Rheumatologic diseases are commonly encountered in rehabilitation practice, in both inpatient and outpatient (ambulatory) settings. These diseases are diffuse and multifactorial. Most are poorly understood. In some diseases, such as rheumatoid arthritis and fibromyalgia, patients present with vague initial symptoms of fatigue and morning stiffness that can progress to a chronic debilitating process. In others, such as giant cell arteritis, immediate diagnosis and treatment is required to prevent disastrous consequences. Most rheumatologic diseases have limited treatment options, some of which (eg, glucocorticosteroids) have significant side effects.
The role of the physiatrist is to recognize common rheumatologic diseases, treat pain conditions that are common in patients with rheumatologic diseases, and assist in diagnosis and referral for proper treatment. A priority is to maintain function in patients by means of proper bracing and assistive devices, physical activities, and exercise programs. Because many rheumatologic diseases are chronic and debilitating, a team approach is preferred. The physiatrist should lead a team of professionals—including rheumatologists; psychiatrists; physical, occupational, and speech therapists; counselors; and social workers—whose combined efforts aid in diagnosing the disease, controlling pain, and improving function.
ESSENTIALS OF DIAGNOSIS
Symmetric polyarticular inflammatory arthritis.
Diagnostic criteria include morning stiffness of joints, lasting at least 1 hour; involvement of three or more joints; and, in the hand joint, involvement of at least one metacarpophalangeal (MCP) or proximal interphalangeal (PIP) joint.
Additional features include the presence of rheumatoid nodules, positive serum rheumatoid factor (seen in 85% of patients), and bony erosions on radiographs.
Rheumatoid arthritis (RA) is the most common inflammatory arthritis, affecting more than 1.5 million adults in the United States. It has a slow, insidious onset and is a chronic, progressive, systemic rheumatic disease. RA affects more women than men, and more whites than other races, with the peak incidence in the third to sixth decades of life. It is thought to be caused by a combination of genetic, environmental, and immune-mediated factors. The most consistent genetic association is with class II major histocompatability genes, especially those containing a specific five amino acid sequence in the hypervariable region of HLA-DR4. Other genetic polymorphisms also are found. RA is associated with several bacterial and viral infections; these include Mycoplasma, Mycobacterium, enteric bacteria, parvovirus, retroviruses, and Epstein-Barr virus.
Clinical criteria for diagnosis of RA are based on the classification criteria published in 1987 by the American Rheumatism Association, now the American College of Rheumatology (ACR; Table 22–1). The criteria were updated in 2010 to focus on features seen in earlier stages of the disease that are consistent with more erosive disease (Table 22–2). In using the updated criteria, each feature that is present is scored as 1 point, and a total score equal to or greater than 6 is indicative of RA.