What is a Rheumatologist?

A rheumatologist is an internist or pediatrician who is qualified by additional training and experience in the diagnosis and treatment of arthritis and other diseases of the joints, muscles and bones. Many rheumatologists conduct research to determine the cause and better treatments for these disabling and sometimes fatal diseases.

What does the word Rheumatology mean?  The term originates from the Greek rheuma, meaning "that which flows as a river " and the suffix -ology, meaning "the study of".  The ancient Greco-Roman doctors believed that arthritis was caused by the flow of the bad humor, phlegm.

What Kind of Training Do Rheumatologists Have?

After four years of medical school and three years of training in either internal medicine or pediatrics, rheumatologists devote an additional two to three years in specialized rheumatology training. Most rheumatologists who plan to treat patients choose to become board certified. Upon completion of their training, they must pass a rigorous exam conducted by the American Board of Internal Medicine to become certified.

What Do Rheumatologists Treat?
Rheumatologists treat arthritis, certain autoimmune diseases, musculoskeletal pain disorders and osteoporosis. There are more than 100 types of these diseases, including rheumatoid arthritis, osteoarthritis, gout, lupus, back pain, osteoporosis, fibromyalgia and tendonitis. Some of these are very serious diseases that can be difficult to diagnose and treat.

Nearly 21 million Americans are living with osteoarthritis today and many are experiencing some limitation in motion as a result. The condition itself can vary dramatically between patients. The good news is osteoarthritis typically is not a crippling form of arthritis and most individuals find a regular regimen of activity, medication and weight control beneficial. However, since damage caused by osteoarthritis is not reversible, the time to seek help is now.

Fast Facts

• Osteoarthritis is caused by cartilage breakdown in one or more joints in the fingers, hips, knees, feet, and the spine in the neck and lower back.

• Being overweight, age, injury and/or stress to the joints, and family history can predispose you to osteoarthritis.

• Your rheumatologist can make medical and physical treatment recommendations that will increase your comfort level.

The circles on this figure indicate joints that are commonly affected by osteoarthritis.

What is osteoarthritis?

Osteoarthritis (OA) is the most common joint disease affecting middle-age and older people. It is characterized by progressive damage to the joint cartilage—the slippery material at the end of long bones—and causes changes in the structures around the joint. These changes can include fluid accumulation, bony overgrowth, and loosening and weakness of muscles and tendons, all of which may limit movement and cause pain and swelling.

Most commonly affected are the weight-bearing joints—the knees, hips and spine. Osteoarthritis in the knee and hip areas can generate chronic pain or discomfort during standing or walking. Deterioration of disks between spine vertebrae can cause back and neck stiffness and pain.

OA also can affect the fingers and any joints with previous injury from trauma, infection or inflammation. Some patients may develop bony knobs or “nodes” that enlarge finger joints, causing pain, stiffness or numbness and later restrict use of the fingers.

Most of those individuals with OA do experience joint pain during activity which can be relieved by rest. Those with later stage OA may suffer more severe pain and unstable joints, causing a sensation in the knees of “giving way” or “locking.” Some OA patients also experience overall stiffness in the morning or after prolonged inactivity, such as riding in a car. This stiffness typically lasts no more than half an hour.

What causes osteoarthritis?

OA arises from problems with the cartilage that cushions the ends of bones. This slippery material serves as the body's “shock absorber,” reducing friction in the joints as the body moves. When the cartilage is damaged or begins wearing away, tendons and ligaments can stretch painfully or, worse, bones can come into contact.

While no one factor appears to cause cartilage damage, researchers point to excess weight that adds to joint stress; sports- and work-related activities and injuries; and a family history of joint and cartilage weakness as contributing to OA. Age, in and of itself, is not a definitive cause of OA, but can worsen the deterioration process.

In osteoarthritis, the cartilage between the bones in the joint breaks down, and bony enlargement occurs.

Who gets osteoarthritis?

OA strikes people of all ages, but is more common in older populations. In fact, 70% of people over the age of 70 have X-ray evidence of the disease. However, only half ever develop symptoms. Women are affected more often than men, especially with OA of the fingers and the knees.

How osteoarthritis is diagnosed?

OA is suspected when patients have pain in the commonly involved joints. It can be confirmed by physical examination showing bony enlargement, fluid accumulation, cracking sensation during movement, muscle weakness and joint instability. X-rays also are useful in making the diagnosis. Occasionally blood work may be necessary to rule out other diseases.

How osteoarthritis is treated?

