Rheumatism and Rheumatology

Whenever we get pain anywhere in our body usually we refer to this as “Rheumatism”. But in the true sense there is no specific disease called “Rheumatism” in modern medicine. It is a layman term denoting all pains in the body. Sometimes we use this term interchangeably with arthritis but in the true sense arthritis means inflammation of the joints. So in arthritis, there will be pain and swelling restricted to different joints of body rather than muscles, tendons etc.

Why this is important to know?

Because whenever we have pain anywhere, we go to doctors who sends some blood tests and give some medications. Most of the times these tests may not be appropriate and moreover they may misguide us as no particular test can diagnose rheumatism. There are several aspects in interpreting a blood test report as they may be falsely positive in many other conditions and sometimes in absolutely normal individuals. More than 90% of the so called rheumatism pain can be diagnosed and treated without doing a single laboratory test. There are more than 100 types of arthritis and each of these diseases has a particular set of useful investigations which are done to either diagnose the disease or to monitor the improvement with treatment. So before sending for any investigation there should be proper assessment of the pain by a trained physician so that unnecessary blood tests and their consequences can be avoided.

How should we approach joint pain?

If somebody is having pain then we have to see the origin of pain, whether it is coming from joints or its surrounding tissues like muscle ,fat, ligament , tendons etc.If the pain is coming from the joint and associated with swelling, it is called arthritis. And if the pain is coming from the surrounding structures it is called as soft tissue rheumatism. Arthritis is broadly divided into inflammatory arthritis and degenerative arthritis.Most common type of arthritis that usually occurs in old age is a type of degenerative arthritis known as osteoarthritis. This occurs due to degeneration of cartilage (sponge like material between the bones to avoid rubbing of bone against each other). This is seen more often in obese patients because of increased load on the weight bearing joints (knee joints). Lifestyle modifications like weight reduction, avoiding squatting, quadriceps exercises, exercise of the thigh muscles etc. helps in decreasing pain and sufferings in most cases. Very few need joint replacement surgeries particularly in advanced cases where the join pain severely affects the quality of life.Inflammatory arthritis usually occurs due to attack of our immune system on our joints. This can happen at any age and different types of arthritis affects different joints. This group includes rheumatoid arthritis, which usually affects women more than men. It is usually seen between age of 15 to 50 years of age and there will be pain and swelling of both the wrist joints and the small joints of hand and feet along with large joints like knee joints and ankle joints. Usually the patient will have difficulty in making a fist, and there is stiffness of body while getting up from the bed in the morning which eases off after resuming normal duties. Blood tests like rheumatoid factor and anti CCP antibody if present in high titre usually denotes severe type of rheumatoid arthritis and mandates for aggressive treatment. Inflammatory arthritis developing in a child before 16 years of age is called Juvenile Idiopathic Arthritis (JIA). Spondyloarthritis or Ankylosing spondylitis is another group of inflammatory arthritis which usually affects the spine and joints of leg and foot. There is a gene called HLA B27 which if present increases the chances of getting spondyloarthritis. Psoriatic arthritis patients usually have both arthritis and skin lesions along with nail changes. Other type of arthritis include crystal induced arthritis (induced by uric acid crystals), infective arthritis ( caused by direct attack of bacteria,fungi,tuberculosis etc.) and malignancy or cancer associated arthritis. Usually we suspect infection when only one joint is swollen, warm, reddish and may or may not be associated with fever. Gout is a type of arthritis caused by uric acid crystals which cause dramatic pain involving the first big toe of both the feet. It is usually an episodic disease where the joint pain episodes last for five to seven days and in between the episodes patient maybe totally normal. Serum uric acid level is done to monitor the treatment rather than diagnosing it because around 40 % of patient during joint pain may have normal blood uric acid level. There are many systemic autoimmune diseases like SLE , Sjogren syndrome( dry eye and dry mouth) etc. where arthritis is only one of the several manifestations of the disease. For example a patient with SLE may have prolonged fever, hair loss, low platelet count etc. along with joint pain and swelling. So a treating physician should have adequate knowledge regarding all these conditions when confronted with arthritis as a manifestation. Otherwise if we will only concentrate on treating arthritis in a SLE patient , the patient may be losing protein in urine which will go unnoticed and finally patient will land in kidney failure. So identifying exactly the pattern of joints involved and correlating this with symptoms other than joint pain if present are very crucial in diagnosing arthritis rather than depending heavily on blood tests which may misguide us.

Should we do Arthritis panel (panel of blood tests to diagnose arthritis) ?

Usually many labs offer a bunch of tests combined together labeling as “Arhritis Panel” and offer it at a discount rate. Usually this involves ESR, CRP, Rheumatoid factor, Uric acid, ASO titre. We often tempted to do this because we believe that it will be of help to diagnose the cause of joint pain and if this is negative this will rule out any arthritis. But believe me, if these tests will be ordered without a proper assesment of type and pattern of arthritis, these may cause more confusion than clarity. Neither can the tests diagnose arthritis themselves because many normal people can have these tests positive, and some true patients of arthritis also may have these tests negative. For example, 5% of normal population may be positive for rheumatoid factor whereas 20% of patients who have rheumatoid arthritis may test negative for these tests.

