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Musculoskeletal Disorders: Introduction
INTRODUCTION
tissue disorders. Metabolic bone disease and autoimmune connective tissue diseases are discussed in MEDICINE 29:12 and 30:10 respectively. • Some musculoskeletal disorders are predominantly genetic (e.g. hypermobility syndrome). • Others depend on genetic and environmental factors (e.g. reactive arthritis). • Some are associated with ageing (e.g. osteoarthritis). • In others (e.g. fibromyalgia), complex psychosocial and biological factors operate.
Musculoskeletal Disorders: Introduction Ian D Griffiths The musculoskeletal disorders encompass diseases of the locomotor system and, traditionally, multisystem connective
ClassiÞcation of rheumatic diseases Inßammatory Monoarticular • Acute Septic arthritis Gout Haemarthrosis Calcium pyrophosphate • Chronic
Non-inßammatory Monoarticular • Acute Fractures Sports injuries Torn meniscus Loose body ‘Sprain’
Tuberculosis Pauci-articular juvenile chronic arthritis
• Chronic
Polyarticular • Acute Viral Rheumatic fever Erythema nodosum • Chronic
Polyarticular • Acute
Symmetrical Rheumatoid arthritis Seronegative juvenile chronic arthritis Polymyalgia rheumatica Chronic tophaceous gout
• Chronic
Asymmetrical Psoriatic arthritis Inflammatory bowel disease Reiter’s syndrome Pauci-articular juvenile chronic arthritis
Spinal • Acute
Systemic Systemic lupus erythematosus Polyarteritis Systemic juvenile chronic arthritis (Still’s disease)
Spinal • Acute • Chronic
Osteoarthritis Shoulder capsulitis Osteonecrosis ‘Enthesitis’ (e.g. tennis elbow, plantar fasciitis)
• Chronic
Generalized nodal osteoarthritis Haemochromatosis Hypermobility syndrome Fibromyalgia Diabetic cheirarthropathy
Disc prolapse Sprain Vertebral collapse Spondylosis Paget’s disease Neoplasia Spondylolisthesis Chronic degenerative disc disease
Osteomyelitis Infective discitis Ankylosing spondylitis Spondyloarthropathies Chronic infection (e.g. brucellosis, tuberculosis)
1
Ian D Griffiths is Consultant Rheumatologist at the Freeman Hospital, Newcastle upon Tyne, UK, and Senior Clinical Lecturer in Rheumatology at the University of Newcastle upon Tyne.
MEDICINE
1
© 2002 The Medicine Publishing Company Ltd
ASSESSMENT OF THE RHEUMATOLOGICAL PATIENT
What’s new
The Rheumatological History
There have been two significant pharmacological developments since the last MEDICINE Rheumatology Chapter was published in 1998. • The selective cyclo-oxygenase 2 (COX-2) inhibitors have been licensed and received approval from the UK National Institute for Clinical Excellence (NICE) for use in higher-risk patients (> 65 years, previous upper gastrointestinal disorders, co-morbidities, prolonged use). Two large randomized controlled trials suggest that these agents reduce serious upper gastrointestinal events by about 50%. • In 2002, NICE approved the use of two biological agents for the inhibition of tumour necrosis factor α in refractory RA and juvenile idiopathic arthritis (these agents were already licensed in the USA). This is the first highly targeted therapy in the treatment of RA, and an interleukin-1 inhibitor has also recently been licensed.
Jane E Dacre Jennifer G Worrall
A wide range of diseases may affect the musculoskeletal system, from minor regional soft tissue conditions (e.g. tennis elbow), to life-threatening systemic connective tissue diseases (e.g. systemic lupus erythematosus, SLE). The taking of a rheumatological history must therefore be flexible. Appropriate information must be gathered to make a quick diagnostic hypothesis, and time and understanding must be given to patients with severe disability. History-taking is an essential part of any consultation. It is important to recognize that several processes are occurring while you talk – you are gathering sufficient information to make an appropriate diagnosis, in addition to putting the patient at ease and developing a good relationship with him or her. An effective consultation is one in which a rapport is established with the patient. Patients generally feel better after talking to a doctor who listens to their problems and appears to be taking them seriously, and are also more likely to comply with proposed treatments. This is particularly important in patients with inflammatory arthritides or connective tissue diseases. These are chronic diseases requiring long-term follow-up. Patients need education and support, and may need to take toxic drugs under the doctor’s supervision. Patients with degenerative and overuse syndromes also need education and advice on how they can manage their symptoms for themselves.
