Rheumatology

Rheumatology is the study of rheumatism, arthritis and other disorders of the joints, muscles and ligaments.  This is normally investigated by a Rheumatologist to effectively refer you to the correct treatment, which could be a medical management, referral to a different specialist consultant or Physiotherapy.

Gout is a type of arthritis that not many people have heard of, but the symptoms come suddenly and severely. These symptoms are painful, hot and swollen joints, and skin over the affected joint is shiny in appearance.  Commonly this is seen in the big toe but it is also seen in joints of the midfoot, ankles, knees, elbows, wrists and fingers.

Your symptoms will be due to high levels of urate (a chemical that is produced when certain food or drinks are broken down) in your blood caused by genetics, being overweight, high blood pressure, type 2 diabetes and kidney disease. Although there are certain activities which can cause a flare up in the joints such as injury to the joint, inflammatory illness, an operation, eating certain food groups, too much alcohol and dehydration.

Gout symptoms can be managed with appropriate medication prescribed to you by your GP and lifestyle changes but it is recommended to seek advice from a physiotherapist if you have damage to a joint.   A Physiotherapist could provide you with appropriate exercise programme to assist with maintaining range of movement, improving muscle strength and reducing the risk of further damage to the joint. This can help you return to sporting activities or just make activities of daily living more comfortable or achievable.  Physiotherapist can also help with losing weight if you have been advised by your doctor or consultant, in conjunction with a dietician or nutritionist.

Rheumatoid arthritis is an autoimmune disease (meaning the immune system attacks your body’s own tissue) that causes inflammation in the joints particular seen in wrists, hands and feet, but it can affect all joints.

Common symptoms are deformity, pain, swelling and stiffness around the joints which often affect most people in the morning or when the weather is cold.  Other symptoms that are not commonly known are tiredness, anaemia (low haemoglobin in the blood, which oxygen attaches to to transport around the body), weight loss, inflammation in the eyes and nodules (fleshy lumps) around elbow, hands and feet. The visual deformity in the joints is caused by stretching of the capsule around the joint during the inflammatory period and also changes in the joint surface.  These changes cause the mal-alignment on the joint.

You will not suffer severely from these symptoms all the time, as Rheumatoid arthritis is known to have flare-ups.  This can help your consultant distinguish the type of arthritis you are suffering from. Other investigation that can be undertaken to diagnosis you are blood tests, X-ray and scans.  These can help your consultant chose the right management for you.

Rheumatoid arthritis can be managed with medication that consist of a variety of drugs to manage different symptoms, such as pain killers, anti-inflammatories, steroids and disease modifying anti-rheumatic drugs.  Your Physiotherapist can provide you with a bespoke exercise programme on land and in a hydrotherapy pool to maintain flexibility and strength in the joints that are affected by the disease so that you can maintain independence with activities of daily living and continue performing your hobbies if that is sporting or craft. Other practitioners that can be beneficial are podiatrist for advice on footwear to make mobility more comfortable or a surgeon if conservative management is no longer effective.

Osteoarthritis is also described as the wear and tear of a joint as it is caused by changes in the bone and cartilage at the joint surfaces. These changes include thinning of the cartilage and thickening of the bone underneath it.  This results in the body trying to repair these tissues more rapidly than it would normally.  This can result in additional bone being lied down at the edge of the joint (called bony spurs/osteophytes), the synovium (inner layer of the joint capsule) thickening and making extra fluid.  This will be seen as swelling around the joint. The capsule and surrounding ligaments will also thicken and contract to try to stabilise the joint. These changes can force the joint to adapt to abnormal positions.

Factors that can influence the likelihood of having osteoarthritis are age, gender, increased weight, previous joint injuries, joint abnormalities and genetics. It is commonly seen in the back, neck, hands, knees and hips with symptoms of pain, stiffness, grating or grinding sensation, swelling and difficulty with normal activities, which can be on and off but as the disease progresses it can become more constant.  The most common joints affecting by osteoarthritis is your knees and hips.

Even though rheumatoid arthritis is common in the hands, you can also get osteoarthritis.  Differentiating diagnosis characteristics are osteoarthritis usually affects the base of the thumb and joints at the end of your fingers.  The joints become swollen and tender, but they will gradually over several years form firm knobbly swellings caused by additional bone being formed.  They are often called Heberden’s nodes at the end of the fingers or Bouchard’s nodes when at mid finger.  The only way that this disease is different to rheumatoid arthritis is the fingers still work well.

