Rheumatology – FAQs

A Rheumatologist is a specialist who deals with the diagnosis and treatment of patients with joint and musculoskeletal problems. He/she first has to specialise as a physician and then receives additional training and experience in the diagnosis and treatment of arthritis and related musculoskeletal conditions.

Arthritis literally means inflammation of a joint. This is due to inflammation of the joint lining called synovium, which results in joint swelling and causes pain and stiffness as the main symptoms.

Patients with Arthritis may experience the following symptoms: pain and swelling of one or more joints, feel stiffness in the joints – more in the morning, redness and warmth of the affected joints and these symptoms van be recurrent or persistent.

No, this is a common misconception. Arthritis can affect any age group- even children. However, osteoarthritis which is a disease of the cartilage of the joint (also referred to as ‘wear and tear’ arthritis), affects older people.

Yes, arthritis generally is more common in women than men. Rheumatoid arthritis is 3 times more common in women.

It is a disease of the cartilage- the soft material between the bones of a joint. The loss of this cartilage results in changes at the joint. This is seen generally in older individuals, with symptoms starting only after 45 to 50 years of age.

A genetic predisposition is the most important risk factor. Other factors that may impact osteoarthritis are: Obesity, Mechanical/surgical trauma to a joint, Excessive use of a joint such as with impact sports or ballet dancers.

No special diet is required for arthritis patients except Gout where a diet low in animal protein and limiting alcohol intake can be helpful in the overall treatment.

Exercise is important to maintain the flexibility, range of movement at the joint and to strengthen the muscles. However, exercise will not reduce joint inflammation and usually should be started, only after effective control of inflammation with proper therapy.

Rheumatologists are Physicians and Orthopaedic surgeons are surgeons; therefore all medically related joint disorders are dealt by a Rheumatologist. When the joints are badly damaged or when there are fractures, then you need to consult an orthopedic surgeon

Rheumatologists are specially trained to deal with different arthritic conditions, autoimmune disorders, metabolic bone diseases and soft tissue rheumatic conditions.

Rheumatological conditions can be considered under two main headings- inflammatory or non-inflammatory.

The inflammatory conditions include: Rheumatoid Arthritis; SLE (Systemic Lupus Erythematosus); Gout and other crystal deposition diseases; Connective tissue diseases (Scleroderma, Wegener’s, Churg-strauss, Polyarteritis nodosa, MCTD, Polymyositis, Dermatomyositis, Polymyalgia Rheumatica, Giant cell arteritis); Ankylosing Spondylitis; Psoriatic Arthritis; Reactive Arthritis; Juvenile (Paediatric) Idiopathic Arthritis.

The non-inflammatory conditions include: Osteoarthritis; Osteoporosis; Osteomalacia; Rickets; low back pain; Fibromyalgia; Tendonitis and bursitis.

The drugs/medicines used for the treatment of arthritis and related disorders can be classified under the following categories:

• Non-steroidal anti-inflammatory agents (NSAIDs): These drugs, as the name implies, are anti-inflammatory and are not steroids. They are commonly referred to as ‘pain-killers’. However, they work by reducing inflammation and in addition also have pain relieving (analgesic) properties. They do not have any specific disease modifying or controlling actions, but can be useful for symptomatic benefit. Some NSDAIDs are: Ibuprofen, Diclofenac, Naproxen etc. There is a group of NSAIDs called Cox-II inhibitors that are considered to be easier on the stomach and they include: Etoricoxib and Celecoxib.
• Analgesics: These include: Paracetamol and Tramadol and are ‘pure’ pain relievers.
• Disease-Modifying Drugs (DMARDs): These are medicines that have a specific disease modifying/controlling effect and are also referred to as immuno-suppressants. These include: Chloroquine, Methotrexate, Sulfasalazine, Azathiaprine, Cyclophosphamide etc.
• Miscellaneous: There are a number of other medicines that may be used, such as Colchicine, Allopurinol or Febuxostat, used for Gout.

