What is Rheumatology?

According to the American College of Rheumatology, rheumatology is a specialty under the umbrella of internal medicine. This specialty focuses on researching and treating diseases related to the joints and muscles of the body. These are called “rheumatic diseases” and include rheumatism and at least 100+ other related disorders with symptoms ranging from mild to severe. These represent some of the most common diseases being researched and treated within the greater field of rheumatology:

• Rheumatism

A catch-all term that is most commonly used to refer to rheumatoid arthritis is a disease of the autoimmune system.

Rheumatoid arthritis, which is commonly called RA for short, attacks the lining of the joints, causing system-wide pain, stiffness, and swelling. Most commonly, both sides of the body are affected simultaneously.

• Scleroderma

Scleroderma is a term that translates to mean “hard skin” in a common language. The term is derived from the body’s overproduction of collagen. In normal amounts, collagen is the protein that keeps skin soft and young-looking. But with too much collagen, skin becomes rigid and hard, along with the surrounding blood vessels, joints, and tissues.

• Gout

Once thought to be an “old rich man’s” disease, gout has made a comeback today. Gout arises when the body cannot metabolize uric acid properly, and it crystallizes, most commonly in the lower extremities (ankles, feet, toes). This causes pain and swelling.

• Fibromyalgia

Fibromyalgia is a disease that impacts the tendons and muscles whose job it is to help joints function. Fibromyalgia can cause generalized pain and stiffness and disrupt sleep.

• Ankylosing spondylitis

Ankylosing spondylitis is a type of rheumatism that directly impacts the spinal column. Considered a chronic condition, the inflammation in the spinal column can impact the whole body, particularly the major joints (shoulders, hips, knees), resulting in spinal curvature and/or fusing of vertebrae.

• Osteoarthritis

Osteoarthritis is often called simply “arthritis” because it is so common. It can happen anywhere there is a joint in the body but is most common in the knees. When the cartilaginous covering at the joint bones wears away, this causes the stiffness, pain, and inflammation that characterizes osteoarthritis. There are more than 100 other diseases under the umbrella of rheumatism, and many share symptoms, which can mean that obtaining the most precise diagnosis can take some time.

To obtain a diagnosis, it is necessary to be seen by a rheumatologist. A rheumatologist is a physician trained to treat rheumatic diseases. Many practicing rheumatologists also perform research to better understand the complexities of the diseases in their field. Some may also choose to further specialize in one or a handful of related diseases under the rheumatology umbrella.

Rheumatism History

The word “arthritis” itself translates to mean “inflammation of the joint,” according to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMSD). Arthritis has existed for far longer than the words rheumatology and rheumatologist, both of which were coined just over a half-century ago.

It is thought that the word “rheumatism” emerged around 1595 and came from Greek and Latin root terms that refer to inflammation and discharge. However, it also likely arose from a prior term, “rheumatismus,” which was first used around 216 AD.

Many historical references to joint disease and joint stiffness have been found throughout the centuries. Some of these references date back as far as 1500 BC! Archeological research also points to arthritic conditions as being common in ancient Egyptian culture, as evidenced by studying mummified human remains. Early Indian medical writings also refer to a joint condition with symptoms that closely match what is called rheumatism today. In 400 BC, the scholar and medic Hippocrates referred to a condition he called “arthritis” in his writings. In the 1800s, medical science distinguished rheumatoid arthritis from other similar conditions (gout, osteoarthritis). In 1932, the American College of Rheumatology (which was first named the International Committee on Rheumatism and then the American Rheumatism Association) was established.

Initial medical treatments involved the use of leeches and traditional bloodletting. Then, cupping, acupuncture, acupressure, and, in time, the use of precious metals like gold were introduced. Gold continues to be used as a part of the treatment regimen that is today called DMARDS, or Disease-Modifying Anti-rheumatic Drugs.

To relieve discomfort and pain, what was initially used (willow bark plant extracts) and what is used today (aspirin in the form of synthesized salicylic acid) is still largely the same.

DMARD-based anti-inflammatories still rely on a form of quinine, the sulfa drug sulphasalazine, and cortisone. In addition, the cancer medication methotrexate is also still used regularly.

Risk Factors

Today much more is known about risk factors that can predispose one person to develop rheumatism over others. However, these risk factors can vary from disease to disease under the rheumatism umbrella. For example, some diseases are much more common in men (gout is an example), while others occur predominantly in women (such as fibromyalgia). For rheumatoid arthritis, which is the most closely linked to rheumatism, gender studies show that women bear a greater risk of developing RA than men.

Other risk factors include (but are not limited to) these:

• Age

The period between the age of 40 and 60 appears to be a time when more people will develop symptoms or signs of rheumatism.

• Family medical history

If other individuals in the family have been diagnosed with rheumatism, it is more likely to see future cases as well. This points to a genetic link that is (as of yet) only partially understood.

• Tobacco use

Tobacco use and smoking have been clearly linked to rheumatism. The more tobacco is used, the more severe the person’s rheumatism symptoms are likely to be. The tobacco user is also genetically predisposed to develop rheumatism in the most severe cases through family history.

