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.
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.
Doctors who have undergone formal training in rheumatology are called rheumatologists.
Many of these diseases are now known to be disorders of the
immune system
The immune system is a network of biological processes that protects an organism from diseases. It detects and responds to a wide variety of pathogens, from viruses to parasitic worms, as well as cancer cells and objects such as wood splint ...
, and rheumatology has significant overlap with
immunology
Immunology is a branch of medicineImmunology for Medical Students, Roderick Nairn, Matthew Helbert, Mosby, 2007 and biology that covers the medical study of immune systems in humans, animals, plants and sapient species. In such we can see the ...
, the branch of medicine that studies the immune system.
Rheumatologist
A rheumatologist is a
physician
A physician (American English), medical practitioner (Commonwealth English), medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through th ...
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.
Rheumatologists treat
arthritis,
autoimmune
In immunology, autoimmunity is the system of immune responses of an organism against its own healthy cells, tissues and other normal body constituents. Any disease resulting from this type of immune response is termed an "autoimmune disease". ...
diseases, pain disorders affecting joints, and
osteoporosis. There are more than 200 types of these diseases, including
rheumatoid 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 invol ...
,
osteoarthritis
Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone which affects 1 in 7 adults in the United States. It is believed to be the fourth leading cause of disability in the w ...
,
gout
Gout ( ) is a form of inflammatory arthritis characterized by recurrent attacks of a red, tender, hot and swollen joint, caused by deposition of monosodium urate monohydrate crystals. Pain typically comes on rapidly, reaching maximal intens ...
,
lupus, back pain, osteoporosis, and
tendinitis
Tendinopathy, a type of tendon disorder that results in pain, swelling, and impaired function. The pain is typically worse with movement. It most commonly occurs around the shoulder (rotator cuff tendinitis, biceps tendinitis), elbow (tennis elbo ...
. 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
*
Osteoarthritis
Osteoarthritis (OA) is a type of degenerative joint disease that results from breakdown of joint cartilage and underlying bone which affects 1 in 7 adults in the United States. It is believed to be the fourth leading cause of disability in the w ...
Inflammatory arthropathies
*
Rheumatoid 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 invol ...
*
Spondyloarthropathies
Spondyloarthropathy or spondyloarthrosis refers to any joint disease of the vertebral column. As such, it is a class or category of diseases rather than a single, specific entity. It differs from spondylopathy, which is a disease of the vertebra ...
**
Ankylosing spondylitis
Ankylosing spondylitis (AS) is a type of arthritis characterized by long-term inflammation of the joints of the spine typically where the spine joins the pelvis. Occasionally areas affected may include other joints such as the shoulders or hi ...
**
Reactive arthritis
Reactive arthritis, also known as Reiter's syndrome, is a form of inflammatory arthritis that develops in response to an infection in another part of the body (cross-reactivity). Coming into contact with bacteria and developing an infection can t ...
(
reactive arthropathy
Reactive arthritis, also known as Reiter's syndrome, is a form of Inflammation, inflammatory arthritis that develops in response to an infection in another part of the body (cross-reactivity). Coming into contact with bacteria and developing an in ...
)
**
Psoriatic arthropathy
Psoriatic arthritis is a long-term inflammatory arthritis that occurs in people affected by the autoimmune disease psoriasis. The classic feature of psoriatic arthritis is swelling of entire fingers and toes with a sausage-like appearance. Thi ...
**
Enteropathic arthropathy
Enteropathic arthropathy or enteropathic arthritis refers to acute or subacute arthritis in association with, or as a reaction to, an enteric (usually colonic) inflammatory condition.
Causes and associations
* Reactive arthritis (Reactive to ent ...
*
Juvenile Idiopathic Arthritis
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'' r ...
(JIA)
* Crystal arthropathies:
gout
Gout ( ) is a form of inflammatory arthritis characterized by recurrent attacks of a red, tender, hot and swollen joint, caused by deposition of monosodium urate monohydrate crystals. Pain typically comes on rapidly, reaching maximal intens ...
,
pseudogout
Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease, also known as pseudogout and pyrophosphate arthropathy, is a rheumatologic disease which is thought to be secondary to abnormal accumulation of calcium pyrophosphate dihydrate crys ...
*
Septic arthritis
Acute septic arthritis, infectious arthritis, suppurative arthritis, osteomyelitis, or joint infection is the invasion of a joint by an infectious agent resulting in joint inflammation. Generally speaking, symptoms typically include redness, h ...