A Rheumatologist helps by:

• Evaluating a patient with joint complaints and making a correct diagnosis;
• Planning the correct treatment for the patient;
• Monitoring the patient periodically as indicated, to recognise and complications and/or side effects as early as possible;
• In preventing joint damage and improving quality of life of the patient.

Arthritis literally means joint inflammation. Although joint inflammation describes a symptom or sign rather than a specific diagnosis, the term “arthritis” is often used to refer to any disorder that affects the joints. These disorders fall within the broader category of rheumatic diseases. These are diseases characterized by inflammation (signs include redness or heat, swelling, and symptoms such as pain) and loss of function of one or more connecting or supporting structures of the body. These diseases especially affect joints, tendons, ligaments, bones, and muscles. Common signs and symptoms are pain, swelling, and stiffness. Some rheumatic diseases also can involve internal organs.

There are more than 100 rheumatic diseases. Some are described as connective tissue diseases because they affect the supporting framework of the body and its internal organs. Others are known as autoimmune diseases because they occur when the immune system, which normally protects the body from infection and disease, harms the body’s own healthy tissues.

Osteoarthritis – This is the most common type of arthritis, affecting an estimated 27 million adults in the United States. Osteoarthritis primarily the cartilage, which is the tissue that cushions the ends of bones within the joint, as well as the underlying bone. In osteo¬arthritis, there is damage to the cartilage, which begins to fray and may wear away entirely. There is also damage to the bone stock of the joint. Osteoarthritis can cause joint pain and stiffness. Disability results most often when the disease affects the spine and the weight-bearing joints (the knees and hips).

Rheumatoid arthritis – This inflammatory disease of the immune system targets first the synovium, or lining of the joint, resulting in pain, stiffness and swelling of the affected joints initially and then if persistent, joint damage and loss of function of the joints. Inflammation most often affects joints of the hands and feet and tends to be symmetrical (occurring equally on both sides of the body). This symmetry helps distinguish rheumatoid arthritis from other forms of the disease. The world wide prevalence of rheumatoid arthritis is about 1%.

Juvenile idiopathic arthritis – This disease is the most common form of inflammatory arthritis in childhood, causing pain, stiffness, swelling, and loss of function of the joints. This condition may be associated with rashes or fevers and may affect ¬various parts of the body.

Fibromyalgia – Fibromyalgia is a chronic disorder that ¬causes pain throughout the tissues that support and move the bones and joints. Pain, stiffness, and localized tender points occur in the muscles and tendons, particularly those of the neck, spine, shoulders, and hips. Patients also may experience fatigue and sleep disturbances. Fibromyalgia affects millions of adults in the United States.

Systemic lupus erythematosus – Systemic lupus erythematosus (also known as lupus or SLE) is an autoimmune disease in which the immune system harms the body’s own healthy cells and tissues. This can result in inflammation of and damage to the joints, skin, kidneys, heart, lungs, blood vessels, and brain. By conservative estimates, lupus affects about 150,000 people.

Scleroderma – Also known as systemic sclerosis, scleroderma means literally “hard skin.” The disease affects the skin, blood vessels, and joints. It may also affect internal organs, such as the lungs and kidneys. In scleroderma, there is an abnormal and excessive production of collagen (a fiber-like protein) in the skin and internal organs.

Spondyloarthropathies – This group of rheumatic diseases principally affects the spine. One common form – ankylosing spondylitis – also may affect the hips, shoulders, and knees. The tendons and ¬ligaments around the bones and joints become inflamed, resulting in pain and stiffness. Ankylosing spondylitis tends to affect people in late adolescence or early adulthood. Reactive arthritis is another spondyloarthropathy. It develops after an infection involving the lower urinary tract, bowel, or other organ. It is commonly associated with eye problems, skin rashes, and mouth sores.

