Rheumatologists are internists with extra training in the diagnosis and treatment of arthritis and rheumatism. Our doctors are all Board Certified in Internal Medicine as well as Rheumatology. Their strong foundation in internal medicine prepares them as specialists in managing complex autoimmune diseases as well as may non-operative orthopedic problems. Rheumatologists are experts in the management of both localized and systemic (generalized) pain. For example, they treat localized pain in the back, neck, shoulders and hands, including osteoarthritis, tendonitis and bursitis, as well as complex systemic pain caused by diseases like rheumatoid arthritis or systemic lupus. Carpal tunnel syndrome and Lyme disease are other examples of the diverse problems treated by rheumatologists. Please see the list below for more examples with some information on the individual diseases.

Because many rheumatic diseases change or evolve, you may have to make more than one office visit before your rheumatologist reaches a definitive diagnosis. The diagnostic process usually includes a complete medical history, physical examination and, if indicated, blood tests and x-rays or MRI.

Your rheumatologist will take the lead in diagnosing and caring for your condition and will communicate with your primary care physician about your illness. Over 500 specialists in the Los Angeles and surrounding areas area have referred patients to and requested consultations from the physicians at Rheumatology Therapeutics Medical Center.

Our center is staffed by medical doctors board certified in Rheumatology and Internal Medicine and by allied heath professionals that are experienced and caring. By offering on-site Rheumatology Consultative Services, X-ray, DEXA, MRI, Laboratory, Physical Therapy, Clinical Trials, and Infusion Services we make your total care convenient for you.

RTMC exists to provide only the highest level of Rheumatology care available:

• Provide Board Certified Specialists in Rheumatology to the communities we serve.
• Physical Therapists and nurses who are experienced, board certified and have special training and interest in taking care of Rheumatic Diseases.
• Have a courteous, helpful, and knowledgeable staff that will enhance your experience in our center.
• Have convenient locations, so that we can bring state-of-the-art arthritis care for our community.
• Incorporate your doctors, x-ray, bone density testing (DEXA), laboratory, infusion therapy, clinical studies, and physical therapy all in one space, to make your total care convenient for you.

Our center combines state-of-the-art medical care with a friendly relaxed environment.

RTMC is located in San Fernando Valley of Los Angeles. The center is only one block off the 101 Freeway and one block off Ventura Boulevard. The center is also across the street from Encino-Tarzan Medical Center, a leading hospitals in Los Angeles. The area around the center also has multiple pharmacies, grocery and retail stores, as well as a multitude of multicultural restaurants.

In an effort to accommodate our patients we have assembled an all star international staff. Different languages spoken by our staff to accomodate you include: English, Spanish, Russian, Farsi, Tagalog, and Korean.

As an innovative medical practice we take a comprehensive approach combining  traditional westernized medicines as well as nutritional supplements such as vitamins, herbs, and trace minerals.  Dr Jenny S. Oh and Dr Boris Ratiner are both dual board certified physicians in Internal Medicine and Rheumatology.  We believe strongly in utilizing and recommending only those nutritional supplements that we feel will optimize care.  Through our own extensive research, we have custom formulated  supplements at therapeutic dosages specifically for use in our patients with rheumatological conditions such as osteoarthritis, rheumatoid arthritis, chronic pain syndromes including fibromyalgia, muscle pain, bursitis, and tendonitis.

Nutritional supplements are frequently falsely advertised in regards to its effectiveness and purity of product.  Since they are often unregulated by the Federal Drug Administration (FDA), these supplements are marketed without undergoing rigorous clinical trials and are recommended by non-medical sales people whose interests do not lie with the patient.

The supplement mixtures that we make are unique and these combinations of nutritional supplements, herbs, vitamins, and minerals cannot be found at any local health food store.  We use only the most respected manufactures who guarantee the purity of their ingredients.  We do not plan to mass produce these supplements as we will constantly be monitoring its effects and modifying dosages and ingredients as new information is released in the scientific literature.  Our goal is to remain at the forefront of complimentary supplement use for rheumatological diseases.

We are currently in the process of custom manufacturing supplements that block different points in the pathway of joint destruction in osteoarthritis, rheumatoid arthritis, and other inflammatory diseases.  We believe that use of natural supplements will provide a superior alternative to NSAIDS such as the COX-2 inhibitors and others such as indomethacin, tylenol, and other pain medications.  We also believe that these supplements may help prevent joint damage and help joint pain, but with less adverse reactions and toxicities than are seen in conventional pain medications.