Systemic conditions and connective tissue diseases
![Laserbehandling](https://upload.wikimedia.org/wikipedia/commons/b/b1/Laserbehandling.jpg)
*
Lupus
*
Ehlers-Danlos syndrome
*
Sjögren's syndrome
*
Scleroderma
Scleroderma is a group of autoimmune diseases that may result in changes to the skin, blood vessels, muscles, and internal organs. The disease can be either localized to the skin or involve other organs, as well. Symptoms may include areas ...
(systemic sclerosis)
*
Polymyositis
Polymyositis (PM) is a type of chronic inflammation of the muscles (inflammatory myopathy) related to dermatomyositis and inclusion body myositis. Its name means "inflammation of many muscles" ('' poly-'' + '' myos-'' + '' -itis''). The inflam ...
*
Dermatomyositis
Dermatomyositis (DM) is a long-term inflammatory disorder which affects skin and the muscles. Its symptoms are generally a skin rash and worsening muscle weakness over time. These may occur suddenly or develop over months. Other symptoms may inc ...
*
Polymyalgia rheumatica
Polymyalgia rheumatica (PMR) is a syndrome experienced as pain or stiffness, usually in the neck, shoulders, upper arms, and Hip (anatomy), hips, but which may occur all over the body. The pain can be sudden or can occur gradually over a period. ...
*
Mixed connective tissue disease
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 ...
*
Relapsing polychondritis
Relapsing polychondritis is a multi-systemic condition characterized by repeated episodes of inflammation and deterioration of cartilage. The often painful disease can cause joint deformity and be life-threatening if the respiratory tract, heart ...
*
Adult-onset Still's disease
Adult-onset Still's disease (AOSD) is a form of Still's disease, a rare systemic autoinflammatory disease characterized by the classic triad of fevers, joint pain, and a distinctive salmon-colored bumpy rash. The disease is considered a diagno ...
*
Sarcoidosis
Sarcoidosis (also known as ''Besnier-Boeck-Schaumann disease'') is a disease involving abnormal collections of inflammatory cells that form lumps known as granulomata. The disease usually begins in the lungs, skin, or lymph nodes. Less commonly a ...
*
Fibromyalgia
*
Myofascial pain syndrome
*
Vasculitis
Vasculitis is a group of disorders that destroy blood vessels by inflammation. Both arteries and veins are affected. Lymphangitis (inflammation of lymphatic vessels) is sometimes considered a type of vasculitis. Vasculitis is primarily caused ...
**
Microscopic polyangiitis
Microscopic polyangiitis is an ill-defined autoimmune disease characterized by a systemic, pauci-immune, necrotizing, small-vessel vasculitis without clinical or pathological evidence of necrotizing granulomatous inflammation.
Signs and symptoms
C ...
**
Eosinophilic granulomatosis with polyangiitis
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 ...
**
Granulomatosis with polyangiitis
Granulomatosis with polyangiitis (GPA), previously known as Wegener's granulomatosis (WG), is a rare long-term systemic disorder that involves the formation of granulomas and inflammation of blood vessels (vasculitis). It is a form of vasculitis ...
**
Polyarteritis nodosa
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' ...
**
Henoch–Schönlein purpura
Henoch–Schönlein purpura (HSP), also known as IgA vasculitis, is a disease of the skin, mucous membranes, and sometimes other organs that most commonly affects children. In the skin, the disease causes palpable purpura (small, raised areas of ...
**
Serum sickness
Serum sickness in humans is a reaction to proteins in antiserum derived from a non-human animal source, occurring 5–10 days after exposure. Symptoms often include a rash, joint pain, fever, and lymphadenopathy. It is a type of hypersensitivity ...
**
Giant cell arteritis
Giant cell arteritis (GCA), also called temporal arteritis, is an inflammatory autoimmune disease of large blood vessels. Symptoms may include headache, pain over the temples, flu-like symptoms, double vision, and difficulty opening the mouth. ...
,
Temporal arteritis
Temporal may refer to:
Entertainment
* Temporal (band), an Australian metal band
* ''Temporal'' (Radio Tarifa album), 1997
* ''Temporal'' (Love Spirals Downwards album), 2000
* ''Temporal'' (Isis album), 2012
* ''Temporal'' (video game), a 200 ...
**
Takayasu's arteritis
Takayasu's arteritis (TA), also known as aortic arch syndrome, nonspecific aortoarteritis, and pulseless disease, is a form of large vessel granulomatous vasculitisAmerican College of Physicians (ACP). Medical Knowledge Self-Assessment Program (MK ...
**
Behçet's disease
Behçet's disease (BD) is a type of inflammatory disorder which affects multiple parts of the body. The most common symptoms include painful sores on the mucous membranes of the mouth and other parts of the body, inflammation of parts of the ey ...