Infectious arthritis – This is a general term used to describe forms of arthritis that are caused by infectious agents, such as bacteria or viruses. Parvovirus arthritis and gonococcal arthritis are examples of infectious arthritis. Arthritis symptoms also may occur in Lyme disease, which is caused by a bacterial infection following the bite of certain ticks. In those cases of arthritis caused by bacteria, early diagnosis and treatment with antibiotics are crucial to removing the infection and minimizing damage to the joints.

Gout – This type of arthritis results from deposits of needle-like crystals of uric acid in the joints. The crystals cause episodic inflammation, swelling, and pain in the affected joint, which is often the big toe. An estimated 2.1 million Americans have gout.

Polymyalgia rheumatica – Because this disease involves tendons, muscles, ligaments, and tissues around the joint, symptoms often include pain, aching, and morning stiffness in the shoulders, hips, neck, and lower back. It is sometimes the first sign of giant cell arteritis, a disease of the arteries characterized by headaches, inflammation, weakness, weight loss, and fever.

Polymyositis – This rheumatic disease causes inflammation and weakness in the muscles. The disease may affect the whole body and cause disability.

Psoriatic arthritis – This form of arthritis occurs in some patients with psoriasis, a scaling skin disorder. Psoriatic arthritis often affects the joints at the ends of the fingers and toes and is accompanied by changes in the fingernails and toenails. Back pain may occur if the spine is involved.

Bursitis – This condition involves inflammation of the bursae, small, fluid-filled sacs that help reduce friction between bones and other moving structures in the joints. The inflammation may result from arthritis in the joint or injury or infection of the bursae. Bursitis produces pain and tenderness and may limit the movement of nearby joints.

Tendonitis (tendonitis) – This condition refers to inflammation of tendons (tough cords of tissue that connect muscle to bone) caused by overuse, injury, or a rheumatic condition. Tendonitis produces pain and tenderness and may restrict movement of nearby joints.

Rheumatic diseases are generally believed to be caused by a combination of genetic and environmental factors. In other words, you may be born with a susceptibility to a disease, but it may take something in your environment to get the disease started. Some of these factors have been identified. For example, in osteoarthritis, inherited cartilage weakness or excessive stress on the joint from repeated injury may play a role. In rheumatoid arthritis, juvenile idiopathic arthritis, and lupus, patients may have a variation in a gene that codes for an enzyme called protein tyrosine phosphatase nonreceptor 22 (PTPN22). Certain viruses may trigger disease in genetically susceptible people. For example, scientists have found a connection between Epstein-Barr virus and lupus. There are likely many genes and combinations of genes that predispose people to rheumatic diseases, and many different environmental factors that trigger them.

Gender is another factor in some rheumatic diseases. Lupus, rheumatoid arthritis, scleroderma, and fibromyalgia are more common among women. This indicates that hormones or other male-female differences may play a role in the development of these ¬conditions.

Approximately 4-6 out of 10 consultations with a family physician are for a musculo[skeletal complaint. Rheumatic ¬ diseases are a more frequent cause of activity limitation than heart disease, cancer, or diabetes.

Rheumatic diseases affect people of all races and ages. Some rheumatic conditions are more common among certain populations. For example:

• Rheumatoid arthritis occurs two to three times more often in women than in men.
• Scleroderma is more common in women than in men.
• Nine out of 10 people who have lupus are women.
• Nine out of 10 people who have fibromyalgia are women.
• Gout is more common in men than in women. After menopause, the incidence of gout for women begins to rise.
• Systemic lupus erythematosus is more common in women than in men, and it occurs more often in African Americans and Hispanics than in Caucasians.

Diagnosing rheumatic diseases requires a systematic approach in evaluating the symptoms and signs. A general practitioner or family doctor may be able to recognise the presence of a rheumatic disease and should then refer the patient to a rheumatologist (a doctor who specializes in treating arthritis and other rheumatic diseases).

