Getting down to the bones of the issue- a conversation with a rheumatologist.

Article

12. 07. 2022 Rheumatology

Joint and muscle pain can be caused by an endless plethora of reasons. From something so rectifiable as exhaustion to inflammation, and all the way to degenerative diseases…. the list goes on. We asked Tomáš Zitek, a rheumatologist at Canadian Medical, questions regarding who gets affected by this problem, how it can be prevented and what treatment options are available.

What are the most common complaints that patients come to you with?

Most often, I see patients in my clinic who are suffering from joint pain. Next with muscle pain, sometimes pain throughout the whole body. We are also one of the specialisations that deal with the differential diagnosis of chronic back pain. Sometimes the person doesn't even have any pain, they've been referred to us for some abnormality in blood tests or maybe on an x-ray or bone densitometry. In the inpatient wards, rheumatologists then consult for various obscure internal organ affections, such as kidney or lung inflammation or severe rashes.

What can a patient expect during an examination? What do you look for?

In the case of non-trauma-related pain in one or more joints, which is most common, we first decide whether the disease is inflammatory, degenerative or other. If there are signs of inflammation, we determine which inflammatory disease it may be. A comprehensive rheumatology examination consists of an examination of all the joints in the body and the standard internal examination that people are familiar with from a preventive check-up at the GP.

So which diseases are classified as rheumatic? And which ones do you see in your practice the most?

Rheumatic in the narrower sense means systemic inflammation, i.e. inflammation mediated by a disorder of the immune system, not by infection. The most common ones include rheumatoid arthritis, ankylosing spondylitis (Bechterew's disease), psoriatic arthritis and systemic lupus erythematosus. We often treat patients with gout, in which inflammation is caused by excess uric acid crystals. However, the general public uses the word rheumatic to refer to any non-traumatic joint pain, including non-inflammatory disorders, which "fortunately" tend to be much more common than inflammatory ones. The main non-inflammatory joint disease is osteoarthritis or, in layman's terms, simply arthrosis; we continue to see patients with fibromyalgia syndrome or joint hypermobility. We also deal with the treatment of osteoporosis. In this case, the person can be completely unaware of an issue, but they do have to live with a high risk of fracture.  

How much do these diseases affect people's lives?

It depends on the specific diagnosis, possibly the current state of the inflammation. For example, with active rheumatoid arthritis or another inflammatory disease, some patients are unable to dress and often do not sleep because of the pain. It is then beautiful and enjoyable to watch them completely blossom and their lives return to normal with the right treatment.

How did the myth arise that rheumatic problems are a matter for older people?

It's a myth… but it's also not. It depends on how you interpret the term "rheumatic". The usual cause of non-traumatic joint pain is osteoarthritis and this is strongly associated with older age. So the claim of rheumatism being associated with older age is true to some extent. However, inflammatory diseases, in general, affect all ages and sometimes even children.

Rheumatic diseases afflict three times more women than men. Do they know why?

There are a number of possible causes, the main hypothesis being differences in hormones. In reality, however, only certain diseases are more common in women, the aforementioned rheumatoid arthritis and systemic lupus. Psoriatic arthritis affects women and men equally, and Bechterew's disease and gout are more common in men.

What are the causes of these diseases?

Most inflammatory diseases are a combination of genetic disposition and environmental influences. Unfortunately, for most diseases, we are unable to find one specific factor that, if eliminated, will cure the disease. The exception is perhaps the heavy beer drinker suffering from gout, who could get rid of the disease by simply not drinking so much beer.

So how much of a role does lifestyle play?

In systemic inflammatory diseases, "rheumatism" in the narrower sense, the main risk factor is smoking, probably even passive. Obesity is also a high-risk factor. However, the influence of physical activity is unclear and the question of dietary composition is - apart from gout, which was mentioned above - completely open. Chronic stress has a rather minor influence on inflammatory diseases.

And genetics?

The influence of genetic predisposition is always a key player to some extent. The likelihood of developing the disease in a patient's relatives varies according to the type of disease; for some diagnoses, it is small, around 40 per cent for rheumatoid arthritis and 50 per cent for osteoarthritis.

Can these diseases be prevented?

Unfortunately, the answer is that in the majority of cases, no. You can only reduce the risk. The most important thing is not to smoke. Then maintain a healthy weight and perhaps regular exercise at a reasonable intensity. It is probably also important to treat chronic infections, the most common (and mostly hidden) of which is periodontitis. Here, we can reduce the risk by regularly brushing our teeth, including the spaces between the teeth, and visiting the dental hygienist and dentist regularly.

How is the inflammatory disease, "rheumatism", typically treated?

The main means of treatment are anti-inflammatory drugs, for which the term DMARDs, from the English term: Disease Modifying Anti-Rheumatic Drugs, is used in rheumatology. It is a broad group of drugs whose main effect is to modify and suppress the immune response. The most commonly used is methotrexate.

What about biological treatment? 

Biological therapy is one of the subtypes of DMARDs. But the word biological here just means a production process using biotechnology, "using bacteria". As opposed to conventional drugs, which are prepared by chemical synthesis. Biological drugs precisely target a specific receptor or mediator of inflammation. They are very effective and relatively safe, but they are not suitable for everyone, unfortunately.

Is it possible to be completely cured?

In general, systemic inflammatory diseases cannot be completely cured, unlike infections, which can be completely eliminated with a single course of antibiotics. Most patients with more severe forms of the disease need medication for a long time, often for life, but with the right treatment, they are virtually unaware of their illness.

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