Chapter 3 Initial clinical assessment of patients with possible rheumatic disease

Andrew Hassell, MD FRCP MMedEd, School of Medicine, Keele University, Keele, UK

Janet Cushnaghan, MSc MCSP, Epidemiology Resource Centre, Southampton General Hospital, Southampton, UK

CHAPTER CONTENTS

Introduction 27

Principles of rheumatological physical assessment 27

Overview 27

Joint pain 28

Evaluating regional joint pains 29

Musculoskeletal red flags 29

Further evaluation of the patient presenting with inflammatory joint pains 29

Assessing osteoporosis risk 29

Screening for Locomotor problems 30

The GALS tool: gait, arms, legs, spine 30

Gait 30

Spine 31

Arms 31

Legs 31

Outline of regional joint examination 31

Introduction 32

Look 32

Feel 32

Move 32

Function 32

Principles of investigations in evaluating patientswith rheumatic diseases 32

Blood tests 33

Imaging 33

Conclusion 33

Acknowledgement 33

KEY POINTS

Rheumatic diseases are frequently multi-system and multi-joint conditions and this should be considered in the therapy assessment

Screening for rheumatic disease in therapy assessments can be undertaken using careful history taking and simple physical tests

Simple screening questions and physical examinations can guide the clinical assessment.

INTRODUCTION

This chapter describes the key components of screening for rheumatic disease in clinical assessment. It can be used alongside the disease specific chapters following and can be embedded in routine musculoskeletal examinations and assessments of activities of daily living. The chapter draws on the arc-funded Handbook on the Clinical Assessment of the Musculoskeletal System (which comes accompanied by a DVD on regional examination) (http://www.arc.org.uk/arthinfo/documents/6321.pdf accessed March 2009).

PRINCIPLES OF RHEUMATOLOGICAL PHYSICAL ASSESSMENT

OVERVIEW

Successful identification and management of rheumatological problems in patients is predicated upon accurate history taking and examination. In this chapter we consider key aspects of history taking, physical examination and investigations in patients in whom rheumatological disease is suspected. For purposes of this chapter, we interpret rheumatological as pertaining to disorders of the musculoskeletal system (Doherty & Woolf 1999).

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JOINT PAIN

By far the commonest symptom with which patients with a rheumatological problem present is pain. For such patients, clinical assessment should first be undertaken to establish answers to the following five questions:

1. Does the problem seem musculoskeletal in nature?

2. Is the problem acute or chronic?

3. Is the problem inflammatory or non-inflammatory?

4. What is the pattern of joint involvement?

5. What is the impact of the symptoms on the patient?

Accurate addressing of the above questions should allow the therapist to go a long way in identifying the problem and appreciating the patient’s perspective. Over the next paragraphs, we will briefly expand upon each of these key questions.

1. Does the problem seem musculoskeletal in nature? Patients sometimes present with symptoms they perceive to be arising from their bones or joints when in fact this is not the case. Classic examples are patients with a biliary problem presenting with shoulder pain, patients with angina presenting with left arm pain and/or pins and needles, and patients with intra-abdominal or retro-peritoneal problems presenting with back pain. Careful history taking can often clarify and prevent such confusion.

2. Is the problem acute or chronic? Mode of onset and course is often very helpful in elucidating the nature of a patient’s rheumatological problem. The first issue is whether symptoms were related to any physical trauma which could be relevant in their causation – a fall, a possible sports injury, accident, etc. The second issue is the onset and duration. In the absence of injury, acute onset peripheral joint pains often are inflammatory in causation. Peripheral joint symptoms which fluctuate quite markedly are again, often inflammatory. By contrast, pain arising in association with osteoarthritis is often insidious in onset and gradually progressive.