• Infectious arthritis causes pain and swelling in the joints. Joints are the places where two or more bones come together. The pain and swelling is called inflammation.
• The inflammation is caused by a germ. The germ can be a bacterium (back-teer-e-um), a virus, or a fungus.
• Infectious arthritis normally affects only one joint, but sometimes affects more.
• It does not usually last a long time if it is treated early.
  Infectious arthritis is a form of joint inflammation caused by a germ. The germ can be a bacterium, a virus or a fungus. Infection of the joints usually occurs after a previous infection elsewhere in the body. There is usually only one joint involved, though sometimes two or three joints can become infected. Mostly, infectious arthritis affects the large joints (shoulders, hips, knees), but smaller joints (fingers, ankles) can also be involved.

How common is infectious arthritis?

• Both men and women can get infectious arthritis.
• It can affect people of any age.
• Some people are more likely to get infectious arthritis than others. For example, a person who has an illness that makes it harder to fight off other infections may be more at risk.

Any person, at any age, can get infectious arthritis. However, some people are more likely to get infectious arthritis than others. These include those with conditions that make it difficult to fight off infection, such as:

• diabetes
• sickle-cell anaemia
• severe kidney disease
• AIDS
• immune deficiency
• some forms of cancer
• alcoholism
• intravenous drug abuse

People with an existing arthritis are also more likely to develop infectious arthritis, because germs tend to infect a joint that is damaged, and therefore weaker than a healthy one. If a person has had surgery to replace a joint with an artificial one, this can also provide a slight chance of infection developing. If it does, it usually occurs a short time after the surgical procedure. However, it is not unheard of for infection to show up in a person years after having joint replacement surgery.
Some of the stronger medications used to treat certain types of inflammatory arthritis also lower the body’s resistance to infection, making it easier for infectious arthritis to take hold.
People who work in jobs where exposure to animals, plants, marine life and soil is common also have a higher chance of contracting infectious arthritis.

What are the warning signs of infectious arthritis?

• If you have infectious arthritis, the warning signs are different depending on what type of germ causes it.
• If it is caused by a bacterium, the pain and swelling is usually only in one spot. It tends to come on suddenly. You may also have a fever and chills.
• If it is caused by a virus, you may have pain all over. Usually there is no fever.
• If it is caused by a fungus, the pain and swelling comes on very slowly, over weeks or months. The pain and swelling can be in one spot or all over the body. There may be a mild fever.

The symptoms of infectious arthritis vary according to the type of germ causing it. If the arthritis is caused by a bacterium, inflammation is generally located in only one place or area. The infection is often accompanied by fever and chills and its onset is quite sudden. With infectious arthritis caused by a virus, there is usually no fever, but there is an aching feeling all over the body. Inflammation caused by a fungal infection can be in one area or throughout the body, and it usually occurs very slowly, over weeks or months. You may have a mild fever or no fever at all.

Acute or short-term low back pain generally lasts from a few days to a few weeks. Most acute back pain is mechanical in nature — the result of trauma to the lower back or a disorder such as arthritis. Pain from trauma may be caused by a sports injury, work around the house or in the garden, or a sudden jolt such as a car accident or other stress on spinal bones and tissues. Symptoms may range from muscle ache to shooting or stabbing pain, limited flexibility and/or range of motion, or an inability to stand straight. Occasionally, pain felt in one part of the body may “radiate” from a disorder or injury elsewhere in the body. Some acute pain syndromes can become more serious if left untreated.

Chronic back pain is measured by duration — pain that persists for more than 3 months is considered chronic. It is often progressive and the cause can be difficult to determine.

What structures make up the back?

The back is an intricate structure of bones, muscles, and other tissues that form the posterior part of the body’s trunk, from the neck to the pelvis. The centerpiece is the spinal column, which not only supports the upper body’s weight but houses and protects the spinal cord — the delicate nervous system structure that carries signals that control the body’s movements and convey its sensations. Stacked on top of one another are more than 30 bones — the vertebrae — that form the spinal column, also known as the spine. Each of these bones contains a roundish hole that, when stacked in register with all the others, creates a channel that surrounds the spinal cord. The spinal cord descends from the base of the brain and extends in the adult to just below the rib cage. Small nerves (“roots”) enter and emerge from the spinal cord through spaces between the vertebrae. Because the bones of the spinal column continue growing long after the spinal cord reaches its full length in early childhood, the nerve roots to the lower back and legs extend many inches down the spinal column before exiting. This large bundle of nerve roots was dubbed by early anatomists as the cauda equina, or horse’s tail. The spaces between the vertebrae are maintained by round, spongy pads of cartilage called intervertebral discs that allow for flexibility in the lower back and act much like shock absorbers throughout the spinal column to cushion the bones as the body moves. Bands of tissue known as ligaments and tendons hold the vertebrae in place and attach the muscles to the spinal column.

