Does He Have Back Pain or Rheumatism?

WIESBADEN, Germany — To differentiate temporary or even long-lasting symptoms, such as in the back, from one of the 100 or so "actual" rheumatologic conditions is not easy, even for specialists.

"Inflammatory conditions of the connective tissue, which pervades the body, can be found throughout, in joints, muscles, vessels, organs," explained Ulf Müller-Ladner, MD, chair of internal medicine with a focus on rheumatology, Justus Liebig University of Giessen, Kerckhoff campus, Bad Nauheim, Germany, at the annual conference of the German Society of Internal Medicine (DGIM).

Complicated Search for Evidence

If pain or inflammation develops anywhere in the body, medical specialists are in a "constant state of tension" and must discover whether the patient is still "healthy" or is actually "rheumatic." This is because the differentiation between "normal and ill is not strictly defined but is instead a sliding scale and is a little different for each individual rheumatic condition," said Müller-Ladner.

It is particularly difficult to differentiate between typical symptoms of rheumatic or systemic-inflammatory conditions, such as lasting joint or muscle pains, recurrent bouts of fever, or increasing loss of performance, without evidence of malignant disease or of reaction to conventional pain medication, the expert commented.

To get closer to a diagnosis, symptoms are mostly combined with imaging procedures and laboratory values — and like detectives at a crime scene, medical specialists use a network of evidence to find the right track to the "perpetrator" (ie, the condition).

"The rheumatic-immunologic search for evidence is often made even more complicated by the fact that individual or multiple laboratory parameters are measured and, just as with a crime, can lead to a perpetrator, but may also be a decoy for an incorrect track," said Müller-Ladner. "They have to identify the perpetrator in order to be able to arrest it and lock it away so that it cannot cause any more trouble."

Misleading Laboratory Parameters

According to Müller-Ladner, laboratory parameters may be indicative on the one hand, but may also be misleading on the other. Their correct assessment is therefore indispensable for finding a diagnosis. By using numerous examples, the rheumatologist explained the dilemma that medical specialists face when searching for evidence to identify the rheumatic condition.

"A positive rheumatoid factor in combination with short-term oligoarthritis following viral infection is definitely not rheumatoid arthritis. In contrast, deeply ingrained low-back pain in the mornings in combination with positive HLA-B27 allows the diagnosis of a rheumatic condition as inflammatory back pain, of the initial stage of ankylosing spondylitis," explained the rheumatologist.

"A positive ANA titer in a young woman who has mild skin redness following sun exposure does not automatically mean that systemic lupus erythematosus is present. In contrast, multiple stillbirths in combination with positive cardiolipin antibodies signifies antiphospholipid syndrome, which may define the rest of their life," said Müller-Ladner.

The problem is that the diagnosis of a rheumatic condition often takes a long time. However, for many of these symptoms, especially for inflammatory-rheumatic conditions such as rheumatoid arthritis, the operative premise is "time is joint." In other words, the earlier the condition is diagnosed and the treatment initiated, the more likely it is that joint stiffness will be delayed and irreparable damage prevented.

Unfulfilled Treatment Criteria

According to Müller-Ladner, the dilemma associated with rheumatic conditions goes even deeper. Only if the diagnosis is issued in accordance with certain criteria can certain medications be prescribed within the authorization.

"Highly effective, special medications that may lead to long-term remission and are not completely affordable" are authorized for certain rheumatic conditions. It is not rare that they are not prescribed "on-label" to a patient because not all the criteria required for evidence of the condition can be detected.

For example, one such criterion is symmetrical arthritis of the wrist detected by MRI, which is a very definite, early form of rheumatoid arthritis. The practitioner is then faced with the problem of "treating the patient in accordance with scientifically substantiated state-of-the-art knowledge and protecting the joints and ability to work in the long-term, but without there being a single on-label authorized medication available."

Treat Early, Prevent Damage

Müller-Ludner said that the only opportunity to differentiate normal muscle or joint pains from a rheumatic condition and to finally find appropriate treatment lies in "regularly checking every symptom that suggests a rheumatic condition with the up-to-date classification criteria of the different entities" and regularly incorporating new or altered symptoms, whether or not they are consistent with the respective indication.

Multidisciplinary cooperation is necessary for the exchange of expertise — such as between internal medicine specialists and rheumatologists, or rheumatologists and nephrologists — "in order to achieve the best possible for the patients."

Through new insights, such as those from clinical studies, classifications for individual rheumatic conditions are adapted internationally, as was the case with the criteria for systemic sclerosis, explained Müller-Ladner. Earlier, there were four to five criteria for this rare chronic condition; today there are at least 10. The situation is similar with systemic lupus, such that the variety and variability of the conditions are depicted through the criteria.

"The task for the future is to modify the current classification criteria through the new insights in such a way that the conditions requiring treatment can actually be treated in the interests of the patient at a stage at which long-term damage can be prevented," claimed Müller-Ladner.

This article was translated from the Medscape German edition.

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