[Guideline for the joint swelling symptom--primary physician problem management and referral indications. German Society of Rheumatology "Quality Assurance" Committee]. / Leitlinie für das Symptom Gelenkschwellung--Primärärztliches Problemmanagement und Uberweisungsindikationen. Deutsche Gesellschaft für Rheumatologie Kommission "Qualitätssicherung".

The guideline "Joint Swelling" is addressed to primary care physicians--general practitioners, internists or orthopedists without special experience in rheumatology. It provides a framework for interviewing patients, as well as for physical, laboratory and imaging examinations and for selection of treatment appropriate to the level of primary care. Situations which call for urgent evaluation and criteria for referral to rheumatologists are described. The appendix contains comments on signs and symptoms to differentiate arthralgia from joint swelling and on the diagnostic value of a history of joint swelling without confirmation by the physician. Further recommendations for the evaluation of patient history and physical and technical examinations are given in a tabular form. The significance of laboratory and imaging procedures is discussed.

[Expanded anamnesis and psychodiagnostic classification of psychosomatic rheumatic patients. I: Anamnestic indications of psychosomatic correlations with manifestations of the locomotor system]. / Erweiterte Anamnese und psychodiagnostische Einordnung beim psychosomatischen Rheumapatienten. Teil I: Anamnestische Hinweise auf psychosomatische Zusammenhänge mit Manifestationen am Bewegungsapparat.

The author describes the information gained from anamnesis which points to a psychogenetic cause of rheumatic complaints. These symptoms are part of the diagnostically important criteria which must be supplemented still further by means of a personal discussion with the patient. A great deal depends on the skill of the physician in conducting these talks, with regard to obtaining relevant information on personal problems which may be underlying the disease patterns. Of course the possibility of a connection of the detected problems with the clinical picture should be given.

[The therapy of pain in rheumatic joint-and spine diseases.]. / Die Schmerztherapie bei rheumatischen Gelenk-und Wirbelsäulenerkrankungen.

The therapy of pain caused by rheumatic diseases above all must take into consideration the cause of the pain. In rheumatoid arthritis, especially in the early stages, inflammation is the primary cause of the pain. The pain decreases the inflammation subsides following the administration of non-steroidal anti-inflammatory drugs (NSAIDs), or corticosteroids, if necessary. The so-called disease modifying anti-rheumatic drugs do not influence the inflammation or consequently, the pain directly, but rather through mechanisms before the local joint process some of which are not exactly known. In later stages of the progressive joint degeneration the NSAIDs only have a limited effect regarding the inhibition of inflammation. In osteoarthrosis, in which the pain is caused by a secondary inflammation and increasingly by capsular, muscular and tendon involvement, the pain is only treated by NSAIDs in active inflammatory stages; otherwise, the treatment is physical activity and medication. In degenerative and static disorders of the spine the pain is caused predominantly by muscular bracing. Therefore, physical and especially gymnastic therapy play a major role. Whether muscle relaxants have an effect on muscle bracing is doubtful. If there is pressure on the ligaments and, in cases of vertebral dislocation with overstraining of the vertebral joints, therapy with local injections is indicated. The pain in osteoporosis is also predominantly muscular and must be treated accordingly. Above all, high doses of calcium and calcitonin are effective analgesics. Moreover, fluoride also acts as an analgesic once the osteoporosis has stabilized. In most cases fibromyalgia, which is mostly of a psychosomatic nature, cannot be influenced by medical therapy. Instead repeated attempts at treatment help to make the affliction chronic with neurotic fixation. Also, as a rule, myotonolytic and tranquilizing substances are not effective.

[Expert assessment of psychosomatic disorders in rheumatology]. / Die Begutachtung psychosomatischer Leiden in der Rheumatologie.

There are often big problems regarding expert evidences of psychosomatic clinical pictures, because, contrary to the complaints expressed and perceived by the patient, somatic findings are not evident to justify a permanent disablement. Nearly without exception it is a question of chronified cases of psychosomatic complaints up to real psychoneuroses. The diagnosis and delimination from a simulation is difficult and is frequently failed. Without doubt there are cases, in which only the psychic component determines the vocational disablement.

[Work disability and the granting of pensions in psychogenic rheumatic diseases]. / Das Problem der Arbeitsunfähigkeit und Berentung bei psychogenen rheumatischen Erkrankungen.

This paper is the result of a symposium that addressed the problem of disablement and social pension for patients with psychosomatic-rheumatological complaints. This especially concerns patients suffering from psychosomatic manifestation at the locomotor apparatus, who are increasingly disabled and necessitating a pension, without actual somatic findings justifying a vocational disablement. Primarily it is a clinical picture of a generalized tendomyopathy, often underestimated in its importance. Definitions, causes, and clinical pictures are presented. A critical phase decisive for the disablement, the personality of the would-be pensioner, considerations for the physician regarding diagnostic and therapeutic efforts, elements of time and environment, and conditions at the work-place are discussed. In some cases a pension will be unavoidable and justifiable, even if the somatic findings seem not to be sufficient. The psychogenic picture must be carefully determined differentiated from simulation; determining the cause of aggravation is essential.

[HLA B27-associated rheumatic diseases from the clinical viewpoint]. / Zum Problem der HLA-B 27-assoziierten rheumatischen Erkrankungen aus klinischer Sicht.

On the basis of the description of the possible variable courses and symptoms of ankylosing spondylitis, Reiter's syndrome, and reactive arthritides (spondarthritides) frequently produced by intestinal infections, all of which show HLA B27 as the predisposing hereditary antigen in about 90% of the cases, it is discussed whether these conditions represent a disease entity in which additional unknown factors determine the expression and the tendency of the course of the disease.

[Seronegative, HLA B 27-associated spondylarthritis. - New orientation in nomenclature and classification?]. / Seronegative, HLA B 27-assoziierte Spondarthritiden. - Neuorientierung in Nomenklatur und Klassifikation?

It is shown that the concept of "seronegative HLA B 27 associated spondarthritis," which is unsatisfactory even as a name, cannot be accepted as a new overgroup in a logically constructed classification. HLA B 27 occurs in certain of these illnesses almost inevitably as a predisposing antigen; in others it is merely a factor modifying the pattern of disease. The illnesses thus are obviously different. In any case, the concept itself is not a diagnosis, in spite of the fact that it is at present often employed as a diagnostic term.