• swelling in one or more joints
• stiffness around the joints that lasts for at least 1 hour in the early morning
• constant or recurring pain or tenderness in a joint
• difficulty using or moving a joint normally
• warmth and redness in a joint

Common laboratory tests and procedures include the ¬following:

Antinuclear antibody (ANA) – This test checks blood levels of antibodies that are often present in people who have connective tissue diseases or other autoimmune disorders, such as lupus. Because the antibodies react with material in the cell’s nucleus (control center), they are referred to as anti¬nuclear antibodies. There are also tests for individual types of ANAs that may be more specific to people with certain autoimmune disorders. ANAs are also sometimes found in people who do not have an autoimmune disorder. (In such cases, the result is referred to as a “false positive.”) Therefore, having ANAs in the blood does not necessarily mean that a person has a disease and it is important to analyse the result in the light of the patients’ symptoms.

CCP (or anti-CCP) – This test checks blood levels of antibodies to citrulline, a protein that can be detected in up to 70 percent of people in the early stages of rheumatoid arthritis. Because the presence of anti-CCPs is associated with more aggressive disease, the test can also be useful in helping doctors plan treatment.

C-reactive protein test – This nonspecific test is used to detect generalized inflammation. Levels of the protein are often increased in patients with active disease such as rheumatoid arthritis or any other disease that causes inflammation.

Complement – This test measures the level of complement, a group of proteins in the blood. Complement helps destroy germs and other foreign substances that enter the body. A low blood level of complement is common in people who have active lupus.

Complete blood count (CBC) – This test determines the number of white blood cells, red blood cells, and platelets present in a sample of blood. Some rheumatic conditions or drugs used to treat arthritis are associated with a low white blood count (leucopenia), low red blood count (anemia), or low platelet count (thrombocytopenia).

Creatinine – This blood test measures the level of creatinine, a breakdown product of creatinine, which is an important component of muscle. Creatinine is excreted from the body entirely by the kidneys, and the level remains constant and normal when kidney function is normal. This test is commonly used to diagnose and monitor kidney disease in patients who have a rheumatic condition such as lupus.

Erythrocyte sedimentation rate (or ESR) – This blood test is used to detect inflammation in the body. High ESR, indicates the presence of inflammation, and is seen in many forms of arthritis, such as rheumatoid arthritis and ankylosing spondylitis. High ESR is also typical of many of the immunologic connective tissue diseases, such as lupus, scleroderma and Polymyalgia rheumatica. However, the ESR may also be elevated in the presence of other conditions such as some infections and malignancy.

Haematocrit (PCV, packed cell volume) – This test and the test for hemoglobin (a substance in the red blood cells that carries oxygen throughout the body) measure the number of red blood cells present in a sample of blood. A decrease in the number of red blood cells (anemia) is common in people who have inflammatory arthritis or another rheumatic disease. Rheumatoid factor – This test detects the presence of rheumatoid factor, an antibody found in the blood of most (but not all) people who have rheumatoid arthritis. In rheumatoid arthritis, it may be associated with more aggressive disease. Rheumatoid factor may be found in many diseases besides rheumatoid arthritis and sometimes in people without health problems.

Synovial fluid examination – Synovial fluid may be examined for white blood cells (found in patients with rheumatoid arthritis and infections), bacteria or viruses (found in patients with infectious arthritis), or crystals in the joint (found in patients with gout or other types of crystal-induced arthritis). To obtain a specimen, the doctor injects a local anesthetic, then inserts a -needle into the joint to withdraw the synovial fluid into a syringe. The procedure is called arthrocentesis or joint aspiration.

Urinalysis – In this test, a urine sample is studied for protein, red blood cells, white blood cells, and bacteria. These abnormalities may indicate kidney disease, which may be seen in lupus as well as several rheumatic conditions. Some medications used to treat arthritis also can cause abnormal findings on urinalysis.