The goal of treatment is to reduce pain and improve function of the affected joints. This can be achieved with a combination of physical measures, drug therapy and, sometimes, surgery.

Physical measures – Exercise, support devices and thermal therapy usually are effective. Some forms of unproven alternative treatment such as spa, massage, acupuncture and chiropractic manipulation can help relieve pain for a short duration, but usually are costly and require repeated treatments.

Drug Therapy – Available forms of drug therapy include topical agents such as capsaicin cream, oral pain relievers such as acetaminophen, and nonsteroidal anti-inflammatory drugs (NSAIDs) for swelling and inflammation. For more serious pain, stronger medications such as narcotics may be required. Joint injections with corticosteroids or a form of lubricant called hyaluronic acid (HA) derivatives have proven effective for some patients.

Surgery – Arthroscopy and/or joint replacement is considered when the joint is seriously damaged, or the patient is in intractable pain and experiencing significant loss of function.

Supplements – Many nutritional supplements have been used for treatment of OA, but most lack good research data to support their effectiveness and safety. Recent study from the National Institute of Health showed that patients with moderate to severe pain from knee OA might benefit from chondroitin/glucosamine sulfate supplementation. However, to ensure safety and avoid drug interaction, consult your doctor or pharmacist before using any of these agents, especially in combination with prescribed drugs.

Living with osteoarthritis

There is no cure for OA, but you can help manage how it impacts your lifestyle. For instance, giving proper positioning and support to the neck and back during sitting or sleeping; adjusting furniture such as raising a chair or toilet seat; and avoiding trauma and repetitive motions of the joint, especially frequent bending, are excellent starts.

Adding regular exercise to your daily activities will improve muscle strength. Exercises that increase strength of the quadriceps muscles (the front thigh muscles) also can help prevent knee OA. Working with a physical or occupational therapist can help you learn the best exercises and assistive devices (e.g., cane, raised toilet seat) for your joints.

Because weight loss in obese people can reduce pain and progression of OA, achieving and keeping an ideal weight will make a substantial difference in comfort levels.

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Carpal tunnel - a syndrome name so well known that nearly everyone has heard of it. Unfortunately, given this widespread familiarity, people often attribute any discomfort or pain in the hand or wrist to carpal tunnel syndrome. Carpal tunnel syndrome is quite common, affecting 3% to 7% of the population, and usually very treatable. However, there are many other conditions which can cause similar complaints. It is important to know the difference.

Fast Facts

• The main symptom of carpal tunnel syndrome is numbness of the fingers.

• Carpal tunnel syndrome may interfere with hand strength and sensation, and cause a decrease in hand function.

• Carpal tunnel syndrome can be effectively treated with medications, splinting, steroid injections in the wrist and/or surgery.

What carpal tunnel syndrome is

Carpal tunnel syndrome is possibly the most common nerve disorder experienced today. The carpal tunnel is located at the wrist on the palm side of the hand just beneath the skin surface (palmar surface). Eight small wrist bones form three sides of the tunnel, giving rise to the name carpal tunnel. The remaining side of the tunnel, the palmar surface, is composed of soft tissues, consisting mainly of a ligament called the transverse carpal ligament. This ligament stretches over the top of the tunnel.

The median nerve and nine flexor tendons to the fingers pass through the carpal tunnel. [Flexor tendons help flex or bend the fingers.] When this median nerve in the wrist is compressed (squeezed by swollen tissues, for example), it slows or blocks nerve impulses from travelling through the nerve. Because the median nerve provides muscle function and feeling in the hand, disabling the nerve results in symptoms ranging from mild occasional numbness to hand weakness, loss of feeling and loss of hand function.

Usually carpal tunnel syndrome affects only one hand, but can affect both at the same time, causing symptoms in all or some of the fingers including thumb, index, middle and adjacent half of the ring finger but rarely the little finger (pinkie). In addition to numbness, those with the syndrome may experience tingling, pins and needle sensation or burning of the hand occasionally extending up to the forearm.

Frequently, symptoms surface in the morning upon awakening, or may cause waking during the night. Symptoms can occur with certain activities such as driving, holding a book or other repetitive activity with the hands, especially those requiring prolonged grasping or flexing (bending) of the wrist. Hand functional activities, such as buttoning, may become difficult, and sufferers may drop things more easily.

Individuals often shake their hands trying to obtain relief and may experience the sensation of swelling when, in fact, no swelling is actually present.