Starting at the top, the spine has four regions:

• the seven cervical or neck vertebrae (labeled C1–C7),
• the 12 thoracic or upper back vertebrae (labeled T1–T12),
• the five lumbar vertebrae (labeled L1–L5), which we know as the lower back, and
• the sacrum and coccyx, a group of bones fused together at the base of the spine.

The lumbar region of the back, where most back pain is felt, supports the weight of the upper body.

What causes lower back pain?

As people age, bone strength and muscle elasticity and tone tend to decrease. The discs begin to lose fluid and flexibility, which decreases their ability to cushion the vertebrae.

Pain can occur when, for example, someone lifts something too heavy or overstretches, causing a sprain, strain, or spasm in one of the muscles or ligaments in the back. If the spine becomes overly strained or compressed, a disc may rupture or bulge outward. This rupture may put pressure on one of the more than 50 nerves rooted to the spinal cord that control body movements and transmit signals from the body to the brain. When these nerve roots become compressed or irritated, back pain results.

Low back pain may reflect nerve or muscle irritation or bone lesions. Most low back pain follows injury or trauma to the back, but pain may also be caused by degenerative conditions such as arthritis or disc disease, osteoporosis or other bone diseases, viral infections, irritation to joints and discs, or congenital abnormalities in the spine. Obesity, smoking, weight gain during pregnancy, stress, poor physical condition, posture inappropriate for the activity being performed, and poor sleeping position also may contribute to low back pain. Additionally, scar tissue created when the injured back heals itself does not have the strength or flexibility of normal tissue. Buildup of scar tissue from repeated injuries eventually weakens the back and can lead to more serious injury.

Occasionally, low back pain may indicate a more serious medical problem. Pain accompanied by fever or loss of bowel or bladder control, pain when coughing, and progressive weakness in the legs may indicate a pinched nerve or other serious condition. People with diabetes may have severe back pain or pain radiating down the leg related to neuropathy. People with these symptoms should contact a doctor immediately to help prevent permanent damage.

The cause of psoriatic arthritis is unknown. Doctors suspect that genetic, environmental and immune factors play a role in the condition. It is classified in the group of diseases called Seronegative Spondyloarthropathies (Other diseases in this group include Behcet’s disease, Reiter’s syndrome, ankylosing sponylitis, Marie-Strumpell arthritis, Rheumatoid spondylitis, psoriatic arthritis, and inflammatory bowel disease.) Approximately 40 percent of people who develop psoriatic arthritis have a family member with either psoriasis or arthritis.

Psoriatic arthritis can start slowly with mild symptoms, or it can develop quickly. Left untreated, psoriatic arthritis can be a progressively disabling disease.

Symptoms include:

• stiffness, pain, swelling and tenderness of the joints and the soft tissue around them
• reduced range of motion
• morning stiffness and tiredness
• nail changes, including pitting or lifting of the nail-found in 80 percent of people with psoriatic arthritis
• redness and pain of the eye, such as conjunctivitis

Joints commonly affected by psoriatic arthritis are the wrists, knees, ankles, lower back and neck. Psoriatic arthritis can develop any time, but for most people it appears between the ages of 30 and 50, and it affects men and women equally.

Five Types of Psoriatic Arthritis (PA)

Symmetric Arthritis
This form of PA is much like rheumatoid arthritis but generally milder with less deformity. It usually affects multiple symmetric pairs of joints and can be disabling. The associated psoriasis is often severe. About 50 percent of people with this form of PA will develop varying degrees of progressive, destructive disease, which can be disabling.

Asymmetric Arthritis
Asymmetric (not occuring in the same joints on both sides of the body) arthritis usually involves only one to three joints. It can affect any joint, such as the knee, hip, ankle or wrist. It could involve just one finger or a number of them. The hands and feet have enlarged “sausage” digits, caused by swelling and inflammation of tendons. The joints may be warm, tender and red. Individuals may experience periodic joint pain that is usually responsive to medical therapy. This form is generally mild, although some people will develop disabling disease.

Distal Interphalangeal Predominant (DIP)
This form of arthritis, although the “classic” type, occurs in only about 5 percent of people with psoriatic arthritis. Primarily, it involves the distal joints of the fingers and toes (the joint closest to the nail). Sometimes it is confused with osteoarthritis, but nail changes are usually prominent.

Spondylitis
In about 5 percent of individuals, inflammation of the spinal column is the predominant symptom. Inflammation with stiffness of the neck, lower back, sacroiliac or spinal vertebrae are common symptoms in a larger number of patients, making motion painful and dificult. Peripheral disease can be present in the hands, arms, hips, legs and feet. Spondylitis, when severe, may be associated with generalized symptoms.