**
Kawasaki disease
Kawasaki disease is a syndrome of unknown cause that results in a fever and mainly affects children under 5 years of age. It is a form of vasculitis, where blood vessels become inflamed throughout the body. The fever typically lasts for more th ...
(mucocutaneous lymph node syndrome)
**
Thromboangiitis obliterans
Thromboangiitis obliterans, also known as Buerger disease (English ; ) or Winiwarter-Buerger disease, is a recurring progressive inflammation and thrombosis (clotting) of small and medium arteries and veins of the hands and feet. It is strongly a ...
*
Hereditary periodic fever syndromes
Soft tissue rheumatism
Local diseases and
lesion
A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals.
Types
There is no designated classif ...
s affecting the joints and structures around the joints including tendons,
ligaments capsules,
bursae,
stress fracture
A stress fracture is a fatigue-induced bone fracture caused by repeated stress over time. Instead of resulting from a single severe impact, stress fractures are the result of accumulated injury from repeated submaximal loading, such as running or ...
s, muscles,
nerve entrapment
Nerve compression syndrome, or compression neuropathy, or nerve entrapment syndrome, is a medical condition caused by direct pressure on a nerve. It is known colloquially as a ''trapped nerve'', though this may also refer to nerve root compress ...
,
vascular lesions, and
ganglia. For example:
*
Low back pain
Low back pain (LBP) or lumbago is a common disorder involving the muscles, nerves, and bones of the back, in between the lower edge of the ribs and the lower fold of the buttocks. Pain can vary from a dull constant ache to a sudden sharp feel ...
*
Tennis elbow
Tennis elbow, also known as lateral epicondylitis or enthesopathy of the extensor carpi radialis origin, is a condition in which the outer part of the elbow becomes painful and tender. The pain may also extend into the back of the forearm. Onse ...
*
Golfer's elbow
Golfer's elbow, or medial epicondylitis, is tendinosis of the medial epicondyle on the inside of the elbow. It is in some ways similar to tennis elbow, which affects the outside at the lateral epicondyle.
The anterior forearm contains several ...
*
Olecranon bursitis
Olecranon bursitis is a condition characterized by swelling, redness, and pain at the tip of the elbow. If the underlying cause is due to an infection, fever may be present. The condition is relatively common and is one of the most frequent typ ...
Diagnosis
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
*
Laboratory
A laboratory (; ; colloquially lab) is a facility that provides controlled conditions in which scientific or technological research, experiments, and measurement may be performed. Laboratory services are provided in a variety of settings: physic ...
tests (e.g.
Erythrocyte Sedimentation Rate
The erythrocyte sedimentation rate (ESR or sed rate) is the rate at which red blood cells in anticoagulated whole blood descend in a standardized tube over a period of one hour. It is a common hematology test, and is a non-specific measure of ...
,
Rheumatoid Factor, Anti-CCP (
Anti-citrullinated protein antibody),
ANA (Anti-Nuclear Antibody) )
*
X-ray
An X-ray, or, much less commonly, X-radiation, is a penetrating form of high-energy electromagnetic radiation. Most X-rays have a wavelength ranging from 10 picometers to 10 nanometers, corresponding to frequencies in the range 30&nb ...
s,
Ultrasound
Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies ...
s, and other imaging methods of affected joints
*
Cytopathology
Cytopathology (from Greek , ''kytos'', "a hollow"; , ''pathos'', "fate, harm"; and , '' -logia'') is a branch of pathology that studies and diagnoses diseases on the cellular level. The discipline was founded by George Nicolas Papanicolaou in ...
and
chemical pathology
Clinical chemistry (also known as chemical pathology, clinical biochemistry or medical biochemistry) is the area of chemistry that is generally concerned with analysis of bodily fluids for diagnostic and therapeutic purposes. It is an applied ...
of fluid aspirated from affected joints (e.g. to differentiate between
septic arthritis
Acute septic arthritis, infectious arthritis, suppurative arthritis, osteomyelitis, or joint infection is the invasion of a joint by an infectious agent resulting in joint inflammation. Generally speaking, symptoms typically include redness, h ...
and
gout
Gout ( ) is a form of inflammatory arthritis characterized by recurrent attacks of a red, tender, hot and swollen joint, caused by deposition of monosodium urate monohydrate crystals. Pain typically comes on rapidly, reaching maximal intens ...