3. Is the problem inflammatory or non-inflammatory? A key aspect of the assessment of a patient presenting with peripheral or spinal joint pain is deciding whether the problem is arising from underlying inflammation as this often has major implications for the diagnosis and management. Prominent joint stiffness, particularly prolonged morning stiffness of the joints (typically in excess of 30 minutes), is suggestive of an inflammatory problem. By contrast, patients with a non-inflammatory problem often report little stiffness. Knee stiffness which comes on after sitting and lasts a minute or two after standing is quite typical of osteoarthritis. Another pointer towards an inflammatory problem which may be reported by patients is joint swelling, particularly swelling which fluctuates. It must be recognised, however, that patients are sometimes not very accurate in reporting joint swelling. Other features suggesting an inflammatory problem include pains, which improve somewhat with activity (particularly in the case of inflammatory back pain) and the presence of systemic upset, e.g. anorexia, weight loss or fever.

4. What is the pattern of joint involvement? This is another highly relevant question. Is the problem monoarticular (one joint), oligoarticular (fewer than five joints) or polyarticular (more than four joints)? Is the joint involvement essentially symmetrical? Are small and large joints involved? If the hands are involved, are the distal interphalanageal (DIP) joints? Taking the information established from points 1-4, one may be able to summarise patients’ presentations thus: a 40-year-old woman with a chronic (4 month) fluctuating symmetrical inflammatory arthropathy involving the hands (sparing the DIPs), wrists and feet, with a sub-acute onset. This would be characteristic of a primary inflammatory arthropathy such as rheumatoid arthritis. Alternatively, a 60-year-old man with a one day history of an acute inflammatory arthropathy involving the right knee only would raise the likelihood of acute septic arthritis or crystal arthritis.

5. What is the impact of the symptoms on the patient? No assessment of a patient presenting with musculoskeletal symptoms is complete without an assessment of the impact of the symptoms on the patient’s activities and quality of life. Are there specific things the patient can’t do? Some therapists talk of a ‘disability ladder’, starting with inability of the patient to perform certain activities such as sport or hobbies, then prevention of activities more essential to the patient such as work or looking after the household, through to inability to perform essential activities such as self hygiene or sleeping. Part of this evaluation includes some assessment of the patient’s mood. Is the patient depressed? It should be remembered that, as well as joint symptoms resulting in patient depression, there are instances in which joint symptoms can be a physical representation of a patient’s depression or mental state, sometimes called somatisation.

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Evaluating regional joint pains

In addition to the above approach for a patient presenting with musculoskeletal pain, there are other specific aspects that require assessment in patients presenting with regional joint pains. Are there aspects of the patient’s activities, occupational or recreational, which may be causally relevant to their symptoms? More obvious examples include the development of heel pain in someone who does unaccustomed exercise or wears inappropriate footwear (possible plantar fasciitis), or lateral elbow pain in someone who has recently resumed racket sports (lateral epicondylitis). Other important questions for patients with a regional pain problem include exacerbating and relieving factors.

Symptoms in certain joints generally require specific questioning. One example is non-inflammatory mono-articular knee pain. In patients presenting with this, it is important to ask about ‘locking’ (an acute inability to extend the knee fully, which subsides spontaneously or with some manipulation by the patient – suggests a loose body within the joint) and ‘giving way’ (the knee acutely letting the patient down). The latter can arise from severe pain but can also be a result of ligamentous instability. In cases of patients presenting with non-inflammatory back pain, it is important to assess for radicular (nerve root compression) or myelopathic (spinal cord compression) problems, by asking about peripheral pins and needles, numbness and weakness, as well as disturbance of control of micturition or bowel evacuation.

MUSCULOSKELETAL RED FLAGS

Red flags are symptoms or signs which raise the possibility of serious underlying disease (Leerar et al 2007, Sizer et al 2007), generally neoplastic (malignant) or infectious. In patients with rheumatological problems, red flags may also reflect inflammatory disease.

Red flags include systemic features such as weight loss and fever, local features of unremitting, boring pain with prominent nocturnal pain, and a past history of cancer. In the case of back pain, the age of presentation can also be a red flag. First onset back pain aged > 50 would itself be deemed a red flag (Leerar et al 2007, Sizer et al 2007). The presence of red flags in a patient presenting with musculoskeletal symptoms generally highlights the necessity for further investigation and evaluation.

