Rheumatology

Last updated
Rheumatology
System Musculoskeletal, Immune
Significant diseases Autoimmune disease Inflammation Rheumatoid arthritis, lupus, Osteoarthritis, Psoriatic arthritis, Ankylosing spondylitis, Gout, Osteoporosis
Significant tests Joint aspirate, Musculoskeletal exam, X-ray
SpecialistRheumatologist

Rheumatology (Greek ῥεῦμα, rheûma, flowing current) is a branch of medicine devoted to the diagnosis and therapy of rheumatic diseases. Physicians who have undergone formal training in rheumatology are called rheumatologists. Rheumatologists deal mainly with immune-mediated disorders of the musculoskeletal system, soft tissues, autoimmune diseases, vasculitides, and inherited connective tissue disorders.

Contents

Many of these diseases are now known to be disorders of the immune system. Rheumatology is considered to be the study and practice of medical immunology.

Beginning in the 2000s, the incorporation of biopharmaceuticals (which include inhibitors of TNF-alpha, certain interleukins, and the JAK-STAT signaling pathway) into standards of care is one of the paramount developments in modern rheumatology. [1]

Rheumatologist

Rheumatologist
Occupation
NamesDoctor, Medical Specialist
Occupation type
Specialty
Activity sectors
Medicine
Description
Education required
Fields of
employment
Hospitals, Clinics

A rheumatologist is a physician who specializes in the field of medical sub-specialty called rheumatology. A rheumatologist holds a board certification after specialized training after attaining a medical degree through fellowship programs in the United States, or specialist registrar positions in the United Kingdom, Pakistan or DM in India or equivalent programs elsewhere in the world. In the United States, training in this field requires four years undergraduate school, four years of medical school, and then three years of residency, followed by two or three years additional Fellowship training. The requirements may vary in other countries. Rheumatologists are internists who are qualified by additional postgraduate training and experience in the diagnosis and treatment of arthritis and other diseases of the joints, muscles and bones. Many Rheumatologists also conduct research to determine the cause and better treatments for these disabling and sometimes fatal diseases. Treatment modalities are based on scientific research, currently, practice of rheumatology is largely evidence based. [2]

Rheumatologists treat arthritis, autoimmune diseases, pain disorders affecting joints, and osteoporosis. [3] There are more than 200 types of these diseases, including rheumatoid arthritis, osteoarthritis, gout, lupus, back pain, osteoporosis, and tendinitis. Some of these are very serious diseases that can be difficult to diagnose and treat. They treat soft tissue problems related to musculoskeletal system sports related soft tissue disorders.

Diseases

Diseases diagnosed or managed by rheumatologists include:

Degenerative arthropathies

Inflammatory arthropathies

Systemic conditions and connective tissue diseases

Medical laser for the treatment of rheumatism. Laserbehandling.jpg
Medical laser for the treatment of rheumatism.

Soft tissue rheumatism

Local diseases and lesions affecting the joints and structures around the joints including tendons, ligaments capsules, bursae, stress fractures, muscles, nerve entrapment, vascular lesions, and ganglia. For example:

Diagnosis

Physical examination

Following are examples of methods of diagnosis able to be performed in a normal physical examination.

Specialized

Treatment

Most rheumatic diseases are treated with analgesics, NSAIDs (nonsteroidal anti-inflammatory drug), steroids (in serious cases), DMARDs (disease-modifying antirheumatic drugs), monoclonal antibodies, such as infliximab and adalimumab, the TNF inhibitor etanercept, and methotrexate for moderate to severe rheumatoid arthritis. [4] The biologic agent rituximab (anti-B cell therapy) is now licensed for use in refractory rheumatoid arthritis. [5] Physiotherapy is vital in the treatment of many rheumatological disorders. Occupational therapy can help patients find alternative ways for common movements that would otherwise be restricted by their disease. Patients with rheumatoid arthritis often need a long term, coordinated and a multidisciplinary team approach towards management of individual patients. Treatment is often tailored according to the individual needs of each patient which is also dependent on the response and the tolerability of medications.

