Transcription:

Melanie Cole (Host): If you have pain in your joints or bones that are affecting your quality of life and your primary care provider has been unable to figure out what’s causing that pain, it may be time to make an appointment with the rheumatologist. My guest today, is Dr. William Saalfeld. He’s a nurse practitioner with the Arthritis Center of Nebraska. William, what is a rheumatologist, and what’s the difference between a rheumatologist and an orthopod?

William Saalfeld (Guest): Well, a rheumatologist – according to the American College of Rheumatology – is an internist who has received training in the diagnosis and detection of musculoskeletal disease and systemic autoimmune conditions, commonly referred to as rheumatic diseases which can affect the joints, muscles and bones, causing pain, swelling, stiffness and deformity. I think that’s a fair enough description, however somewhat limiting. Like many specialties in medicine, rheumatology is shrouded in mystery to the public, patients and even most doctors. It seems as though many providers will consider rheumatological disease when nothing else quite fits. It’s a factor that attracted me to the specialty in that I like intellectual challenges as do many other people that work in rheumatology.

The difference between a rheumatologist and an orthopod is really continuing the answer to the first question in that it addresses a few misconceptions about rheumatology in that it’s not just about rheumatism or arthritis. Most rheumatology patients’ immune systems have a defect, usually linked to a specific gene causing them to overproduce certain factors in the blood that cause inflammatory cells or antibodies to attack any part of the body, including all organs – skin, blood cells, and most famously, the joints.

Most diseases are systemic, so patients feel overall very sick. The kind of arthritis these patients develop is inflammatory, which leads to the two biggest misconceptions. Not all arthritis is the same. Most of us as we age will develop osteoarthritis or degenerative arthritis. It is localized and non-systemic and often comes from wear and tear or trauma. The majority of rheumatologists’ patients have inflammatory arthritis, which can have many causes. Not all arthritis is the same nor is there one treatment that fits all. 

Finally, the average age of onset for many of our diseases is between 20 and 40, and they may occur in children and infants, so rheumatology is not a geriatric specialist. Although we do treat osteoarthritis or the arthritis of older people, the majority of these patients are treated by their primary care physician or orthopedics when surgical intervention or joint replacement is necessary, and that’s what orthopods do. They are surgeons and rehabilitation providers.

Melanie: That is so interesting that you described it as more autoimmune related than orthopedics, and what a very, very good definition. When you’re talking about some of these conditions, whether it’s lupus or arthritis, are medications the only treatments available? What other modalities can a rheumatologist use?

William: Well, even in the cases of osteoarthritic conditions, for example, there is not much pharmacologically available to those patients, and their symptoms can be painful and disabling. For example, in hand osteoarthritis, for example, functional CMC splints made by a hand occupational therapist is the best therapy. For knee osteoarthritis, it is a “move it, or lose it” approach with recommendations for water walking, cycling, swimming, water aerobics, elliptical use, along with weight loss through dietary modification, good support shoes and quadriceps strengthening exercises are also recommended. The same goes for hip osteoarthritis, and in that case, hiking poles can be superior walking aids for people who’d like to try that. In the back with lumbar spondylosis, cervical spondylosis, proper ergonomics are key – Pilates, Yoga, Tai Chi – for flexibility and core strengthening, along with a good physiotherapist and a good attitude because these are all chronic conditions that most of the public suffer from as we age and are not corrected with a pill or intervention in most cases.

Melanie: When people hear rheumatoid arthritis versus osteoarthritis, tell us a little bit about the difference.

William: In terms of – as I discussed earlier, rheumatoid arthritis is an autoimmune, systemic, inflammatory disease caused by inflammatory cells circulating in your bloodstream and causing inflammation in multiple small and large joints along with other areas of the body. General, non-inflammatory osteoarthritis is the classic non-inflammatory osteoarthritis confined to individual joints or the wear-and-tear degenerative arthritis, which we all develop as we age. That is typically treated by primary care physicians or orthopods or orthopedists.

Melanie: Then tell us, William, how do you, as a nurse practitioner, work with the rheumatologist, to do some of these modalities that you mentioned and work on these types of arthritis? How do you work together?