FURTHER EVALUATION OF THE PATIENT PRESENTING WITH INFLAMMATORY JOINT PAINS

If a patient is thought to be suffering from an inflammatory joint problem it is important to assess other body systems because of the known association of multi-system involvement in the various inflammatory joint conditions. Table 3.1 provides some examples of these associations.

Table 3.1 Non-articular associations of inflammatory rheumatic diseases

DISEASE	KNOWN NON-ARTICULAR ASSOCIATIONS	TYPICAL SYMPTOMS
Rheumatoid arthritis	Secondary Sjögren’s syndrome	Gritty eyes, dry mouth
	Raynaud’s phenomenon	Finger/toe colour changes
	Pulmonary fibrosis	Breathlessness
	Anaemia	Fatigue, breathlessness
	Aphthous ulcers	Painful mouth ulcers
Ankylosing spondylitis	Anterior uveitis	Painful red eye with blurring of vision
	Costovertebral involvement	Chest pain and infections
	Apical lung fibrosis	Breathlessness
	Aortic regurgitation	Breathlessness
	Inflammatory bowel disease	Bloody diarrhoea
Psoriatic arthritis	Psoriasis	Skin plaques on extensor surfaces
Psoriatic arthritis		Nail dystrophy
Systemic Lupus	Photosensitivity	Rash on sun exposed skin
Erythematosus	Raynaud’s phenomenon	Finger/toe colour changes
	Alopecia	Hair loss
	Serositis	Pleurisy, pericarditis, peritonitis
	Migraine	Migraine
	Anti-cardiolipin syndrome	Miscarriages, thromboses
Scleroderma	Raynaud’s phenomenon	Finger/toe colour changes
	Oesophageal dysmotility	Difficulty swallowing or heartburn
	Malabsorption	Weight loss, diarrhoea

In practice, screening questions might include:

1. Any skin problems or rashes?

2. Any grittiness of the eyes, red eye or visual problems?

3. Do fingers change colour (in the cold)? The classic triad of Raynaud’s colour changes consists of the fingers initially going white (as blood fails to gain access to the fingers), then blue (cyanosis of what blood is present), then red (re-entry of blood, e.g. on re-warming).

4. Any hair loss?

5. Any mouth ulcers, dryness of the mouth or swallowing difficulties?

6. Any bowel problems?

7. Any cough or breathlessness?

8. Any miscarriages?

9. Ever any thromboses, clots or DVTs

10. Any migraines?

11. Any genital ulcers?

ASSESSING OSTEOPOROSIS RISK

In certain patients encountered within rheumatological practice, the assessment of risk of osteoporosis and fractures is of great importance, particularly as osteoporosis is itself asymptomatic until a fracture occurs. Patients in whom assessment for this is particularly relevant include patients who have suffered a fragility fracture, i.e. a fracture after falling from no more than standing, patients on systemic steroids or patients with known risk factors (SIGN 2003). Table 3.2 indicates the risk factors for osteoporosis. Chapter 20 covers assessment and management of osteoporosis in greater detail.

Table 3.2 Osteoporosis risk factors

NON-MODIFIABLE
Age	Especially each decade after the age of 60
Gender	Female sex at higher risk
Ethnicity	Caucasians at higher risk
Early menopause
Family history of osteoporosis	Family history of kyphosis or low trauma fractures
Previous fragility fracture
Secondary causes of osteoporosis
Anorexia nervosa	Osteoporosis can result from low body mass index, causing a low oestrogen state; calcium and vitamin D deficiency also possible
Chronic liver disease
Coeliac disease
Hyperparathyroidisim
Hypogonadism
Inflammatory bowel disease
Renal disease
Rheumatoid arthritis
Drugs	Corticosteroids
	Heparin
	Certain anti-convulsants, e.g. phenytoin
Modifiable risk factors
Low body mass index
Smoking
Alcohol
Exercise	Sedentary lifestyle and/or history of sedentary adolescence is associated with increased risk
Dietary calcium and Vitamin D intake