To see what the joint looks like inside, the doctor may order x rays or other imaging procedures. X rays provide an image of the bones, but they do not show cartilage, muscles, and ligaments. Other noninvasive imaging methods such as computed tomography (CT or CAT scan), magnetic resonance imaging (MRI), and arthrography show the whole joint. The doctor also may look for damage to a joint by using an arthroscope: a small, flexible tube which is inserted through a small incision at the joint. The arthroscope transmits the image from inside the joint to a video screen.

There is no single treatment for rheumatic diseases and this would depend upon the individual disease or condition and the problems caused, in a given patient. The treatment options may therefore include:

General Measures: General measures as part of the treatment for rheumatic diseases may include (where appropriate) rest, exercise, proper diet, and joint protection measures. Joint protection may require the use of assistive devices, such as splints or braces. In severe cases, surgery may be necessary.

A variety of medications are used to treat rheumatic diseases. The type of medication depends on the rheumatic disease and on the individual patient. The medications used to treat most rheumatic diseases do not provide a cure, but can control the disease and prevent or limit further complications and/or joint damage. Infections in a joint can often be completely treated by appropriate medication. Another exception is Gout, which is virtually curable, if treated properly.

Following are some of the types of medications commonly used in the treatment of rheumatic diseases.

Analgesics – Pure analgesics (or pain relievers) include oral medicines such as Paracetamol or Tramadol and can be used to reduce the pain caused by many rheumatic conditions. In addition to oral medicines, analgesics may also be used as topical preparations; These creams or ointments are rubbed into the skin over sore muscles or joints and relieve pain through one or more active ingredients. These are the most common:

• Counterirritants – These ingredients, such as menthol, oil of wintergreen, eucalyptus oil, or camphor, work by irritating the nerve endings in the skin. This distracts the brain from the deeper source of pain.
• Salicylates – This ingredient works like aspirin, by blocking chemicals in the body that contribute to pain.
• Capsaicin – This natural ingredient found in cayenne peppers is an effective pain reliever by blocking the pain sensing nerve endings.

Nonsteroidal anti-inflammatory drugs (NSAIDS)– This large class of medications is useful against both pain and inflammation of joint diseases. Though they are non-specific and do not act as disease modifying drugs, they are commonly used for symptomatic benefit in addition to other specific medication. Some NSDAIDs are: Ibuprofen, Diclofenac, Naproxen etc. There is a group of NSAIDs called Cox-II inhibitors that are considered to be easier on the stomach and they include: Etoricoxib and Celecoxib.

All NSAIDs work similarly: by blocking substances called prostaglandins that contribute to inflammation and pain. Due to their anti-prostaglandin effects, NSAIDs can cause stomach irritation or can affect kidney function. Therefore they must be used with appropriate caution and an understanding of the benefits and potential risks.

Disease-modifying antirheumatic drugs (DMARDs) – A family of medicines that are used to treat inflammatory arthritis like rheumatoid arthritis and ankylosing spondylitis, DMARDs work by acting upon the mechanisms that cause the inflammation and therefore modify the disease and stop/limit the effects or damage by the disease. DMARDs typically require regular blood tests to monitor possible side effects and with proper monitoring can be continued for prolonged periods, for their beneficial effects. Though DMARDs may help to retard or even stop joint damage from progressing, they cannot change joint damage that has already occurred- therefore, it is imperative that these drugs are started sooner rather than later.

Some of the commonly used DMARDs are Methotrexate, Hydroxychloroquine, Sulfasalazine, Leflunomide, Azathiaprine, Cyclophosphamide.

Biologic response modifiers – Amongst the DMARDs, Biologic response modifiers, or Biologics, are a new family of genetically engineered drugs that block specific molecular pathways of the immune system that are involved in the inflammatory process. Thus, they actually ‘target’ the disease mechanism and can be very effective. They are often prescribed in combination with DMARDs such as methotrexate. They may make an individual more prone to some types of infection and their cost can be a limitation as well. The Biologics currently available in India are: Etanercept, Infliximab, Abatacept, Tocilizumab and Rituximab.