How to treat arthritis ?

Mosts patients having soft tissue rheumatism including muscle pain can do well with physiotherapy and some life style modifications like weight reduction, foot wear modification and change of some routine activities. Patients with osteoarthritis usually do well with weight reduction , thigh muscle exercise, wearing shoes with soft soles and avoiding squatting and climbing the stairs . Only those patients having a definitive type of arthritis like rheumatoid arthritis (Ankylosing spondylitis, gout etc) required prolonged treatment with medicines. Usually two type of drugs are prescribed to decrease inflammation of the joint on short term basis which include pain killers(non steroidial anti inflammatory drugs), and low dose steroid. Prolonged and irrational use of these drugs in an non inflammatory condition can have grave complications like kidney failure, gastritis, gastric ulcer etc. Inflammatory arthritis like rheumatoid arthritis and ankylosing spondylitis required drug another group of drugs known as DMARDS (Disease modifying anti rheumatic drugs) which include Methotrexate, hydroxychloroquine, sulfasalazine, leflunamide etc. these drugs help in modifying the immune system there by decreasing the immune attack in the joints. These are excellent drugs which controls inflammatory arthritis, but each of these drugs has to be monitored for their potential side effects. They are like double are like double-edged sword and if not used by an expert without monitoring it can cause devastating complications like bone marrow suppression. So treatment of arthritis should be done by an experienced specialist, preferably a rheumatologist trained at diagnosing different kind of arthritis, administering proper treatment at proper time, monitor the drug side effects and handling any untoward complications either from the disease or from the drugs. Rheumatology or clinical immunology is a specialised branch of modern medicine where doctors are trained specifically for diagnosis and treatment of arthritis along with other autoimmune diseases.

Do alternative therapies help?

Although many alternative therapies have an ancient origin, the diagnostic approach could not evolve over time. Most of them usually put all types of musculoskeletal pain in a single basket as rheumatism which is not correct. As discussed above different types of pain have different causes and they have to be addressed separately. Although there are some reports that these medicines help there is lack of large scale authentic trials to prove there benefits. Moreover now days many unauthorized, untrained people are practicing alternative therapy without any basic minimum knowledge regarding the cause of arthritis. Over the counter adulterated medicine (mainly with steroids) further complicates the picture.

Does surgery help?

Most of the patients with inflammatory arthritis usually do not require any surgery.Only those patients with long term deformities which cause significant functional difficulties will benefit from corrective surgeries. Osteoarthritis patients with an advanced stage where pain is significantly interfering with quality of life are advised to undergo joint replacement surgeries.