Rheumasurgery

Rheumasurgery - sometimes called rheumatoid surgery - is a subfield of orthopedics occupied with the surgical treatment of patients with rheumatic diseases. [6] The purpose of the interventions is to limit disease activity, soothe pain and improve function. [7]

Rheumasurgical interventions can be divided in two groups. The one is early synovectomies, that is the removal of the inflamed synovia in order to prevent spreading and stop destruction. The other group is the so-called corrective intervention, i.e. an intervention done after destruction has taken place. [8] Among the corrective interventions are joint replacements, removal of loose bone or cartilage fragments, and a variety of interventions aimed at repositioning and/or stabilizing joints, [9] such as arthrodesis.

Research directions

Recently, a large body of scientific research deals with the background of autoimmune disease, the cause of many rheumatic disorders. Also, the field of osteoimmunology has emerged to further examine the interactions between the immune system, joints, and bones. Epidemiological studies and medication trials are also being conducted. The Rheumatology Research Foundation is the largest private funding source of rheumatology research and training in the United States.

History

Rheumasurgery emerged in the cooperation of rheumatologists and orthopedic surgeons in Heinola, Finland, during the 1950s. [10]

In 1970 a Norwegian investigation estimated that at least 50% of patients with rheumatic symptoms needed rheumasurgery as an integrated part of their treatment. [11]

The European Rheumatoid Arthritis Surgical Society (ERASS) was founded in 1979. [12]

Around the turn of the century, focus for treatment of patients with rheumatic disease shifted, and pharmacological treatment became dominant, while surgical interventions became rarer. [13] [14]

Related Research Articles

Arthritis type of joint disorder

Arthritis is a term often used to mean any disorder that affects joints. Symptoms generally include joint pain and stiffness. Other symptoms may include redness, warmth, swelling, and decreased range of motion of the affected joints. In some types of arthritis, other organs are also affected. Onset can be gradual or sudden.

Rheumatoid arthritis type of autoimmune arthritis

Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are involved, with the same joints typically involved on both sides of the body. The disease may also affect other parts of the body, including skin, eyes, lungs, heart, nerves and blood. This may result in a low red blood cell count, inflammation around the lungs, and inflammation around the heart. Fever and low energy may also be present. Often, symptoms come on gradually over weeks to months.

Sjögren syndrome Medical condition

Sjögren's syndrome is a long-term autoimmune disease that affects the body's moisture-producing glands, and often seriously affects other organs systems, such as the lungs, kidneys, and nervous system. Primary symptoms are dryness, pain and fatigue. Other symptoms can include dry skin, vaginal dryness, a chronic cough, numbness in the arms and legs, feeling tired, muscle and joint pains, and thyroid problems. Those affected are also at an increased risk (15%) of lymphoma.

Autoimmunity is the system of immune responses of an organism against its own healthy cells, tissues and other body normal constituents. Any disease that results from such an aberrant immune response is termed an "autoimmune disease". Prominent examples include celiac disease, post-infectious IBS, diabetes mellitus type 1, Henloch Scholein Pupura (HSP) sarcoidosis, systemic lupus erythematosus (SLE), Sjögren syndrome, eosinophilic granulomatosis with polyangiitis, Hashimoto's thyroiditis, Graves' disease, idiopathic thrombocytopenic purpura, Addison's disease, rheumatoid arthritis (RA), ankylosing spondylitis, polymyositis (PM), dermatomyositis (DM) and multiple sclerosis (MS). Autoimmune diseases are very often treated with steroids.

Ankylosing spondylitis A type of arthritis in which there is long term inflammation of the joints of the spine

Ankylosing spondylitis (AS) is a type of arthritis in which there is a long-term inflammation of the joints of the spine. Typically the joints where the spine joins the pelvis are also affected. Occasionally other joints such as the shoulders or hips are involved. Eye and bowel problems may also occur. Back pain is a characteristic symptom of AS, and it often comes and goes. Stiffness of the affected joints generally worsens over time.

