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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 splinte ...
, 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 ther ...
, 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 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 inv ...
,
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 ...
,
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. 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 ...


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 inv ...
* Spondyloarthropathies **
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) ** Psoriatic arthropathy ** Enteropathic arthropathy * Juvenile Idiopathic Arthritis (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 * Septic arthritis


Systemic conditions and connective tissue diseases

* Lupus * Ehlers-Danlos syndrome * Sjögren's syndrome * Scleroderma (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 hips, but which may occur all over the body. The pain can be sudden or can occur gradually over a period. Most people wi ...
*
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 o ...
*
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, hear ...
*
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 diag ...
*
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 af ...
* Fibromyalgia *
Myofascial pain syndrome Myofascial pain syndrome (MPS), also known as chronic myofascial pain (CMP), is a syndrome characterized by chronic pain in multiple myofascial trigger points ("knots") and fascial (connective tissue) constrictions. It can appear in any body part. ...
* Vasculitis ** Microscopic polyangiitis ** Eosinophilic granulomatosis with polyangiitis **
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' c ...
**
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 b ...
** Serum sickness ** Giant cell arteritis, Temporal arteritis ** Takayasu's arteritis ** Behçet's disease ** Kawasaki disease (mucocutaneous lymph node syndrome) ** Thromboangiitis obliterans * 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 fractures, muscles, nerve entrapment, vascular lesions, and ganglia. For example: * Low back pain * Tennis elbow * Golfer's elbow * Olecranon bursitis


Diagnosis


Physical examination

Following are examples of methods of diagnosis able to be performed in a normal physical examination. *
Schober's test Schober's test is a physical examination used in family medicine, physical medicine and rehabilitation, rheumatology to measure the ability of a patient to flex the lower back. Procedure While the patient is in a standing position the examiner mak ...
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: physi ...
tests Test(s), testing, or TEST may refer to: * Test (assessment), an educational assessment intended to measure the respondents' knowledge or other abilities Arts and entertainment * ''Test'' (2013 film), an American film * ''Test'' (2014 film), ...
(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 and chemical pathology of fluid aspirated from affected joints (e.g. to differentiate between septic arthritis 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, NSAIDs (nonsteroidal anti-inflammatory drug), steroids (in serious cases), DMARDs (disease-modifying antirheumatic drugs), monoclonal antibodies, such as infliximab and adalimumab, 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 arthrit ...
etanercept, 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 inv ...
. The biologic agent rituximab (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 (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.


Rheumasurgery

''Rheumasurgery'' - sometimes called rheumatoid surgery - is a subfield of orthopedics occupied with the surgical treatment of patients with
rheumatic diseases Rheumatism or rheumatic disorders are conditions causing chronic, often intermittent pain affecting the joints or connective tissue. Rheumatism does not designate any specific disorder, but covers at least 200 different conditions, including ar ...
. 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 Synovial fluid, also called synovia, elp 1/sup> is a viscous, non-Newtonian fluid found in the cavities of synovial joints. With its egg white–like consistency, the principal role of synovial fluid is to reduce friction between the articular ...
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.


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 Osteoimmunology (όστέον, ''osteon'' from Greek, “bone”; ''immunitas'' from Latin, “immunity”; and λόγος, ''logos'', from Greek “study”) is a field that emerged about 40 years ago that studies the interface between the skeletal ...
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. 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 Quebec

American College of Rheumatology

European League Against Rheumatism

Consortium of Rheumatology Researchers of North America, Inc.

British Society for Rheumatology

Canadian Rheumatology Association

Association of Rheumatology Health Professionals

German Society for Rheumatology
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