In the UK, musculoskeletal diseases are the most common causes of physical disability, producing significant disability in 5% of the population. Musculoskeletal symptoms are very common and account for 20% of general practitioner consultations. Advances in laboratory tests and imaging have improved understanding and evaluation of these conditions, but in most cases diagnosis and management can be based on the history and examination. Pathognomonic tests are relatively few; they include culture of micro-organisms from joint fluid in septic arthritis and demonstration of urate crystals in synovial fluid in gout. In most disorders, diagnosis depends on a combination of clinical signs and symptoms (e.g. rheumatoid arthritis (RA)), clinical and radiological features (e.g. osteoarthritis) or clinical and laboratory findings (e.g. systemic lupus erythematosus). A suggested classification based on inflammation, joint pain, swelling and stiffness, and pattern of joint involvement is shown in Figure 1. There is now sound evidence that early intervention with disease-modifying drugs in RA improves the medium-term outcome. In more complex and chronic disorders, the multidisciplinary team has a central role; depending on the patient’s needs, it may include physicians, surgeons, nurses, physiotherapists, occupational therapists, podiatrists, social workers and orthotists. The most common causes of musculoskeletal disability remain osteoarthritis of the knee and back pain. Clinically significant knee osteoarthritis affects about 15% of individuals over the age of 60 years, and in the UK the size of this age group will increase from 12 million in 2001 to 19 million in 2031. Minimizing the burden of disease caused by musculoskeletal disorders will be a major challenge and should ideally be approached at a preventive level rather than by use of more ‘pills and operations’. There are good experimental and observational data that lifestyle changes (becoming leaner, fitter and stronger) reduce the incidence of knee osteoarthritis and its symptoms and progression. Whether such lifestyle changes can be widely achieved is less certain. u
MEDICINE
General principles Ensure that the patient is comfortable before you begin. This may require rearranging the seating to accommodate those who have difficulty getting in and out of ordinary chairs, or who are confined to a wheelchair. It is important to start with an ‘open’ question that encourages a descriptive answer; for example: ‘Tell me about your joint problems’. This allows the patient to give a broad overview of his or her story. Fill in the details with focused (closed) questions, such as: ‘Which joints are affected? Do they feel stiff? Do they swell?’
Jane E Dacre is Professor of Medical Education and Director of the Academic Centre for Medical Education at the Royal Free and University College Medical School, London, UK, and Consultant Physician and Rheumatologist at the Whittington Hospital, London. Jennifer G Worrall is Consultant Rheumatologist at the Whittington Hospital, London, UK. She qualified from the Royal Free Hospital, London, and trained in general medicine and rheumatology.
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© 2002 The Medicine Publishing Company Ltd
tissue disorders. Metabolic bone disease and autoimmune connective tissue diseases are discussed in MEDICINE 29:12 and 30:10 respectively. • Some musculoskeletal disorders are predominantly genetic (e.g. hypermobility syndrome). • Others depend on genetic and environmental factors (e.g. reactive arthritis). • Some are associated with ageing (e.g. osteoarthritis). • In others (e.g. fibromyalgia), complex psychosocial and biological factors operate.
Musculoskeletal Disorders: Introduction Ian D Griffiths The musculoskeletal disorders encompass diseases of the locomotor system and, traditionally, multisystem connective
ClassiÞcation of rheumatic diseases Inßammatory Monoarticular • Acute Septic arthritis Gout Haemarthrosis Calcium pyrophosphate • Chronic
Non-inßammatory Monoarticular • Acute Fractures Sports injuries Torn meniscus Loose body ‘Sprain’
Tuberculosis Pauci-articular juvenile chronic arthritis
• Chronic
Polyarticular • Acute Viral Rheumatic fever Erythema nodosum • Chronic
Polyarticular • Acute
Symmetrical Rheumatoid arthritis Seronegative juvenile chronic arthritis Polymyalgia rheumatica Chronic tophaceous gout
• Chronic
Asymmetrical Psoriatic arthritis Inflammatory bowel disease Reiter’s syndrome Pauci-articular juvenile chronic arthritis
Spinal • Acute
Systemic Systemic lupus erythematosus Polyarteritis Systemic juvenile chronic arthritis (Still’s disease)
Spinal • Acute • Chronic
Osteoarthritis Shoulder capsulitis Osteonecrosis ‘Enthesitis’ (e.g. tennis elbow, plantar fasciitis)
• Chronic
Generalized nodal osteoarthritis Haemochromatosis Hypermobility syndrome Fibromyalgia Diabetic cheirarthropathy
Disc prolapse Sprain Vertebral collapse Spondylosis Paget’s disease Neoplasia Spondylolisthesis Chronic degenerative disc disease
Osteomyelitis Infective discitis Ankylosing spondylitis Spondyloarthropathies Chronic infection (e.g. brucellosis, tuberculosis)
1
Ian D Griffiths is Consultant Rheumatologist at the Freeman Hospital, Newcastle upon Tyne, UK, and Senior Clinical Lecturer in Rheumatology at the University of Newcastle upon Tyne.