William: Well, our goal as a nurse practitioner is to essentially provide the preventative care, treatment, and management of acute and chronic illnesses. For the nature of – once they see the physician, they’re diagnosed with it, they usually go through a period of stabilization with their therapies, and then with the preventative and ongoing care, we see patients. But also, too – beyond that point – diseases in and of themselves, evolve over time, so sometimes people with medications that previously did work, they’ve stopped basically having their efficacy and so they need to be reevaluated. Sometimes they develop new diagnoses along the way. They are very dynamic and complex diseases, and they’re not necessarily a static disease, so sometimes people get either much better over time, or some people start to accumulate new things over time, too. You just have to be mindful and collaborative with your physician and your group in general just to make sure you’re not missing something in the diagnosis because they’re very complex and evolving. Very rarely are they discrete, where they are very well-defined and clear-cut right from the get-go.

Melanie: Well, that seems to be one of – as you say – the challenges of the field of rheumatology, is that it’s not always so clear-cut. One of the things that people hear about is fibromyalgia. They see commercials on TV or wide-spread pain. Tell us a little bit about fibromyalgia and the treatment options available.

William: Fibromyalgia is a condition associated with diffuse aches and pains, tender points above and below the waist, fatigue – what they refer to as brain fog – and sleeping abnormalities. It is considered a central pain syndrome, so in other words, there is an abnormality or chemical imbalance in the parts of the brain that process sensory input and output, so the sensory pathways are amplified. A minority of patients are depressed. There is also a genetic link, so family history is prevalent in that. There is a high incidence of sleep apnea, so sleep studies for these patients are helpful.

The best long-term treatment is a slow buildup of aerobic exercise. The best short-term treatment that is non-pharmacologically based is usually more desensitizing – even something like hot baths or hot tubs that basically allow the person to relax. The only three approved medications on the market are Cymbalta, Lyrica and Savella, but there are also some other medications that can be helpful. Sometimes these are not always needed. The mainstay of treatment with fibromyalgia patients is establishing regular, aerobic exercise, optimizing their sleep hygiene, and if necessary, cognitive behavioral therapy.

Melanie: Wrap it up for us, William, with your best information about rheumatology, what it is, and why somebody should come see a rheumatologist.

William: Well, with rheumatology, it’s kind of like I alluded to in response to that first question where it’s most of the time people consider a diagnosis when nothing else quite fits, but for the nature of listening to patients if they have swollen, tender joints, if they have any kind of inflammatory process that’s going on, those are usually the times that that warrants a workup to see if there is anything from a rheumatological standpoint.

Other modalities like you asked about earlier – even for the shoulder or knee arthritis, I mean, sometimes occasional intraarticular injections with steroids can be helpful. With knee osteoarthritis, we do synvisc injections as well – or gel made from the rooster cone cartilage. That can help as a lubricant and anti-inflammatory. It alleviates symptoms in about 60 percent of patients for up to six months when combined with appropriate lifestyle modifications. Also, we do a lot of bone mineral density testing to evaluate and treat osteoporosis because in these inflammatory conditions – bones are cells like anything else, and they can be impaired as to how they function and develop over time, as a result. We also have things like nerve conduction studies to assess carpal tunnel and ulnar nerve entrapment.

There is a multitude of diagnoses that we see, everything from rheumatoid arthritis, to mixed connective tissue disease, and even sjogren’s, fibromyalgia, lupus, psoriatic arthritis, and the list just keeps going. It’s pretty esoteric beyond those major diagnoses, but it’s just being mindful of what the patient is coming in complaining about and what their symptoms are. If there is a mindful clinician paying attention to that ongoingly, you can usually catch it early, and it’s very treatable in a lot of conditions.

Melanie: Such great information. Thank you, William, so much, for being with us today and sharing your expertise on this very interesting topic. A special thank you to our podcast partner, Locked In Companies. For more information about rheumatology, please visit nebraskaarthritis.com, that’s nebraskaarthritis.com. This is Bryan Health Podcast. I’m Melanie Cole. Thanks so much, for listening.