Physiotherapy can help you manage your osteoarthritis with an exercise programme to maintain range of movement, muscle strength and correct use of the joint affected to reduce overloading and prevent injuries. Also the exercise programme can assist with losing weight if that is a factor contributing to your symptoms.

Like every cell in the body, when a cell gets old your body replaces it with a new cell.  Unfortunately as we get older the process of replacing the cells is slower and for the bones this means they become more fragile and increases the likelihood of fracturing under minimal stress.

These changes are more frequently seen in females after menopause due to the hormone Oestrogen no longer being released. Other factors that increase the likelihood of you suffering with osteoporosis are long term steroids, and lack of weight bearing exercises.  Also high levels of exercise that cause periods to stop, diets that lack sufficient vitamin D and calcium, heavy smoking and drinking, and low body weight can all lead to osteoporosis.

Vitamin D is also absorbed by the body from the sun, which means people that spend high percentages of the time indoors, their body’s covered up by clothing or wearing sunscreen or block all the time can be reducing the amount they would naturally absorb.  Research performed recently has shown that children in the UK are deficient of vitamin D due to wearing sunscreen and performing less outdoor activities.  It has been advised that people should spend short periods in the sun at start or end of the day daily to get their recommended vitamin D allocation.  This can be difficult during the winter months in the UK; therefore it is advisable to ensure it is in your diet especially if you know you are normally low.

Impact/ weight bearing activities do not have to be rigorous exercises such as running, but it can be walking and climbing the stairs.  It is an action that stimulates the body to keep the joint strong by forces being placed through it. This means that everyone of different mobility abilities is able to keep their bones healthy.  Research has also been shown that by adding weight bearing exercises into your daily life can assist with reverse osteoporotic changes.

Osteoporosis can be diagnosed with a bone density scan, but your consultant or doctor may perform blood tests to distinguish cause of bone changes.  They will also be able to tell how progressive the changes are that are described as osteopenia or osteoporosis.

Osteopenia is slight changes in the bone density but still at relatively low risk of a low impact fracture. Whereas osteoporosis is significant bone density changes which will require treatment to reduce the risk of low impact fractures.

osteoarthritis-osteopenia-illustration

If you are diagnosed with osteoporosis or osteopenia your consultant or doctor will advised you regarding medication and diet changes that can assist with reducing the risk of fractures.  They will also advise you to see a Physiotherapist to provide you with an exercise programme to increase weight bearing activities to strengthen the bones but also incorporate muscle strengthen and balance exercises to reduce the risk of falls which could result in a fracture.

Hypermobility is also known as double jointed or joint hyper laxity, which most people will not experience problems.  It can have its advantages in certain sports or activities, such as gymnastics and dancing.  Although some people will experience pain in the muscles and more at risk of muscle sprains, joint stiffness, joint pains in the foot and ankle, neck pain and backache, and injured or dislocated joints especially shoulders or knee caps.

Factors that may increase the risk of you having hypermobility is  genetics, age, gender (woman are at higher risk due to hormone called Relaxin which is released during pregnancy), ethnic background and sporting activities participating. The shape of bone, weakened or stretched ligaments, muscle tone and sense of joint movement
known as proprioception. Other groups of people that are known to be hypermobile are those with Down syndrome, osteogenesis imperfecta (brittle bone disease), Marfan syndrome (genetic disorder of the connective tissue) and some types of Ehlers-Danlos syndrome (inherited connective tissue disorder).

The shape of your bones could be that the socket part of hip or shoulder are shallower, which will increase the movement in that joint and therefore increase your risk of dislocating.  This is similar for your muscle tone, which is normally more relaxed and so allows for an increase range of movement.

Diagnosis of hypermobility can be achieved by your consultant or GP examining you, but also use the Beighton score and Brighton criteria.

Hypermobility cannot be cured, but there are treatments that can help manage your symptoms and reduce the risk of injuries.  Physiotherapy can help with providing an individually designed exercise programme that will require regular performance to improve muscle strength around the hypermobile joints and improve proprioception to reduce the risk of joint surface, ligament and muscle damage.

Other treatment modalities such as the use of pain killers and anti-inflammatories maybe used when you have symptoms such as pain or swelling due to an injury.  Surgery would only be considered if you have caused damage to soft tissue structures that increase the mobility in the joint, but they are not advised for general hypermobility symptoms.

Treatments include:

  • Tailored exercise programmes
  • Acupuncture
  • Pilates
  • Trigger point release
  • SNAGs, NAGs and MWMs
  • Hydrotherapy
  • Postural re-education
  • Gait re-education
  • Manual therapy
  • Soft tissue release