Because numbness and tingling may be mild and occur only as a periodic episode, many do not seek medical help. However, the disease can progress to more persistent numbness and burning. In some severe and chronic cases of carpal tunnel syndrome, loss of muscle mass (atrophy) occurs at the base of the thumb on the palm side of the hand. In these instances, especially in untreated cases, some weakness or impaired use of the hand as well as loss of sensation can occur with nerve and muscle damage that can’t be reversed by treatment.

What causes carpal tunnel syndrome

Carpal tunnel syndrome may be found in patients who are pregnant, overweight or have various medical conditions, including thyroid disease, diabetes or arthritis, or injuries such as wrist fractures. Whether repetitive work activities cause carpal tunnel syndrome is still controversial, but it is thought that some repetitive hand activities, especially those involving vibratory motion, can worsen the symptoms. Just as frequently, the syndrome occurs on its own.

However, many other conditions also can be responsible for the same symptoms of pain, swelling, numbness or weakness in the hands including diseases of the nerves located anywhere from the neck to the wrist. The pain and swelling in the hand joints and wrists caused by arthritis can also be responsible. For instance, pain at the base of the thumb is commonly caused by osteoarthritis. Tendonitis, an inflammation of the tendons that connect muscles to bones, such as a trigger finger, can cause pain, swelling, and impaired use of the hand or wrist. Raynaud’s phenomena can cause numbness and burning of the fingers as a result of cold exposure and sometimes due to autoimmune diseases. Raynaud’s also causes fingers to change to whitish, bluish, or reddish discoloration at various times, color changes not seen in CTS.

These and other diseases need to be excluded before diagnosing carpal tunnel syndrome.

Who gets carpal tunnel syndrome

Middle aged to older individuals are more likely to develop the syndrome than younger persons, and females three times more frequently than males.

How carpal tunnel syndrome is diagnosed

The diagnosis of carpal tunnel syndrome is often made by the physician based on an accurate description of the symptoms. During physical examination, testing may identify weakness of the muscles supplied by the median nerve in the hand including some thumb muscles affected by the syndrome. There may be decreased sensation in the hand to pin prick or light touch. Bending the wrist to 90 degrees for one minute may cause symptoms to appear in the hand (Phalen test) or tapping on the wrist with a reflex hammer may cause an electric shock-like sensation (Tinel Sign). Late in the disease, there may be thinning of the muscles or muscle atrophy at the base of the thumb.

The diagnosis of carpal tunnel syndrome can be confirmed and severity determined by a two-part electrical test:

• The nerve conduction test is the strongest evidence for carpal tunnel syndrome. The nerve is stimulated with a mild electrical current generated by a small electrode placed on the skin, proximal to the tunnel (elbow side of the tunnel). The impulse travels in the nerve through the tunnel to the hand where the impulse is measured. If the median nerve is affected, the impulse will take a longer time than would be expected to get to the hand. The longer the delay in the nerve impulse, the worse the nerve damage will be.

• The second part of the test, electromyography, measures the degree of abnormal function of the muscles. A small needle is placed in various muscles supplied by the median nerve, and the electrical impulse of the muscle is measured at rest and upon contraction (tightening with use) of the muscle. If the nerve has been severely compressed, these muscles can be affected and will not perform normally on the electrical test.

In recent years, diagnostic ultrasonography and MRI scans have been used to help diagnose CTS and exclude other causes of hand and wrist symptoms. These technologies can identify swelling of the median nerve and abnormalities of the tunnel wall, its contents and surrounding area. This can include the source of median nerve compression including inflammation of structures in the tunnel such as inflamed tendons, which can occur in rheumatoid arthritis. Other tendon abnormalities, including a ganglion, or excessive fat in the tunnel, also can be seen on MRI.

How carpal tunnel syndrome is treated

Medication such as acetaminophen and nonsteroidal anti-inflammatory drugs can be used for symptom relief. Splinting the wrist, especially at night, helps keep the wrist straight during the night and thus decreases the pressure on the median nerve. These splints, which are available in most drug stores, may relieve symptoms, especially in milder cases.

A cortisone injection into the carpal tunnel area is often helpful in relieving symptoms for weeks to months and can be repeated. If there is an underlying disease, such as hypothyroidism (under active thyroid) or rheumatoid arthritis, causing the carpal tunnel syndrome, then treatment of the specific disease may also relieve symptoms.

“Oh my aching back” can signal mechanical and, on occasion, even systemic illnesses that generate very real pain. In fact, back pain is associated with over 60 illnesses, and can result in serious disability and escalating medical bills. The good news is most individuals with low back pain improve within a week or two, and 90 percent of these episodes are resolved in eight weeks.

