Rheumatology

Rheumatology (Greek ῥεῦμα, rheûma, flowing current) is a branch of medicine devoted to the diagnosis and management of disorders whose common feature is inflammation in the bones, muscles, joints, and internal organs.[1] Rheumatology covers more than 100 different complex diseases, collectively known as rheumatic diseases, which includes many forms of arthritis as well as lupus and Sjögren's syndrome.[1] Doctors who have undergone formal training in rheumatology are called rheumatologists.

For the journal, see Rheumatology (journal).
Rheumatology
SystemMusculoskeletal, Immune
Significant diseasesAutoimmune disease Inflammation, Rheumatoid arthritis, Lupus, Osteoarthritis, Psoriatic arthritis, Ankylosing spondylitis, Gout, Osteoporosis
Significant testsJoint aspirate, Musculoskeletal exam, X-ray
SpecialistRheumatologist

Many of these diseases are now known to be disorders of the immune system, and rheumatology has significant overlap with immunology, the branch of medicine that studies the immune system.

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. 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 the musculoskeletal system, and sports related soft tissue disorders.

Diseases
Main article: Rheumatism

Diseases diagnosed or managed by rheumatologists include:

Degenerative arthropathies

Inflammatory arthropathies

Systemic conditions and connective tissue diseases
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
Synovial fluid examination[4][5]
TypeWBC (per mm3) % neutrophilsViscosityAppearance
Normal<2000HighTransparent
Osteoarthritis<5000<25HighClear yellow
Trauma<10,000<50VariableBloody
Inflammatory2,000–50,00050–80LowCloudy yellow
Septic arthritis>50,000>75LowCloudy yellow
Gonorrhea~10,00060LowCloudy yellow
Tuberculosis~20,00070LowCloudy yellow
Inflammatory: Arthritis, gout, rheumatoid arthritis, rheumatic fever

Physical examination

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

  • Schober's test tests the flexion of the lower back.
  • Multiple joint inspection
  • Musculoskeletal Examination
    • Screening Musculoskeletal Exam (SMSE) - a rapid assessment of structure and function
    • General Musculoskeletal Exam (GMSE) - a comprehensive assessment of joint inflammation
    • Regional Musculoskeletal Exam (RMSE) - focused assessments of structure, function and inflammation combined with special testing

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.[6] The biologic agent rituximab (anti-B cell therapy) is now licensed for use in refractory rheumatoid arthritis.[7] 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.

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.[8]

Rheumasurgery

Rheumasurgery (or rheumatoid surgery) is a subfield of orthopedics occupied with the surgical treatment of patients with rheumatic diseases.[9] The purpose of the interventions is to limit disease activity, soothe pain and improve function.[10]

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.[11] 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,[12] 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.[13]

In 1970 a Norwegian investigation estimated that at least 50% of patients with rheumatic symptoms needed rheumasurgery as an integrated part of their treatment.[14]

The European Rheumatoid Arthritis Surgical Society (ERASS) was founded in 1979.[15]

Around the turn of the 21st century, focus for treatment of patients with rheumatic disease shifted, and pharmacological treatment became dominant, while surgical interventions became rarer.[16][17]

References
  1. "Explore Rheumatology". www.rheumatology.org. Retrieved 2022-09-28.
  2. "What is a Rheumatologist?". www.rheumatology.org.
  3. "Rheumatology Specialty Description". American Medical Association.
  4. Flynn JA, Choi MJ, Wooster DL (2013). Oxford American Handbook of Clinical Medicine. US: OUP. p. 400. ISBN 978-0-19-991494-4.
  5. Seidman AJ, Limaiem F (2019). "Synovial Fluid Analysis". StatPearls. StatPearls Publishing. PMID 30725799. Retrieved 2019-12-19.
  6. "Methotrexate for rheumatoid arthritis". Arthritis.about.com. Retrieved 2013-06-24.
  7. 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.
  8. Upchurch Katherine S., Kay Jonathan (2012). "Evolution of treatment for rheumatoid arthritis". Rheumatology. 51 (suppl 6): vi28–vi36. doi:10.1093/rheumatology/kes278. PMID 23221584.
  9. "Norsk forening for revmakirurgi - Med hovedbase på Diakonhjemmet" LB Johannessen Tidsskr Nor Lægeforen 2004; 124:3110 Nr. 23 – 2. December 2004
  10. Rheumakirurgi Archived 2016-01-18 at the Wayback Machine. Arne Skredderstuen November 2000
  11. Den sykehusmessige revmatikeromsorgen i Norge (Kåss and Stene 1970), page 24.
  12. "Surgery for Rheumatic Diseases" Cedars Sinai (http://www.cedars-sinai.edu)
  13. Revmatisme: Gamle plager - ny viten (Munthe and Larsen 1987), page 49.
  14. Den sykehusmessige revmatikeromsorgen i Norge (Kåss and Stene 1970), pages 24-25.
  15. Rydholm, U "Reumakirurgiens uppgång, stabilisering og nedgång ur ett sydsvenskt perspektiv" 2013
  16. Trender i revmakirurgisk behandling av pasienter med leddgikt og andre kronisk inflammatoriske leddsykdommer Archived 2016-01-29 at the Wayback Machine, Norsk Rheumabulletin 4/2012, pages 16-17.
  17. 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. S2CID 25813985.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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