There are many myths doing around regarding Arthritis.Its very important to fact check with a professional and get help instead of believing someone who has either no knowledge or half knoledge on the subjectMyth 1: Arthritis is seen in old people and is a part of aging Fact: There are many type of arthritis. While the degenerative arthritis are more common after 50 years of of age, the inflammatory arthritis like rheumatoid arthritis and ankylosing spondylitis etc. can affect at any age (mostly they start at young –middle age). Even children can get arthritis, which is known as juvenile idiopathic arthritis or JIA.Myth 2: All joint pain are arthritis Fact: Arthritis in true sense means pain and inflammation of joint (which is the meeting point of 2 bones). But there are more structures around the joints like tendon, ligaments, bursa or soft tissue etc which can be inflamed or undergo overuse degenerative changes to cause pain. In fact, they are most common causes of pain than arthritis. Evaluation by trained rheumatologists will help you to find out the exact cause of pain and treat accordingly.Myth 3 : All type of arthritis are same and their treatment is done in same manner ? Fact: There are more than 100 types of arthritis and they have to diagnose properly as their cause, treatment and outcome are different. Arthritis is broadly divided into inflammatory arthritis and degenerative arthritis. Most common type of arthritis that usually occurs in old age is a type of degenerative arthritis known as osteoarthritis. This occurs due to degeneration of cartilage (sponge like material between the bones to avoid rubbing of bone against each other). Inflammatory arthritis usually occurs due to attack of our immune system on our joints. This can happen at any age and different types of arthritis affects different joints. This group includes rheumatoid arthritis, Spondyloarthritis or Ankylosing spondylitis, Psoriatic arthritis etc. Other type of arthritis include crystal induced arthritis (induced by uric acid crystals), infective arthritis (caused by direct attack of bacteria,fungi,tuberculosis etc.) and malignancy or cancer associated arthritis. There are many systemic autoimmune diseases like SLE, Sjogren syndrome (dry eye and dry mouth) etc. where arthritis is only one of the several manifestations of the disease. All of them treated differently. Myth 4: We should do arthritis panel (Panel of blood tests to diagnose arthritis) to diagnose arthritis before going to doctor ? Fact: No, arthritis cannot be diagnosed only by doing arthritis panel tests. Usually many labs offer a bunch of tests combined together labeling as “Arhritis Panel” and offer it at a discount price. Usually this involves ESR, CRP, Rheumatoid factor, Uric acid, ASO titre etc. We often tempted to do this because we believe that it will be of help to diagnose the cause of joint pain and if this is negative this will rule out any arthritis. But believe me, if these tests will be ordered without a proper assessment of type and pattern of arthritis, these may cause more confusion than clarity. Neither can the tests diagnose arthritis themselves because many normal people can have these tests positive, and some true patients of arthritis also may have these tests negative. For example, 5% of normal population may be positive for rheumatoid factor whereas 20% of patients who have rheumatoid arthritis may test negative for these tests.Myth 5: Arthritis once started can’t be treated. Fact: Arthritis is a chronic illness like diabetes or high blood pressure etc. So although many of them cannot be cured, but if treated effectively by a rheumatologist, most patients can lead a normal pain free life. Now, there are very effective medicines available, which are able to halt the disease progression and deformity if started early in the course of arthritis (that’s why early diagnosis is so important). In addition, lifestyle modifications like losing weight, eating balanced diet without junk foods, a healthy sleep routine etc can help tremendously. Myth 6: “Orthopedics” is the only branch in medical science, who should treat arthritis patients? Fact: In contrast to the popular belief that orthopedics is branch to deal with arthritis, the branch of medicine dedicated for arthritis treatment is known as “Rheumatology” and the specialist doctors are known as “Rheumatologist”. Rheumatologist are trained at diagnosing different kind of arthritis, administering proper treatment at proper time, monitor the drug side effects and handling any untoward complications either from the disease or from the drugs. Only in last stage, if surgery is required, it is done by an OrthopedicianMyth 7: In the initial stages, you should try to manage with over the counter “painkillers” or “home remedies”. You have to only consults specialists if you develop severe arthritis or deformity Fact: No, Early diagnosis and treatment is very important for halting the progression of most inflammatory arthritis. When the symptoms start, the initial days or months are known as “window of opportunity” as there is an opportunity for reversing the disease process and avoid progression to deformity if adequate and proper treatment is instituted at this stage. If you miss this period and develop deformities, it become irreversible. So don’t delay and consult a rheumatologist as soon as you have joint pain. Myth 8: If you have arthritis, you have to under a strict dietary control and avoid many foods Fact: As per scientific evidences, there is not much relation between diet and arthritis except few arthritis like Gout where you have to restrict alcohol and red meat. Most arthritis like rheumatoid arthritis, ankylosing spondylitis etc does not need any change in diet and you can take normal diet like an normal individual. It is always important to take healthy balanced diet and do regular exercise. Avoid smoking and as they may aggravate arthritis. Myth 9: Alternative medications like Homeopathy and Ayurveda can cure arthritis and they are free from any side effect. Fact: Although many alternative therapies have an ancient origin, there are several issues with them. The diagnostic approach for identifying different types of arthritis could not evolve over time. Most of them usually put all types of musculoskeletal pain in a single basket as rheumatism which is not correct. Different types of pain have different causes and they have to be addressed separately. Although there are some reports that these medicines help, there is lack of large scale authentic trials to prove their benefits. Moreover now days many unauthorized, untrained people are practicing alternative therapy without any basic minimum knowledge regarding the cause of arthritis. Over the counter adulterated medicine (mainly with steroids) further complicates the picture and may give rise to a lot of side effects. Myth 10: Allopathic treatment for arthritis mostly includes steroids and painkillers and you will have a lot of side effects if you will take allopathic treatment for long time. Fact: Allopathy advocate the use of the drugs which has undergone rigorous randomized clinical trial including thousands of patients, demonstrating their efficacy and lack of significant side effects. But you have to consult a rheumatologist who is trained and experienced enough to use these medications. Inflammatory arthritis like rheumatoid arthritis and ankylosing spondylitis are treated with a group of drugs known as DMARDS (Disease modifying anti rheumatic drugs) which include Methotrexate, hydroxychloroquine, sulfasalazine, leflunamide etc. These drugs help in modifying the immune system there by decreasing the immune attack in the joints. These are excellent drugs, which controls inflammatory arthritis, but each of these drugs has to be monitored for their potential side effects. Recently, Biological drugs are available which are very effective drugs but has to be taken only if recommended by your rheumatologist.

What is Arthritis Arthritis is inflammation of the joints (the points where bones meet) in one or more areas of the body. There are more than 100 different types of arthritis, all of which have different causes and treatment methods. The symptoms of arthritis usually appear gradually but they may also occur suddenly. . Continue reading →

Most teachers have had no first-hand experience contending with the medical problems of the children they have in their classrooms. Teachers need your help to educate them about juvenile rheumatic diseases and how it affects your child. And you need their help to ensure your child has a successful school year. Continue reading →