Fast Facts

·         Back pain is second only to the common cold as an affliction of mankind.

·         Low back pain disables 5.4 million Americans and costs at least $90 billion in medical and non-medical expenses.

·         The diagnosis of low back pain is determined by a medical history and physical examination, and rarely requires expensive or uncomfortable tests.

What back pain is

Back pain is just that—pain in the back. It can be localized to the lumbar spine or may radiate into the legs below the knee (sciatica).

What causes back pain

As a rule, most episodes of back pain are caused by mechanical disorders associated with overuse of the back and spine, or the gradual changes associated with aging. In about 10 percent of the cases, back pain is caused by a systemic illness.

The disorders affecting the low back can be divided into mechanical and systemic disorders. Mechanical disorders that can result in back pain include:

·         Muscle strains usually related to sustained physical activity such as shoveling snow or prolonged gardening. Acute strain may also occur when completing a common task from a twisted posture.

·       Osteoarthritis resulting from the narrowing of the intervertebral discs located between the vertebrae of the spine. The adjacent vertebrae grow spurs in response to the increasing pressure placed on them. The bony growths can cause localized pain in the low back or leg pain related to nerve impingement.

·         A herniated intervertebral disc may cause back pain associated with muscle spasms, but is more commonly severe leg pain related to pinching of the spinal nerve in the low back. The pain radiating down the leg is called sciatica. Disc herniation may cause a loss of function of the nerve that may include a loss of reflex, sensation, or muscle strength.

·         Spinal stenosis is a narrowing or the canal or space that the spinal cord occupies. This narrowing has many causes including bone spurs growing around the spinal joints, thickening of spinal ligaments, or bulging of a disc. The narrowed canal squeezes the nerve roots causing leg pain, numbness, or weakness. The pain is increased by standing and walking, and is relieved with sitting.

·         Diffuse Idiopathic Skeletal Hyperostosis (DISH) resulting from excessive bone growth which can affect the vertebra from the neck to the lower back.

Who gets back pain

In short, almost everyone. In fact, approximately 80 percent of the world's population develops this symptom. In the U.S. alone, 10 percent of the population will report back pain, women slightly more frequently then men.

How back pain is diagnosed

Typically, only a medical history and physical examination are required to diagnose low back pain. In some cases, individuals who do not respond to initial therapy may undergo specialized radiographic tests, such as magnetic resonance imaging (MRI) and computerized tomography to screen for additional involvement of soft tissues, ruptured discs, spinal stenosis, tumors or nerve injuries.  

How back pain is treated

Back pain should not be equated with a need for bed rest. In fact, bed rest should be kept to a minimum. Instead, patients should continue their activities of daily living.

While excessive exercise should be discontinued until the pain is relieved, there are exercises that can help reduce pain. These include flexion exercises (bending forward) for pain with standing, and extension exercises (bending backwards) for pain made worse with sitting.

Five- to ten-minute ice massages applied to a painful area within the first 48 hours of pain onset can help relieve pain as can heat, which relaxes the muscles Heat should be used for pains that last longer than 48 hours. Over-the-counter pain relievers such as aspirin, acetaminophen and non-steroidal anti-inflammatory drugs, are frequently adequate to control episodes of back pain, and muscle relaxants may help those with limited motion secondary to muscle tightness.

Massage therapy has proven helpful for those with chronic muscular pain, and some patients with back pain localized to the lumbar spine have been known to benefit from manipulation of the spine.

A small minority of low back pain patients, particularly those with leg pain due to a herniated intervertebral disc, spinal stenosis, or tumors affecting structures in the spine will require surgery.

Living with back pain

Spinal stenosis (or narrowing) is a common condition that occurs when the small spinal canal that contains the nerve roots and spinal cord becomes restricted. This narrowing can squeeze the nerves and the spinal cord causing lower back and leg pain. In general, spinal narrowing is caused by osteoarthritis, or “wear and tear” arthritis, of the spinal column. This results in a “pinching” of the spinal cord and/or nerve roots.

People suffering from spinal stenosis have trouble walking any significant distance, and frequently must sit or lean over forward on a grocery cart, countertop or assistive device such as a walker. While there are no cures, there are many therapies available.

Fast Facts

·         Spinal stenosis is typically the result of osteoarthritis causing a pinching of the spinal cord.