)
Treatment
Most rheumatic diseases are treated with
analgesics,
NSAID
Non-steroidal anti-inflammatory drugs (NSAID) are members of a therapeutic drug class which reduces pain, decreases inflammation, decreases fever, and prevents blood clots. Side effects depend on the specific drug, its dose and duration of ...
s (nonsteroidal anti-inflammatory drug),
steroids (in serious cases),
DMARD
Disease-modifying antirheumatic drugs (DMARDs) comprise a category of otherwise unrelated disease-modifying drugs defined by their use in rheumatoid arthritis to slow down disease progression. The term is often used in contrast to nonsteroidal ...
s (disease-modifying antirheumatic drugs),
monoclonal antibodies, such as
infliximab
Infliximab, a chimeric monoclonal antibody, sold under the brand name Remicade among others, is a medication used to treat a number of autoimmune diseases. This includes Crohn's disease, ulcerative colitis, rheumatoid arthritis, ankylosing spon ...
and
adalimumab
Adalimumab, sold under the brand name Humira, among others, is a monoclonal antibody used to treat rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease, ulcerative colitis, plaque psoriasis, hidradenitis suppurati ...
, the
TNF inhibitor
A TNF inhibitor is a pharmaceutical drug that suppresses the physiologic response to tumor necrosis factor (TNF), which is part of the inflammatory response. TNF is involved in autoimmune and immune-mediated disorders such as rheumatoid arthritis, ...
etanercept
Etanercept, sold under the brand name Enbrel among others, is a biologic medical product that is used to treat autoimmune diseases by interfering with tumor necrosis factor (TNF), a soluble inflammatory cytokine, by acting as a TNF inhibitor. It ...
, and
methotrexate for moderate to severe
rheumatoid 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 invol ...
. The biologic agent
rituximab
Rituximab, sold under the brand name Rituxan among others, is a monoclonal antibody medication used to treat certain autoimmune diseases and types of cancer. It is used for non-Hodgkin lymphoma, chronic lymphocytic leukemia (in non-geriatric pa ...
(anti-B cell therapy) is now licensed for use in refractory rheumatoid arthritis.
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
A biopharmaceutical, also known as a biological medical product, or biologic, is any pharmaceutical drug product manufactured in, extracted from, or semisynthesized from biological sources. Different from totally synthesized pharmaceuticals, t ...
(which include inhibitors of
TNF-alpha
Tumor necrosis factor (TNF, cachexin, or cachectin; formerly known as tumor necrosis factor alpha or TNF-α) is an adipokine and a cytokine. TNF is a member of the TNF superfamily, which consists of various transmembrane proteins with a homolog ...
, certain
interleukins
Interleukins (ILs) are a group of cytokines (secreted proteins and signal molecules) that are expressed and secreted by white blood cells (leukocytes) as well as some other body cells. The human genome encodes more than 50 interleukins and related ...
, and the
JAK-STAT signaling pathway
The JAK-STAT signaling pathway is a chain of interactions between proteins in a cell, and is involved in processes such as immunity, cell division, cell death, and tumour formation. The pathway communicates information from chemical signals ou ...
) into standards of care is one of the paramount developments in modern rheumatology.
Rheumasurgery
''Rheumasurgery'' - sometimes called rheumatoid surgery - is a subfield of
orthopedics
Orthopedic surgery or orthopedics ( alternatively spelt orthopaedics), is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...
occupied with the surgical treatment of patients with
rheumatic diseases. The purpose of the interventions is to limit disease activity, soothe pain and improve function.
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. 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, such as
arthrodesis
Arthrodesis, also known as artificial ankylosis or syndesis, is the artificial induction of joint ossification between two bones by surgery. This is done to relieve intractable pain in a joint which cannot be managed by pain medication, spli ...
.
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
The Rheumatology Research Foundation funds rheumatology research and training in the United States. The Foundation is a 501(c)(3) charitable organization dedicated to improving the health of people living with rheumatic disease. With an extensiv ...
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
Heinola () is a town and a municipality of inhabitants () located in the eastern part of the Päijänne Tavastia region, Finland, near the borders of the South Savonia region and the Kymenlaakso region. It is the third largest municipality in ...
, Finland, during the 1950s.
In 1970 a Norwegian investigation estimated that at least 50% of patients with rheumatic symptoms needed rheumasurgery as an integrated part of their treatment.
The European Rheumatoid Arthritis Surgical Society (ERASS) was founded in 1979.
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.
References
External links
Association des medecins rhumatologues du QuebecAmerican College of RheumatologyEuropean League Against RheumatismConsortium of Rheumatology Researchers of North America, Inc.British Society for RheumatologyCanadian Rheumatology AssociationAssociation of Rheumatology Health ProfessionalsGerman Society for Rheumatology
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