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is one of the institutes and centers that make up the National Institutes of Health, an agency of the United States Department of Health and Human Services (HHS).

Rheumatism or rheumatic disorders are conditions causing chronic, often intermittent pain affecting the joints or connective tissue. Rheumatism does not designate any specific disorder, but covers at least 200 different conditions, including arthritis and "non-articular rheumatism", also known as "regional pain syndrome" or "soft tissue rheumatism". There is a close overlap between the term soft tissue disorder and rheumatism. Sometimes the term "soft tissue rheumatic disorders" is used to describe these conditions.

Juvenile idiopathic arthritis (JIA), is the most common, chronic rheumatic disease of childhood, affecting approximately one per 1,000 children. Juvenile, in this context, refers to disease onset before 16 years of age, while idiopathic refers to a condition with no defined cause, and arthritis is inflammation within the joint.

Vasculitis Medical condition

Vasculitis is a group of disorders that destroy blood vessels by inflammation. Both arteries and veins are affected. Lymphangitis is sometimes considered a type of vasculitis. Vasculitis is primarily caused by leukocyte migration and resultant damage.

Granulomatosis with polyangiitis Medical condition

Granulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis (WG), is an extremely rare long-term systemic disorder that involves the formation of granulomas and inflammation of blood vessels (vasculitis). It is a form of vasculitis that affects small- and medium-size vessels in many organs but most commonly affects the upper respiratory tract, lungs and kidneys. The signs and symptoms of GPA are highly varied and reflect which organs are supplied by the affected blood vessels. Typical signs and symptoms include nosebleeds, stuffy nose and crustiness of nasal secretions, and inflammation of the uveal layer of the eye. Damage to the heart, lungs and kidneys can be fatal.

Eosinophilic granulomatosis with polyangiitis Medical condition

Eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as allergic granulomatosis, is an extremely rare autoimmune condition that causes inflammation of small and medium-sized blood vessels (vasculitis) in persons with a history of airway allergic hypersensitivity (atopy).

Polyarteritis nodosa Medical condition

Polyarteritis nodosa (PAN), is a systemic necrotizing inflammation of blood vessels (vasculitis) affecting medium-sized muscular arteries, typically involving the arteries of the kidneys and other internal organs but generally sparing the lungs' circulation. Polyarteritis nodosa may be present in infants. In polyarteritis nodosa, small aneurysms are strung like the beads of a rosary, therefore making "rosary sign" an important diagnostic feature of the vasculitis. PAN is sometimes associated with infection by the hepatitis B or hepatitis C virus.

Rituximab Pharmaceutical drug

Rituximab, sold under the brand name Rituxan among others, is a medication used to treat certain autoimmune diseases and types of cancer. It is used for non-Hodgkin lymphoma, chronic lymphocytic leukemia, rheumatoid arthritis, granulomatosis with polyangiitis, idiopathic thrombocytopenic purpura, pemphigus vulgaris, myasthenia gravis and Epstein–Barr virus-positive mucocutaneous ulcers. It is given by slow injection into a vein.

Anti-neutrophil cytoplasmic antibody Group of autoantibodies

Anti-neutrophil cytoplasmic antibodies (ANCAs) are a group of autoantibodies, mainly of the IgG type, against antigens in the cytoplasm of neutrophil granulocytes and monocytes. They are detected as a blood test in a number of autoimmune disorders, but are particularly associated with systemic vasculitis, so called ANCA-associated vasculitides (AAV).

Mixed connective tissue disease commonly abbreviated as MCTD, is an autoimmune disease characterized by the presence of elevated blood levels of a specific autoantibody, now called anti-U1 ribonucleoprotein (RNP) together with a mix of symptoms of systemic lupus erythematosus (SLE), scleroderma, and polymyositis. The idea behind the "mixed" disease is that this specific autoantibody is also present in other autoimmune diseases such as systemic lupus erythematosus, polymyositis, scleroderma, etc. MCTD was characterized as an individual disease in 1972 by Sharp et al., and the term was introduced by Leroy in 1980.