·         There are no cures for spinal stenosis, but therapies can assist in regaining mobility and comfort.

·         Exercise is of paramount importance in the treatment of spinal stenosis.

What is spinal stenosis

Spinal stenosis is a narrowing of one or more areas of the spine. This narrowing, which occurs most often in lumbar region (lower back) can put pressure on the spinal cord or nerves branching out from the compressed areas.

Typically, a person with spinal stenosis complains about developing tremendous pain in the legs or calves and lower back after walking. Pain comes on more quickly when walking up hills. This is usually very reproducible and immediately relieved by sitting down, or leaning over. When the spine is bent forward, more space is available for the spinal cord, causing a reduction in symptoms.

Although symptoms may arise from narrowing of the spinal canal, not all patients with narrowing develop symptoms. Why some patients develop symptomatic stenosis and others do not remains unknown. Therefore, the term spinal stenosis refers not to the finding of spinal canal narrowing, but rather to manifestation of lower extremity pain caused by compression on the affected nerves.

What causes it?

Unless the individual is born with a small spinal canal (congenital stenosis), spinal narrowing most commonly results from progressive degenerative changes. This “acquired spinal stenosis” can occur from the narrowing of the space around the spinal cord due to bony overgrowth from osteoarthritis combined with thickening of one of the ligaments in the back, and a bulge of the intervertebral discs.

Who gets it?

The risk of developing spinal stenosis increases in those who:

·         Are born with a narrow spinal canal

·         Are female

·         Are 50 years of age or older

·         Have had previous injury or surgery of the spine

Conditions that can cause spinal stenosis include:

·         Osteoarthritis and osteophytes (bony spurs) associated with aging

·         Inflammatory spondyloarthritis

·         Spinal tumors

·         Trauma

·         Paget's disease of the bone

·         Previous surgery

How is it diagnosed?

Your doctor will ask about your symptoms and medical history, and perform a physical exam if spinal stenosis is suspected. Your symptoms may include: numbness, weakness, cramping, or pain in the legs and thighs; radiating pain down the leg; abnormal bowel and/or bladder function; decreased sensation in the feet causing difficulty placing the feet when walking; loss of sexual function; and/or partial or complete leg paralysis.

Additional tests conducted to confirm and assess the diagnosis may include:

·         An X-ray of the spine to check for abnormalities in the bones of the back including osteoarthritis, bone spurs and obvious narrowing of the spinal canal.

·         A computed tomography (CT) scan to take images of the bony architecture of the back. This helps to evaluate the spinal canal.

·         A magnetic resonance imaging (MRI) scan of the spine to make pictures of soft tissues such as the spinal cord and the spinal nerves inside the back.

·         An EMG which may show active and chronic neurological changes.

How is it treated?

Although there is no cure for spinal stenosis, various therapies are available, one of the most important being exercise. Keeping the hip adductors and abductors, quadriceps and hamstrings from developing atrophy helps increase stability and the ability to walk.

Medications such as nonsteroidal anti-inflammatories (NSAIDs) also may be appropriate and helpful in pain relief. Cortisone injections into the epidural space, the area around the spinal cord, can afford tremendous temporary or permanent relief to people suffering this disorder.

Under severe circumstances, surgery to correct this disorder may be appropriate. However, adequate decompression of the neural elements and maintenance of bony stability are necessary for a good surgical outcome for patients with spinal stenosis. Decompression laminectomy, which is the removal of a build-up of bony spurs or increased bone mass in the spinal canal, can free space for the nerves and the spinal cord.

Spinal fusion to fuse two vertebrae together to provide stronger support for the spine almost always follows a decompression laminectomy.

Several studies report that surgical treatment produces better outcomes than non-surgical treatment in the short term. However, results tend to deteriorate with time. Lumbar decompressive surgery can be complicated by epidural hematoma, deep venous thrombosis, dural tear, infection, nerve root injury and recurrence of symptoms.

Broader health impacts

The most serious health consequence of spinal stenosis is progressive loss of strength of the lower extremities. However, patients with spinal stenosis may be quite disabled due to pain. This pain decreases work capacity and significantly decreases quality of life, even if they have no appreciable muscle weakness.

Living with spinal stenosis

·         Exercise regularly. Regular exercise, which focuses on flexion-based exercise, often reduces pain symptoms. Add in some walking, swimming and stretch exercises for even better results.

·         Modify activity. Avoid activities that can cause or worsen pain and disability.

·         Talk to your physician about pain medications, and other methods recommended for pain reduction.