What is a rheumatologist?
A rheumatologist is a physician who has completed a three year internal medicine residency followed by additional two or more years of subspecialty training in the care of arthritis, immunologic and musculoskeletal diseases.
Sometimes our role is to ‘solve the riddle’ and determine if there is an underlying immunologic disease causing peoples’ symptoms. Other times the problem is already defined and our job is to integrate medical, rehabilitative and cognitive interventions to control the disease process. Common themes are to reduce pain, maximize function, prevent joint contractures, as well as maintain physical strength, work and social integration.
We do not always have all the answers. There are times when the best conclusion is a rheumatic disease is ruled out.
In all cases we work to create a balanced treatment plan that emphasizes adaptation, self-management and effective coping. Medical treatments may include: exercise, occupational and physical therapy, non-steroidal anti-inflammatory drugs, corticosteroids, and a toolbox of immunomodulators.
View this short video about rheumatology to learn more about the preparation and professional roles of rheumatologists.
As rheumatologists, we offer diagnostic and therapeutic services for in-patients and out-patients. Outpatient services are at our office on East Paris SE in Grand Rapids. We perform hospital consultations at Mercy Health Saint Mary’s Mercy Medical Center.
We work to extend our impact beyond Grand Rapids and with strive to serve as many patients ase we can from underserved North and West Michigan. We request physician referrals, so that we can work as a team with your primary physician. We currently co-manage complex rheumatic disease patients with physicians in Holland, Muskegon, Ludington, Mt Pleasant, Traverse City, Gaylord, Petosky, Roger City and Sault St. Marie, MI.
Deep knowledge and broad experience caring for people with:
Rheumatoid arthritis is a relatively common disease the effects 1.2% of the US population. It is more common in woman and can occur at any age. Warning signs are prolonged morning stiffness, swelling of the bilateral wrists, knuckles, elbows or knees for more than 6 weeks and possibly marble sized nodules under the skin at the elbows. It often develops abruptly over a few days or weeks. Prompt treatment can help control swelling and prevent joint damage. Physicians at WMR have an active 20 year long research thread of clinical investigations of new treatment for rheumatoid arthritis. Check out our research page for details.
Between 15 and 30 % of people with psoriasis develop inflammatory arthritis. This has varied patterns, but can cause swelling of joints (the pinky joint above), dactylitis or sausage digit (#2,3 toes above). Psoriasis is a red-based, silvery, scaling rash that involves the scalp, elbow, knees, groin folds and can cause pitting or other deformities of the nails.
Ankylosing Spondylitis (AS) typical causes its first symptoms of non-trauma induced, gradual onset low back pain and stiffness before the age of 30. It can be progressive and cause fusion of the spine. Though up to 20 % of Americans experience low back pain < 1 % have AS. It is often associated with joint swelling, achilles tendonitis, plantar fasciitis or iritis. X-ray and MRI of the sacroiliac joints and the spine can help with diagnosis. Recognition is key as specific immune blocking therapies can improve symptoms.
Enteric Arthritis (occuring with Crohn’s Disease and Ulcerative Colitis)
Inflammatory bowel disease (IBD) can affect multiple parts of the body outside the digestive system. Of people with (IBD) 13% will develop joint inflammation, 10 % sacroiliitis, and 3% ankylosing spondylitis. Control of the bowel typically improves the joints. In some cases inflammatory arthritis predates development of bowel related symptoms.
Systemic Lupus Erythematosus
Systemic Lupus Erythematosis (SLE) is a disease of the control of antibody producing cells and their partners in inflammation complement. Any part of the body can be effected but in particular people develop:
- Sun senstive rashes (see papulosquamous (left) and discoid (right))
- Inflammation with swelling of the joints
- Inflammation with fluid collection around the heart or lungs
- Inflammation and damage of the filtering units of the kidney causing protein and blood cells to spill in to the urine.
- Immune based reduction of white, red or clotting cells
- Abnormal clotting which can cause recurrent miscarriage, stroke or blood clots in the calf or lung.
98 % of people with lupus will have a + ANA test, though 10% of healthy young woman are also ANA +. So the diagnosis of lupus is lead by the detection of physical findings and antibody testing is used to refine the diagnosis.
Raynaud’s phenomenon can occur by itself – primary raynauds – or secondary to another immune based disease such as scleroderma, lupus or other connective tissue disease. Scleroderma presents with raynauds and tense, shiny skin typically initially effecting the fingers and lower legs. This can be progressive and effect the upper limbs, face, chest and abdomen. About 1/2 those with scleroderma will develop lung scarring. Pulmonary hypertension occurs in about 20 % of patients. Early diagnosis and intervention can improve skin and stablize lung function. West Michigan Rheumatology has been a member of the Scleroderma Clinical Trials Consortium since 1993 and participated in many of the foundational studies in scleroderma therapy.
Eosinophilic fasciitis, morphea and other scarring skin conditions
There are a number of other mimickers of scleroderma. These typically present with more limited areas of skin thinkening, are not associated with raynauds phenomenon and usually do not involve internal organs. It is important for the rheumatologist to make the correct diagnosis – which may be based on the physical exam and in some cases imaging studies or deep tissue biospy.