Arthritis Mutilans
This is a severe, deforming and destructive arthritis that affects fewer than 5 percent of people with psoriatic arthritis. It principally affects the small joints of the hands and feet, though there is frequently associated neck or lower back pain. This type can progress over months and years. Arthritic flares and remissions tend to coincide with skin flares and remissions.

Approach to Therapy of Psoriatic Arthritis:
Current therapy for psoriatic arthritis (PA) can relieve pain, reduce swelling, help keep joints working properly and possibly prevent further tissue damage. Physicians will choose treatments based on the type of PA, its severity and an individual’s reaction to treatment.

What Is Pseudogout and How Is It Different from Gout?
Pseudogout, is very similar to gout, but is caused by deposits of calcium pyrophosphate dihydrate crystals in and around the joints. (It is, in fact, medically referred to as calcium pyrophosphate dihydrate deposition disease, or CPPD.) Though pseudogout resembles gout in some ways, there are differences:

• The first attack typically strikes the knee rather than the joint of the big toe.
• At least two-thirds of cases affects more than one joint during a first attack.
• The symptoms of pseudogout also appear more slowly than those of gout, taking days rather than hours to develop.
• Pseudogout is more likely to first develop in elderly people, particularly those with osteoarthritis. (It affects between 10% and 15% of people over 65.)
• Pseudogout is more likely to occur in the autumn while gout attacks are most common in the spring

How Serious is Pseudogout?
There is no cure for pseudogout. It is a progressive disorder that can eventually destroy joints.

How is Pseudogout Treated?
Treatments for pseudogout are similar to those for gout and are aimed at relieving the pain and inflammation and reducing the frequency of attacks.

• Drug treatments for acute attacks of gout are aimed at relieving pain and reducing inflammation. They should be started as early as possible.
  Powerful forms of nonsteroidal anti-inflammatory drugs (NSAIDs) or COX2 inhibitors are the drugs of choice for an acute attack in younger, healthy patients with no serious health problems.
• Corticosteroids or corticotropin (ACTH) may be used in patients who cannot tolerate NSAIDs and they may be particularly beneficial for elderly patients. Injections into the affected joints provide effective relief for many patients. Oral steroids may be used for patients who cannot take NSAIDs or colchicine.
• Colchicine. Colchicine is used in healthy adults only and with caution. It should not be used in patients with kidney or liver problems.
• In severe cases surgery to remove the calcifications or joint replacement is necessary.
  Rest, applying cold, and protecting the affected joint with a splint can also promote recovery. After the first attack, some physicians advise their patients to keep a supply of medications on hand so that self-medication can begin at the first sign of symptoms of a second acute attack

Osteoporosis is a common bone disease that affects both men and women, usually as they grow older. Fortunately, you can take steps to reduce your risk of developing osteoporosis and avoiding the often-debilitating bone fractures that can result from this disease. If you already have osteoporosis, new medications are available to slow or even stop its progression.

Fast Facts

• Age is not the only risk factor for osteoporosis. Other diseases and even medications can cause this condition.
• A simple diagnostic test known as a bone density test can provide valuable information about your bone strength.
• New medications exist to slow and even stop the progression of osteoporosis.

What osteoporosis is

Osteoporosis is a silent disease of the bones that makes them weaken and prone to fracture. Bone is living tissue that is in a constant state of regeneration, as old bone is removed (bone resorption) and replaced by new bone (bone formation). By their mid-30s, most people begin to gradually lose bone strength as the balance between bone resorption and bone formation shifts, so that more bone is lost than can be replaced. As a result, bones become thinner and structurally weaker.

The disease is “silent” because there are no symptoms when you have osteoporosis, and the condition may come to attention only after you break a bone. When you have osteoporosis, this can occur even after a minor injury, such as a fall. The most common fractures occur at the spine, wrist and hip. Spine and hip fractures in particular may lead to chronic pain, long-term disability and even death. The goal of treating osteoporosis is to prevent such fractures in the first place.

