If definitions are needed, then rheumatology may be described as the study and management of disorders of the musculoskeletal system; however, this is too vague and so needs further refining. For example, where does involvement of blood vessels, lung parenchyma, renal, brain and cardiac muscle fit in? Some have suggested that vasculitis is the basic pathological lesion that results in cascading damage to multiple organ systems.
Orthopaedic surgeons are increasingly proclaiming tenure to the term ‘musculoskeletal disorders’, but surely this too is the domain of rheumatology practice?
These various points may lead to confusion in non-specialists and patients. So, to whom does a patient attend with a painful joint, back pain or some other pain affecting the musculoskeletal system? Perhaps another role that rheumatologists fulfil is that of non-surgical orthopaedic surgeons? After all, rheumatology did evolve from ‘physical therapy’, which begs the question: what is any therapy, if not physical or mental?
Enough of definitions – what are rheumatologists doing now? There is the classical triad of diagnosis, treatment and research. Most rheumatologists do all and their training embraces the major medical specialties with a strong grounding in general internal medicine. In fact, rheumatologists may be annointed as the classical general physicians who deal with inflammation, whether of a septic or non-septic cause, as well as understanding anatomy, which sadly is all too poorly taught and, even worse, poorly remembered.
In this edition of the Hamdan Medical Journal, the contributors have been selected by virtue of their specialist interest and knowledge of their subjects. These subjects have been carefully chosen as they are the most frequently encountered in the practice of rheumatology.
Research is expanding the knowledge base of causation and continuation of these conditions, yet the triggers are proving elusive. Treatment, thankfully, is improving control and outcomes, but these advances have been aided by stringent clinical trials that have tried to show which groups of patients respond best to certain interventions.
Translation of research from Petri dish to patient has been supported by large patient and drug registries, which have highlighted the risk–benefit ratios of various drugs. Despite the introduction of new drugs, existing agents have been found to beneficial when used in in combination and have also proven to be less expensive, especially in the treatment of rheumatoid arthritis.
The most common condition presenting in a routine rheumatology clinic is osteoarthritis. To call it a ‘degenerative condition of joints’ is ignoring the evidence of the existence of inflammation in the disease in the absence of significant trauma. However, therapies to control its progress are experimental at best. In this condition, pain management is paramount, but its causation is enigmatic. However, significant progress is being made in an attempt to minimize disability resulting from its effects.
Disability is what all specialties are trying to avoid, and rheumatologists have acknowledged that, as in diabetes, tight control of the (probable) inflammatory process has to be achieved, and it must be achieved early in the disease progression. One must not tolerate gradual loss of joint or other organ function, but what is the ‘target health state’ that should be aimed at?
Simplistic guides such as inflammatory markers, e.g. erythrocyte sedimentation rate or C-reactive protein, cannot be relied upon. So Disease Activity Scores (DAS) have been devised which, though laborious, may give a better guide as to control of the condition and hopefully a better outcome for the patient.
However, herein lies a dilemma: how long do patients need to continue with therapy once their disease process has been halted? Does recurrence herald resistance to the therapy or that the DAS are no longer reflecting the condition, which may have altered in its pathophysiology? Perhaps a different therapy and scoring system should be instituted after a period of time? The use of genomics and disease registries will help elucidate this.
In conclusion, the future for patients with rheumatic conditions looks less bleak, but those treating such patients have to maintain a general health perspective of their patients. Maintaining continual professional development and incorporating therapeutic advances is vital, as is the support of other specialties to approach treatment in a multidisciplinary fashion. Pain control and minimizing disability must be the goal, and the arrival of new tests, therapies and clinicians gives hope to those with rheumatic diseases.
I hope that the reader enjoys the current state of play in the care of those who are enduring these conditions and thereby aid their patients.