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.