Palindromic rheumatism (PR) is a syndrome characterised by recurrent, self-resolving inflammatory attacks in and around the joints, consists of arthritis or periarticular soft tissue inflammation. The course is often acute onset, with sudden and rapidly developing attacks or flares. There is pain, redness, swelling, and disability of one or multiple joints. The interval between recurrent palindromic attacks and the length of an attack is extremely variable from few hours to days. Attacks may become more frequent with time but there is no joint damage after attacks. It is thought to be an autoimmune disease, possibly an abortive form of rheumatoid arthritis.

Childhood arthritis, is any form of chronic arthritis or chronic arthritis-related conditions which affects individuals under the age of 16. It is an autoimmune disease.

Scleromyositis, is an autoimmune disease. People with scleromyositis have symptoms of both systemic scleroderma and either polymyositis or dermatomyositis, and is therefore considered an overlap syndrome. Although it is a rare disease, it is one of the more common overlap syndromes seen in scleroderma patients, together with MCTD and Antisynthetase syndrome. Autoantibodies often found in these patients are the anti-PM/Scl (anti-exosome) antibodies.

An overlap syndrome is a medical condition which shares features of at least two more widely recognised disorders. Examples of overlap syndromes can be found in many medical specialties such as overlapping connective tissue disorders in rheumatology, and overlapping genetic disorders in cardiology.

Necrotizing vasculitis, also called systemic necrotizing vasculitus (SNV), is a category of vasculitis, comprising vasculitides that present with necrosis.

References

  1. Upchurch Katherine S., Kay Jonathan (2012). "Evolution of treatment for rheumatoid arthritis". Rheumatology. 51 (suppl 6): vi28–vi36. doi: 10.1093/rheumatology/kes278 .
  2. "What is a Rheumatologist?". www.rheumatology.org.
  3. "Rheumatology Specialty Description". American Medical Association.
  4. "Methotrexate for rheumatoid arthritis". Arthritis.about.com. Retrieved 2013-06-24.
  5. Edwards J; Szczepanski L; Szechinski J; Filipowicz-Sosnowska A; et al. (2004). "Efficacy of B-cell-targeted therapy with rituximab in patients with rheumatoid arthritis". N Engl J Med. 350 (25): 2572–2581. doi:10.1056/NEJMoa032534. PMID   15201414.
  6. "Norsk forening for revmakirurgi - Med hovedbase på Diakonhjemmet" LB Johannessen Tidsskr Nor Lægeforen 2004; 124:3110 Nr. 23 – 2. December 2004
  7. Rheumakirurgi. Arne Skredderstuen November 2000
  8. Den sykehusmessige revmatikeromsorgen i Norge (Kåss and Stene 1970), page 24.
  9. "Surgery for Rheumatic Diseases" Cedars Sinai (http://www.cedars-sinai.edu)
  10. Revmatisme: Gamle plager - ny viten (Munthe and Larsen 1987), page 49.
  11. Den sykehusmessige revmatikeromsorgen i Norge (Kåss and Stene 1970), pages 24-25.
  12. Rydholm, U "Reumakirurgiens uppgång, stabilisering og nedgång ur ett sydsvenskt perspektiv" 2013
  13. Trender i revmakirurgisk behandling av pasienter med leddgikt og andre kronisk inflammatoriske leddsykdommer, Norsk Rheumabulletin 4/2012, pages 16-17.
  14. Nikiphorou E, Carpenter L, Morris S; et al. (2014). "Hand and foot surgery rates in rheumatoid arthritis have declined from 1986 to 2011, but large-joint replacement rates remain unchanged: results from two UK inception cohorts". Arthritis Rheumatol. 66 (5): 1081–9. doi:10.1002/art.38344. PMID   24782174.CS1 maint: multiple names: authors list (link)