What is a rheumatologist?
A rheumatologist is a physician who has completed a three year internal medicine or four year combined internal medicine – pedicatrics 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 interventions to control the disease process. Common themes are to reduce pain, maximize function, prevent organ damage (including structural joint damage), 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, therapy, pain relievers, oral and intra-articular corticosteroids, and a toolbox of twenty 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, Hastings, Ionia, Mt Pleasant, Traverse City, Gaylord, Petosky, 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. The onset is can be relatively quickly over days to weeks with swelling of the joints of the hands, wrists, elbows, knees and feet. Sometimes this happens in the post-partum period. Later in the course some people develop rubbery, pea sized nodules under the skin at the elbows or heels. Early recognition is important as treatment with targeted immune modulators can control symptoms and prevent or slow the development of joint damage.
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.
Other Forms of Vasculitis
Polyarteritis Nodosum (PAN) is a vasculitis which compromises blood flow to virtually any organ including: skin, skin, joints, nerves, bowel, and testicle. Henoch Shoenlein 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 (including Hepatitis C) 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.
West Michigan Rheumatology has provided bone mineral screening via dual x-ray adsorptometry (DEXA) since 1996. Managing bone health by preventing or treating osteoporosis is an core aspect of rheumatology care. This is another cost-saving, efficiency of the integrated care we provide
Digital x-rays are an important tool in evaluating and monitoring varied forms of arthritis. They can help differentiate osteoarthritis, pseudogout, gout and rheumatoid arthritis. In patients with osteoporosis spinal compression fractures can only be detected via x-ray as they are often without symptoms. In clinical trials digital xrays of the hands and feet are electronically transfered to research radiologists to compare Sharp Scores – the key measure of progression of structural joint damage in rheumatoid arthritis. Though costly MRI may be needed, usually x-rays of the sacroiliac joints and lumbar spine are sufficient to support the diagnosis of ankylosing spondylits. So having radiology services available at the point of care is efficient and less expensive than hospital associated clinics (no added facility fees).
Having the ability to immediately evaluate a patient on immunosuppressive medications for pneumonia can impact our decision making and increase patient safety. The rheumatologist interpreting x-rays in light of their clinical examination adds another level of sophistication and value for patients.
Clinic Based Infusion Therapy
Rheumatologists have a toolbox of biologic therapies that target and block specific aspects of the immune system with the goal of returning immune regulation closer to normal. At West Michigan Rheumatology we have provided infusions services for our patients since 1998. Infiximab (Remicade), abatacept (Orencia), rituximab (Rituxan), and tocilizumab (Actemra) as well as their related biosimilar preparations are important options in our toolbox of rheumatoid arthritis therapy. In addition Benlysta, rituximab (Rituxan) and IV steroid bursts are used in SLE and tocilizumab (Actemra) in giant cell arteritis. We also administer Reclast for the treatment of osteoporosis.
We believe having a dedicated infusion nurse that knows you who is within arm reach of your physician increases the safety of your care. We specialize in caring for our patients, so you will never be exposed to patients receiving intra-venous antibiotics for drug resistent infections or patients receiving cancer chemotherapy.