Polymyositis and Dermatomyositis
There are a number of inflammatory diseases of the muscle that rheumatologists diagnosis and manage. This could be a disease only effecting muscles or could be a broader connective tissue disease that effects s, lung, and nerves. Lupus, Sjögren’s Syndrome, Scleroderma and Sarcoidosis can have related muscle inflammation. Typically a muscle biopsy is utilized to make a sure diagnosis. Myositis responds to many of the same treatments used in lupus and rheumatoid arthritis.
Sjögren’s Syndrome is an immune disease of the glands that produce tears, saliva and digestive enzymes. Dry, sandy eyes, dry mouth causing dental decay are the usual first symptoms. Rarely other parts of the body can be effected. Dryness symptoms are managed with fluid replacement therapies. Close collaboration with dentists, ophthamologists and optometrists is important.
Giant cell arteritis
Giant cell arteritis, which is also known as Temporal Arteritis, is the most common large vessel vasculitis. It typically begins in the 60s -70s with symptoms of new temple region headpain, scalp tenderness, aloss of vision, cramping jaw muscle pain with chewing associated with an elevated marker of inflammation – the sed rate (ESR) > 50. Its most serious complications are blindness and aortic aneurism. Diagnosis may require blood tests, imaging studies and temporal artery biopsy. Treatment is with corticosteroids often with adjunctive immunomodulators. Check out our research page for details of a new study evaluating a potential steroid sparing medication.
Wegener’s Granulomatosis (ANCA associated vasculitis)
Wegener’s Granulomatosis is a disease of the small and medium blood vessels. Is is also called ANCA associated vasculitis and subclassified into two groups: granulomatosis with polyangiitis and microscopic polyangiitis. These are both serious diseases that can involve the eye, sinsus, inner ear, lung, skin, kidneys and nerves. The photo shows infarcted finger tip skin and nailbeds. Connecting the dots to establish a sure diagnosis can challenge even experienced rheumatologists. Without treatment ANCA vasculitis can be deadly. Fortunately there are several immunomodulator treatments that can control or induce remission.
Henoch Schoenlein Purpura
Henoch Schonlein purpura (HSP) is an IgA mediated small vessel vasculitis that can present with purpura typically affecting the lower legs in patients who do not have defects in clotting. A similar pattern may be seen in leucocytoclastic vasculitis, which is a hypersensitivity reaction to a variety of drug of infectous exposures as well associated with some rheumatic diseases or rarely cancers. Treatment depends on the trigger.
Gout & Pseudogout
Typically these start as intermittant painful swelling of a single joint. With time multiple joints can be involved with persistent joint swelling. The two figures to the left show swelling and hints of pink white gout ‘tophi’ translucent through the skin. Diagnosis may require withdrawing joint fluid with a needle (chaulk like material on the slide to the right) and examining it for the presence of crystals. In most cases gout should be able to be completely controlled.
Osteoarthritis is caused by progressive cracking and thinning of the cartilage surface adjacent to joints. Bones remodel and make the joints appear larger. Osteoarthritis is caused by genetics, aging, and joint stress from activity and weight. There is no disease modifying drug to treat osteoarthritis, though simple pain relievers, activity modification, and exercise programs can help.
Osteoporosis relates to thinning of the bones. It is a silent disease that affects women most. One will not know they have it unless they have a bone density x-ray /DEXA or develop a fracture. This is typically wrist fractures in the 50s, spinal compression fractures in the 60s-70s and hip fractures in the 70s-80s. The best treatment is to prevent osteoporosis. Screening around menopause or for those treated with chronic steroids at any age is good practice. There are a variety of medications available to strengthen bone and reduce fracture risk.
How to prepare for your consultation
- Prior to arriving for your consultation, please fill out the “Patient Registration Form” and the “WMR New Patient Health Questionnaire”. This will save you time answering questions and leave more time with the doctor to address your questions. Be sure to bring both of these with you.
- You may also wish to bring records of any previous evaluation for the problem you think would be useful. In addition bring your regular shoes, orthotics, splints, canes or other adaptive equipment you feel the doctor should evaluate.
- If you would be more comfortable wearing a T-shirt and shorts rather than a traditional medical examination gown, please feel free to bring such attire.
- Please arrive at least 15 minutes prior to your appointment time for registration, so that completion of these procedures does not cut into the time scheduled for you to consult with the doctor.
How we use technology to enhance and coordinate your care
- We use eClinical Works electronic medical records (EMR) software
- The EMR records are securely stored on Amazon Cloud with mirror backups in 5 US cities.
- Interoperability – our EMR ‘talks’ with other EMRs via the national standard protocols Carequality Framework and Commonwealth Health Alliance.
- Laboratory interfaces – we have built electronic bridges to Spectrum Health, MercyHealth – Common Spirit, MetroHealth – UM, Quest and LabCorp. This means you can get your blood drawn at ANY of these venders and they will be reported to our portal.
- Technology is used to increase patient engagement & shared decision making. We provide a free web-based patient portal and Healow App with patient specific educational resources.
- WMR website has multimedia patient decision aids for high stakes meds.