• Overweight

If a person becomes overweight or obese, there is a stronger possibility of developing rheumatism at some future point. In addition, the risk becomes greater for women who are diagnosed with rheumatism before the age of 60.

• Toxic exposure

Researchers are still trying to determine why people exposed to toxins such as asbestos and silica seem to develop rheumatism more frequently than a similar demographic that has not been so exposed.

This newer understanding arose in part following the events of 9/11 when emergency workers who arrived to help with the search, rescue, and cleanup effort later developed rheumatoid arthritis and other similar diseases related to joint and autoimmune function. The Centers for Disease Control (CDC) also found that exposure to toxins early in life can increase the risk of developing rheumatism later on in life.

• Low testosterone

Swedish researchers have more recently discovered a link between men who have low testosterone and a higher risk of developing rheumatism.

• Hormonal issues in women

In some cases, the presence of ongoing hormonal disruption can predispose a woman to a greater risk of developing rheumatism later on. Examples include PCOS (polycystic ovarian syndrome), early onset menopause, never having children, or never having breastfed. Conversely, using birth control pills appears to lower the risk of rheumatism later on.

Screening

It is currently possible to perform genetic testing to screen for higher risk of rheumatism. In addition, performing rheumatism screening can aid physicians in determining the best medications and treatment methods to pursue to alleviate symptoms or modify the severity of disease progression.

Evidence also shows that early detection and intervention (in the form of treatment within the first 6 months of symptoms) can reduce the severity of symptoms for the duration of the individual’s life. This also makes genetic screening desirable, especially for those with a more significant number of risk factors or a family history of rheumatism.

To date, researchers have studied several genes looking for possible genetic markers for rheumatism. One particular gene that has garnered a great deal of research interest is HLA-DRB1. This gene is part of a group of genes known as HLA genes or human leukocyte antigen genes. These genes have been implicated in developing autoimmune-type diseases such as certain types of rheumatism. This is because they make proteins that are important for a proper immune system function.

However, researchers have not yet identified exactly how HLA gene mutations may pass from one generation to the next.

What is known is that the closer an affected relative is to the person being tested (say, an aunt versus a third cousin), the more likely it is that the person may develop rheumatism in the future. This also means that, at this point in researchers’ progress to identify genes to look for during rheumatism screening, genetic testing is most likely to be productive when there is already a known family history of rheumatism.

Symptoms

As mentioned here, one of the challenges with rheumatism in obtaining a precise diagnosis is the overlap often seen between symptoms of rheumatism and symptoms of other diseases (for example, pain and tenderness in joints can also be warning signs of flu or even the common cold).

However, symptoms can serve as potentially the first warning signs of an unfolding case of rheumatism and are invaluable for this reason (early detection and treatment reduce later disease severity).

Some of the most commonly reported rheumatism patient symptoms include these:

• Pain (localized to certain joints or more generalized).
• Stiffness in the joints.
• Fatigue and weakness.
• Joint warmth, tenderness, redness, swelling, and discomfort.
• Range of motion restriction in joints.
• Deformity of joints.
• Loss of function in joints.
• Symmetry in symptoms (i.e., both sides of the body are affected equally).
• Difficulty moving or walking.
• Fever.
• Blood issues (i.e., anemia, low white blood cell, or platelet count).
• Seizures or strokes.
• Back or chest pain.
• Issues with non-joint affected areas (i.e., skin, nerves, tissues, organs, circulator system).

Rheumatism covers a broad spectrum of health issues, so it is unnecessary to have all or even a majority of these symptoms diagnosed with rheumatism. For example, symptoms symmetry typically only appears with rheumatoid arthritis specifically.

Here, it can be helpful to focus on the primary symptoms that tend to cross any other boundaries between individual issues under the rheumatology umbrella.

These primary symptoms include:

• Joint pain and tenderness.
• Joint stiffness.
• Joint inflammation (warmth, redness, swelling).
• Joint mobility issues.
• Greater difficulty with these issues first thing in the morning.

In other words, if one of the primary words used to describe major health symptoms includes “joint,” this may be an early marker indicating a need to look more closely at rheumatism as a possible culprit.

A visit to a rheumatologist can then provide additional information and diagnostic testing to determine a more precise diagnosis.

Diagnosis and Stages

Unfortunately, while rheumatism research, knowledge, and treatment have come a very long way from the earliest days of bloodletting and leeches, in its earliest stages, rheumatism is still quite challenging to diagnose precisely.

For this reason, it is of vital importance that patients keep a symptoms log to share with a rheumatologist. Symptoms are the most important early warning signs. An attentive patient who seeks out early medical care can greatly minimize the ultimate severity of an unfolding case of rheumatism. A rheumatologist will want a detailed symptoms list to work from. In addition, obtaining an accurate family history can be critical to determine the genetic risk factor for any given individual.

Because there is some evidence that rheumatism can arise due to toxic exposure, it is also important to review post possible exposure – recent or long-term – and report this during the rheumatology appointment. The actual diagnostic process begins in earnest once rheumatism is suspected (through review of symptoms, medical history, family history, prior toxic exposure, risk factors, etc.).