Corticosteroids– Corticosteroids, such as prednisolone, dexamethasone, betamethasone, and methyl-prednisolone, can be used to treat many rheumatic conditions, because they decrease inflammation and suppress the immune system. The dosage of these medications as well as their method of administration may vary depending on the condition being treated. Corticosteroids can be given by mouth, in creams applied to the skin, intravenously, or by injection directly into the affected joint(s). Short-term side effects of corticosteroids include swelling, increased appetite, weight gain, and emotional ups and downs. These side effects generally stop when the drug is stopped. It can be dangerous to stop taking corticosteroids suddenly, so it is very important that the doctor and patient work together when changing the corticosteroid dose. Side effects that may occur after long-term use of corticosteroids include stretch marks, excessive hair growth, osteoporosis, high blood pressure, damage to the arteries, high blood glucose, infections, and cataracts.

Hyaluronic acid substitutes – Hyaluronic acid products, such as Hyalgan and Synvisc, mimic a naturally occurring body substance that serves to lubricate joints and is believed to be deficient in joints with osteoarthritis. Depending on the particular product, patients receive a series of three to five injections, which are administered directly into the affected knee(s) or hip(s) to help provide temporary relief of pain and flexible joint movement.

Splints and Braces – Splints and braces are used to support weakened joints or allow them to rest. Some prevent the joint from moving; others allow some movement. A splint or brace should be used only when recommended by a doctor or therapist, who will explain to the patient when and for how long the device should be worn. The doctor or therapist also will demonstrate the correct way to put it on and will ensure that it fits properly. The incorrect use of a splint or brace can cause joint damage, stiffness, and pain.

Assistive Devices – A person with arthritis can use many kinds of devices to ease the pain. For example, using a cane when walking can reduce some of the weight placed on a knee or hip affected by arthritis. A shoe insert (orthotic) can ease the pain of walking caused by arthritis of the foot or knee. Other devices can help with activities such as opening jars, closing zippers, and holding pencils.

Surgery – Surgery may be required to repair damage to a joint after injury or to restore function or relieve pain in a joint damaged by arthritis. Many types of surgery are performed for arthritis. These include:

• Arthroscopic surgery – surgery to view the joint using a thin lighted scope inserted through a small incision over the joint. If repair is needed, tools may be inserted through additional small incisions.
• Bone fusion – surgery in which joint surfaces are removed from the ends of two bones that form a joint. The bones are then held together with screws until they grow together forming one rigid unit.
• Osteotomy – a surgery in which a section of bone is removed to improve the positioning of a joint.
• Arthroplasty – also known as total joint replacement. This procedure removes and replaces the damaged joint with an artificial one.

Many people find that having arthritis or another rheumatic disease limits their activities. When people can no longer participate in some of their favorite activities, their overall well-being can be affected. Even when arthritis impairs only one joint, a person may have to change many daily activities to reduce pain and protect that joint from further damage. When a condition affects the entire body, as it often does with rheumatoid arthritis, lupus, or fibromyalgia, many daily activities have to be changed to deal with pain, fatigue, and other symptoms.

Changes in the home may help a person with chronic arth¬ritis continue to live safely, productively, and with less pain. People with arthritis may become weak, lose their balance, or fall. In the bathroom, installing grab bars in the tub or shower and by the toilet, placing a secure seat in the tub, and raising the height of the toilet seat can help. Special kitchen utensils can accommodate hands affected by arthritis to make meal preparation easier. An occupational therapist can help people who have rheumatic conditions to identify and make adjustments in their homes to create a safer, more comfortable, and more efficient environment.

Friends and family members can help a patient with a rheumatic condition by learning about that condition and understanding how it affects the patient’s life. Friends and family can provide emotional and physical assistance. Their support, as well as support from other people who have the same disease, can make it easier to cope

Patient educational leaflets published by the Indian Rheumatology Association (IRA) are available and can also be downloaded from the IRA website- www.indianrheumatology.org