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SCREENING FOR LOCOMOTOR PROBLEMS

THE GALS TOOL: GAIT, ARMS, LEGS, SPINE

One challenge facing clinicians in practice has been the development of a screening tool to rapidly identify whether a patient might have significant locomotor problems. It has long been common practice, faced with a new patient presenting with any symptoms, for clinicians to include some brief specific questions and examination to identify potential cardiac disease. Traditionally, no such screen was performed for the locomotor system. This had two effects: important locomotor problems were missed or ignored and more generally, the importance of the locomotor system to a patient’s well being was under-estimated. This has been addressed by a group of clinicians who developed the GALS screen (Doherty et al 1992), a simple method of screening for locomotor problems. A normal GALS means significant locomotor problems are unlikely. An abnormal GALS means that there is a problem of some nature which requires further assessment. This problem could be musculoskeletal or neurological.

GALS is an acronym, standing for gait, arms, legs, spine. The screen begins with three questions:

1. Do you have any pain or stiffness in your muscles, joints or back?

2. Can you dress yourself completely without any difficulty?

3. Can you walk up and down stairs without any difficulty?

The screen continues with a physical assessment (Doherty et al 1992):

Gait

• Watch the patient standing, walking and turning, looking for symmetry, smoothness of movement, normal stride pattern and ability to turn quickly.

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Spine

• Inspect from behind: check for straight spine, normal paraspinal muscles, shoulder and gluteal muscle bulk, level iliac crests, no popliteal swelling, no hindfoot swelling or deformity.

• Inspect from the side: check for normal spinal curves. Ask the patient to touch their toes. Check for normal lumbar and hip flexion.

• Inspect from in front: ask the patient to tilt their head to bring their ear towards their shoulder on both sides. Check normal lateral cervical flexion.

Arms

• Ask the patient to put their hands behind their head with their elbows back. Check normal shoulder movements.

• Ask the patient to place both hands by their side with their elbows straight. Check full elbow extension

• Ask the patient to hold their hands out with palms down and fingers straight. Check no wrist or finger swelling or deformity.

• Ask the patient to turn both their hands over, so their palms face upwards. Check normal supination/pronation, normal palms.

• Ask the patient to make a tight fist. Check for normal fist formation.

• Ask the patient to place the tip of each finger on the tip of their thumb, in turn. Check normal fine precision and pinch grip.

• The examiner then squeezes across the second to fifth metacarpal head to test for tenderness suggestive of metacarpophalangeal (MCP) synovitis.

Legs

• With the patient standing, inspect from in front for normal lower limb appearances.

• Ask the patient to lie supine on the couch. Flex each hip and knee while holding the knee: check for normal knee flexion and for crepitus.

• Internally rotate each hip in flexion.

• Press on each patella for patellofemoral tenderness and palpate for an effusion.

• Squeeze across the metatarsal heads to check for tenderness due to metatarsophalangeal joint (MTP) disease.

• Inspect both soles for callosities.

Any abnormalities detected on the GALS screening examination would demand further evaluation by history and examination.

OUTLINE OF REGIONAL JOINT EXAMINATION

Regional examination of the musculoskeletal system is necessary if any abnormalities have been revealed by the history or the screening assessment (e.g. GALS). This is a more detailed examination and involves the examination of a group of joints, which are linked by function. There are five stages to examination of the joints:

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1. Introduce the examination

2. Look at the joints

3. Feel the joint(s)

4. Move the joint(s)

5. Assess the function of the joint(s).

Introduction

It is very important to introduce the examination, explain what you are going to do, gain verbal consent to examine and ask the person to let you know if you cause them any pain or discomfort. To be sure not to miss any important clinical signs it is vital that the patient is relaxed and that they feel comfortable about being examined.

Look

Start with a visual inspection of the area at rest. Compare sides, looking for symmetry. Look for skin changes, muscle bulk, swelling in and around the joint, deformity and posture of the joint.