At this point, the first step is for the rheumatologist to do a physical exam, paying close attention to affected areas. For rheumatism, in particular, the rheumatologist will be looking for the number of affected joint areas, symptoms symmetry (across both sides of the body), and also other markers such as swollen glands or back pain. Several diagnostic tests may prove helpful if the exam yields further evidence that rheumatism may be developing.

These tests represent some of the most commonly performed tests when diagnosing rheumatism:

• Blood antibody tests: These tests look for certain antibodies that indicate rheumatism is present. The antibodies include anti-CCP (anti-cyclic citrullinated peptide) and rheumatoid factor.
• Blood inflammation tests: These tests look for evidence of inflammation by measuring a protein called C-reactive and ESR (erythrocyte sedimentation rate).
• CBC (complete blood count): This test measures blood composition and looks for anemia or other rheumatism-implicated blood issues.
• Imaging tests: X-rays, MRI (magnetic resonance imaging), and ultrasound can also be helpful to look inside your body and assess the condition of your joints. Imaging can be particularly pertinent when trying to diagnose rheumatism early.
• Other specialized tests: There are times when symptoms seem so similar to another disorder or disease that the physician may order tests to rule out other possibilities. While this type of specialized testing can take more time, it is often critical to obtain the most precise and accurate diagnosis upon which to base treatment.

Treatments

To date, treating rheumatism focuses on symptom management rather than an acute one. Currently, there is no known cure for rheumatism. The best substitute is to catch rheumatism very early and begin treatment to minimize symptoms severity. In some instances, with early and aggressive treatment, some patients can achieve remission (cessation of symptoms). However, treating rheumatism is a very individual process.

The treatment prescribed for any individual will be based on the specific symptoms, their severity, how long the person has had rheumatism, their age and general state of health, the presence of any co-occurring conditions, and the specific type of rheumatism. Typically rheumatism treatment takes a combination approach, using medications, lifestyle and/or dietary modifications, or even surgery in specific cases. The patient may pursue alternative medicine to control rheumatism symptoms in some cases.

Here are the elements most commonly found in the treatment of rheumatism:

• Medication

Medication itself is often prescribed in categories. For instance, non-steroidal anti-inflammatory drugs, or NSAIDs, can ease pain from symptoms. Corticosteroids can reduce inflammation and relieve pressure on the joints. And DMARDs (Disease-Modifying Anti-rheumatic Drugs) are typically prescribed to prevent permanent joint damage and keep rheumatism from becoming severe.

• Therapy and lifestyle and/or diet modification

Physical therapy can be useful in teaching patients modified approaches for common daily tasks (examples might be opening jars or using assistive tools to put on shoes). If there is an issue with tobacco use or weight management, the patient may be referred for dietary consultation or a smoking cessation program.

• Surgical intervention

While surgery is never a first-choice treatment method, having surgery can make a major impact on a patient’s quality of life in some situations.

One of the most common surgeries is joint replacement. Knee or hip replacement, in particular, can assist with limited or no mobility due to rheumatism. For patients who are not eligible for joint replacement, joint fusion may be an option. Other surgical interventions can include removing compromised joint lining or repairing inflamed tendons and ligaments.

• Supplementation via alternative medicine

There is some scientific evidence that certain herbs, plants, and supplements may provide additional support as part of a comprehensive rheumatism treatment plan.

In particular, adding omega-3 fatty acids via fish oil or plant oils can help reduce pain or stiffness, especially in the first part of the day when symptoms tend to be worse.

• Self-care or at-home care

In addition to a course of medication, therapy, and other treatments as needed, there is much that patients can do to alleviate their symptoms at home.

Using hot-cold therapy, learning gentle and appropriate stretches, deep breathing, applying magnets, pain management via biofeedback or acupuncture, meditation, visualization, and learning stress management methods can help alleviate discomfort from rheumatism.

Specialties

Rheumatism itself is considered a specialty within the broader field of internal medicine. But within the specialty of rheumatism are additional sub-specialties:

• Pediatric rheumatology: Some rheumatologists, for instance, focus on diagnosing and treating rheumatic diseases in children.
• Geriatric rheumatology: The rheumatologist focuses on treating rheumatic diseases in older adults in this sub-specialty.
• Rheumatology research: Some rheumatologists choose to focus their careers on researching the origins and genetic basis for rheumatic diseases.
• Rheumatology education: Other rheumatologists become professors to teach the next generation of rheumatologists how to diagnose and treat rheumatism more effectively.
• Autoimmune-specific rheumatology: A rheumatologist can also choose to focus on a specific disease within the greater field of rheumatology, such as rheumatism that arises as a direct result of an underlying autoimmune issue such as lupus.
• Public health or policy advocate: Another sub-specialty option within rheumatology is to serve as a public health or policy advocate to educate the greater community about rheumatism and/or lobby for more research funding and better physician education about rheumatism.
• Surgical rheumatology: A rheumatic surgeon specializes in performing surgery to alleviate symptoms of rheumatism.