MEDICINE
1
© 2002 The Medicine Publishing Company Ltd
ASSESSMENT OF THE RHEUMATOLOGICAL PATIENT
What’s new
The Rheumatological History
There have been two significant pharmacological developments since the last MEDICINE Rheumatology Chapter was published in 1998. • The selective cyclo-oxygenase 2 (COX-2) inhibitors have been licensed and received approval from the UK National Institute for Clinical Excellence (NICE) for use in higher-risk patients (> 65 years, previous upper gastrointestinal disorders, co-morbidities, prolonged use). Two large randomized controlled trials suggest that these agents reduce serious upper gastrointestinal events by about 50%. • In 2002, NICE approved the use of two biological agents for the inhibition of tumour necrosis factor α in refractory RA and juvenile idiopathic arthritis (these agents were already licensed in the USA). This is the first highly targeted therapy in the treatment of RA, and an interleukin-1 inhibitor has also recently been licensed.
Jane E Dacre Jennifer G Worrall
A wide range of diseases may affect the musculoskeletal system, from minor regional soft tissue conditions (e.g. tennis elbow), to life-threatening systemic connective tissue diseases (e.g. systemic lupus erythematosus, SLE). The taking of a rheumatological history must therefore be flexible. Appropriate information must be gathered to make a quick diagnostic hypothesis, and time and understanding must be given to patients with severe disability. History-taking is an essential part of any consultation. It is important to recognize that several processes are occurring while you talk – you are gathering sufficient information to make an appropriate diagnosis, in addition to putting the patient at ease and developing a good relationship with him or her. An effective consultation is one in which a rapport is established with the patient. Patients generally feel better after talking to a doctor who listens to their problems and appears to be taking them seriously, and are also more likely to comply with proposed treatments. This is particularly important in patients with inflammatory arthritides or connective tissue diseases. These are chronic diseases requiring long-term follow-up. Patients need education and support, and may need to take toxic drugs under the doctor’s supervision. Patients with degenerative and overuse syndromes also need education and advice on how they can manage their symptoms for themselves.
In the UK, musculoskeletal diseases are the most common causes of physical disability, producing significant disability in 5% of the population. Musculoskeletal symptoms are very common and account for 20% of general practitioner consultations. Advances in laboratory tests and imaging have improved understanding and evaluation of these conditions, but in most cases diagnosis and management can be based on the history and examination. Pathognomonic tests are relatively few; they include culture of micro-organisms from joint fluid in septic arthritis and demonstration of urate crystals in synovial fluid in gout. In most disorders, diagnosis depends on a combination of clinical signs and symptoms (e.g. rheumatoid arthritis (RA)), clinical and radiological features (e.g. osteoarthritis) or clinical and laboratory findings (e.g. systemic lupus erythematosus). A suggested classification based on inflammation, joint pain, swelling and stiffness, and pattern of joint involvement is shown in Figure 1. There is now sound evidence that early intervention with disease-modifying drugs in RA improves the medium-term outcome. In more complex and chronic disorders, the multidisciplinary team has a central role; depending on the patient’s needs, it may include physicians, surgeons, nurses, physiotherapists, occupational therapists, podiatrists, social workers and orthotists. The most common causes of musculoskeletal disability remain osteoarthritis of the knee and back pain. Clinically significant knee osteoarthritis affects about 15% of individuals over the age of 60 years, and in the UK the size of this age group will increase from 12 million in 2001 to 19 million in 2031. Minimizing the burden of disease caused by musculoskeletal disorders will be a major challenge and should ideally be approached at a preventive level rather than by use of more ‘pills and operations’. There are good experimental and observational data that lifestyle changes (becoming leaner, fitter and stronger) reduce the incidence of knee osteoarthritis and its symptoms and progression. Whether such lifestyle changes can be widely achieved is less certain. u
MEDICINE
General principles Ensure that the patient is comfortable before you begin. This may require rearranging the seating to accommodate those who have difficulty getting in and out of ordinary chairs, or who are confined to a wheelchair. It is important to start with an ‘open’ question that encourages a descriptive answer; for example: ‘Tell me about your joint problems’. This allows the patient to give a broad overview of his or her story. Fill in the details with focused (closed) questions, such as: ‘Which joints are affected? Do they feel stiff? Do they swell?’
Jane E Dacre is Professor of Medical Education and Director of the Academic Centre for Medical Education at the Royal Free and University College Medical School, London, UK, and Consultant Physician and Rheumatologist at the Whittington Hospital, London. Jennifer G Worrall is Consultant Rheumatologist at the Whittington Hospital, London, UK. She qualified from the Royal Free Hospital, London, and trained in general medicine and rheumatology.
2
© 2002 The Medicine Publishing Company Ltd