What causes osteoporosis

Many factors will increase your risk of developing osteoporosis and suffering a fracture. Some of these risk factors can be changed, while others cannot. Recognizing your own risk factors is important so that you can take steps to prevent this condition from developing or treat it before it becomes worse. Major risk factors include:

• Older age (starting in the mid-30s but accelerating after 50)
• Non-Hispanic white and Asian ethnic background
• Small bone structure
• Family history of osteoporosis or osteoporosis-related fracture in a parent or sibling
• Previous fracture following a low-level trauma, especially after age 50
• Sex hormone deficiency, particularly estrogen deficiency, both in women (e.g. menopause) and men
• Anorexia nervosa
• Cigarette smoking
• Alcohol abuse
• Low dietary intake or absorption of calcium and vitamin D
• Sedentary lifestyle or immobility
• Medications: glucocorticoid medications such as prednisone (Prelone)(see fact sheet on glucocorticoid-induced osteoporosis); excess thyroid hormone replacement; the blood thinner heparin (Calciparine, Liquaemin, etc.); certain anti-convulsant medications such as phenytoin (Dilantin) and ethotoin (Peganone), etc.
• Certain diseases can affect bone, such as endocrine disorders (hyperthyroidism, hyperparathyroidism, Cushing’s disease, etc.) and inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, etc.)

For most people, lupus is a mild disease affecting only a few organs. For others, it may cause serious and even life-threatening problems. More than 16,000 Americans develop lupus each year. It is estimated that 500,000 to 1.5 million Americans have been diagnosed with lupus.

TYPES OF LUPUS

There are three types of lupus: discoid, systemic, and drug-induced. Discoid (cutaneous) lupus is always limited to the skin. It is identified by a rash that may appear on the face, neck, and scalp. Discoid lupus is diagnosed by examining a biopsy of the rash. In discoid lupus the biopsy will show abnormalities that are not found in skin without the rash. Discoid lupus does not generally involve the body’s internal organs. Therefore, the ANA test, a blood test used to detect systemic lupus, may be negative in patients with discoid lupus. However, in a large number of patients with discoid lupus, the ANA test is positive, but at a low level or “titer.”

In approximately 10 percent of patients, discoid lupus can evolve into the systemic form of the disease, which can affect almost any organ or system of the body. This cannot be predicted or prevented. Treatment of discoid lupus will not prevent its progression to the systemic form. Individuals who progress to the systemic form probably had systemic lupus at the outset, with the discoid rash as their main symptom.

Systemic lupus is usually more severe than discoid lupus, and can affect almost any organ or system of the body. For some people, only the skin and joints will be involved. In others, the joints, lungs, kidneys, blood, or other organs and/or tissues may be affected. Generally, no two people with systemic lupus will have identical symptoms. Systemic lupus may include periods in which few, if any, symptoms are evident (“remission”) and other times when the disease becomes more active (“flare”). Most often when people mention “lupus,” they are referring to the systemic form of the disease.

Drug-induced lupus occurs after the use of certain prescribed drugs. The symptoms of drug-induced lupus are similar to those of systemic lupus. The drugs most commonly connected with drug-induced lupus are hydralazine (used to treat high blood pressure or hypertension) and procainamide (used to treat irregular heart rhythms). Drug induced lupus is more common in men who are given these drugs more often. However, not everyone who takes these drugs will develop drug-induced lupus. Only about 4 percent of the people who take these drugs will develop the antibodies suggestive of lupus. Of those 4 percent, only an extremely small number will develop overt drug-induced lupus. The symptoms usually fade when the medications are discontinued.

Although drug-induced lupus and discoid lupus share features of systemic lupus, the rest of this brochure primarily discusses systemic lupus.

Who Gets Behçet’s Syndrome?
Behçet’s syndrome is common in the Middle East, Asia, and Japan, but rare in the United States. In Middle Eastern and Asian countries, the syndrome affects more men than women. In the United States, the opposite is true. Behçet’s syndrome tends to develop in people in their twenties or thirties, but people of all ages can develop it.

What Causes Behçet’s Syndrome?
The exact cause of Behçet’s syndrome is unknown. Most of the symptoms are caused by inflammation of the blood vessels, particularly veins. Inflammation is the body’s characteristic reaction to injury or syndrome and is marked by four signs: swelling, redness, heat, and pain. Doctors think that an autoimmune reaction may cause blood vessels to become inflamed, but they do not know what triggers this reaction. In an autoimmune reaction, the immune system mistakenly attacks and harms the body’s own tissues. Under normal conditions, the immune system protects the body from syndromes and infections by killing harmful “foreign” substances, such as germs, that enter the body.

Behçet’s syndrome is not contagious and does not spread from one person to another. Researchers think that two factors are probably important in its development. First, it is believed that abnormalities of the immune system make some people susceptible to the syndrome. Researchers think that this problem may be inherited; that is, it may be due to one or more specific genes. Second, something in the environment, possibly a bacterium or virus, might trigger or activate the syndrome in susceptible people. Researchers have found that people who have frequent strep infections (caused by Streptococcus bacteria) are more likely to develop Behçet’s syndrome.