary Psychology of people 55 and older concluded that people who get bouquets of flowers have better memory, less stress and are generally in a better mood.
 
This health tip is a prelude to one of the most important initiatives that FJMC Foundation for Jewish Life and FJMC have brought to the movement in the last 5 years.  We are very excited to bring to convention “Imagine Life” - A Mental Wellness Initiative / Before it is too late.  Come to the FJMC Convention in Toronto in July to make helping your Jewish community with addictions and mental health awareness your priority.  “Imagine Life” through the FJMC Foundation for Jewish Life / FJMC will be providing programs ready for you to take back to your synagogues.

China Investing Tip
by Gary Smith

Over the last two years I have been pounding investments in China.  Believe it or not the success of our relationship with China is and will continue to be the cornerstone of our investment future. 

First the background review.  China is right now the second largest economy in the world.  It is rapidly becoming number one and it is just a matter of time.  One and one-half years ago China became the first country in over 30 years to become part of the IMF.  This means that other countries will be able to trade with China in the Chinese currency, the Yuan.  Second - Chinese companies were never part of the MSCI.  Money managers for the first time can invest a portion of their international portfolios into Chinese companies and funds.  There are individual companies, such as Tencent, Baidu, Alibaba, JD.Com,  and there are ETF’s and Chinese mutual funds thru Fidelity.  Also, there is KBA, FXI, and many others that may provide investment opportunities.
 
Lastly, there is the 4-2-1 rule.  Couples were only allowed to have one child over the last generation.  They are charged with taking care of their parents and grandparents as is custom.  Each child is now responsible to provide for up to 7 people.  Further, China in the past disallowed their citizen to invest in their markets.  Now it is a necessity.  The government, realizing that there will not be enough money for children to take care of the elderly, has now allowed its citizens to invest in Chinese markets.  The projection is that between 1 and 2 trillion dollars will flow into Chinese companies from the world and from Chinese citizens in the next 3 years.
 
In December Trump put huge tariffs on Chinese products and has caused an international crisis.   This included American companies dependent on China for growth having a severe correction; Apple, Starbucks, Qualcomm, Nvidia, Microsoft, JNJ, McDonalds, and many others.  America’s future was looking bleak.
 
As some of the angst associated with the tariffs subsided the markets began to start the march toward the Melt Up.  The negotiations with China are causing Chinese companies to begin their assent as well.  They have gone up 30-40% this year with significant long-term upside. Also, important was getting a deal done to prevent the government from defaulting.  My feeling is that we not be afraid to invest in Chinese companies or companies in America that are heavily invested in China.  
 
This tip was composed as a result of two years of research from several different sources.
Peter Churchill, Porter Stansberry, Steve Shuggerud and others. 
 
At the FJMC convention in Toronto in July the FJMC Foundation for Jewish Life is sponsoring a Wealth Conference.  The agenda tentatively will include intergenerational retirement planning by Dan Goldfarb, Venture Capital opportunities in Israel for the small investor, non-professional options investing for income and more.  We will also have the FJMC Foundation for Jewish Life annual meeting luncheon for present and potential new Foundation members.  PLEASE TRY TO ATTEND - IT WILL BE AN INCREDIBLE EXPERIENCE, potentially life changing.    
 
The Thursday keynote with breakouts on “Living a Life of Legacy” will be given by Rabbi Daniel Cohen.  His books and YouTube videos should entice you with topics like: “What will they say about you when you are gone?” and “Living your Elijah moment”.  Are you intrigued yet?  There is still time to bring a personal focus on your whole-life’s-legacy; to appreciate the life of legacy you are now living, in part through your commitment to your men’s club, and to become more aware of how you can do more to be even more aware and proud of the current and future formation of your legacy.