Feel

Feel the skin temperature with the back of your hand across the joint line. Assess any swelling for fluctuance and mobility. Hard bony swelling of osteoarthritis should be distinguished from the soft, boggy swelling of inflammatory arthritis. You should be able to elicit synovitis by the triad of warmth, swelling and tenderness.

Move

The full range of movement of the joint should be assessed. Compare sides. Both active and passive movement should be performed. The loss of active movement with full passive movement suggests a problem with the muscles, tendons or nerves rather than in the joints, or it may be an affect of pain in the joints. Joints may move further than expected – this is called hypermobility. Joint hypermobility is seen either as a localised condition in a single joint or a more generalised one. When seen in conjunction with musculoskeletal problems, it is recognised as a pathological condition and called hypermobility syndrome (uul-Kristensen et al 2007). A screen for hypermobility can be used e.g. Beighton (uul-Kristensen et al 2007).

Function

Make a functional assessment of the joint for example if there is limited elbow flexion can the person bring their hand to their mouth? In the lower limb function mainly involves gait, standing balance and the ability to rise from a sitting position.

Box 3.1 illustrates how these approaches might be put into practice using an examination of the hand and wrist as an example.

Box 3.1 Examination of the hand and wrist

Introduce examination/gain consent

Inspect palms and back of hands for muscle wasting, skin and nail changes, nodes and deformities

Check for scars (e.g. carpal tunnel release)

Feel radial pulse, tendon thickening, bulk of thenar and hypothenar eminences

Assess median, ulnar and radial nerve sensation

Assess skin temperature

Squeeze metacarpophalageal joints (MCPJs)

Palpate swollen or painful joints, including wrists

Palpate for bony enlargement, nodules, cysts

Look and feel along ulnar border of the wrist (for signs of inflammation)

Assess full finger extension and full finger flexion (finger tuck)

Assess active and passive wrist flexion and extension

Assess median and ulnar nerve power

Assess function: grip and pinch, picking up small objects

Perform any special tests e.g. carpal tunnel syndrome, Phalen’s test (Miedany et al 2008)

PRINCIPLES OF INVESTIGATIONS IN EVALUATING PATIENTS WITH RHEUMATIC DISEASES

The physical assessment of patients with rheumatological problems often includes performance of further investigations. A detailed description of such investigations is beyond the scope of this chapter. However, an outline of commonly performed tests, the indications for performing them and common abnormalities found are described. Greater detail will be provided, where relevant, elsewhere in the book.

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BLOOD TESTS

Blood tests are usually performed, in the context of rheumatological disorders, where there is a suspicion of inflammatory, infective, neoplastic or metabolic disease. Common tests performed within the haematology laboratory are full blood count, Erythrocyte sedimentation rate (ESR) and clotting studies. Table 3.3 illustrates how blood tests can be used to detect abnormalities.

Table 3.3 Blood tests

BLOOD TEST	COMMON ABNORMALITIES	EXAMPLES OF CONDITIONS ABNORMALITY FOUND IN
Full blood count (FBC) includes:	Anaemia (low Hb)	Inflammatory diseases
Haemoglobin (Hb)		Deficiency states
Haemoglobin (Hb)		NSAID related bleeding
White cell count (WCC)	High white cell count	Bacterial infection Inflammation
Platelet count	Low white cell count	Certain anti-rheumatic drugs
	High platelet count	Inflammation Bleeding
	Low platelet count	Idiopathic autoimmune thrombocytopaenia
Erythrocyte Sedimentation rate (ESR)	Raised ESR	Inflammation Infections Malignancies
C reactive protein (CRP)	Raised CRP	As ESR (Quicker to change than ESR)

IMAGING

To complete the ‘jigsaw’ and arrive at a diagnosis, imaging is often undertaken. The gold standard for this is the plain radiograph. Plain radiographs can show the alignment of the bones, the joint space (indicating the thickness of the articular cartilage), the density of the bones, sometimes a joint effusion can be seen and intra-articular bodies may be seen.

More sophisticated imaging is also available such as ultrasound, magnetic resonance imaging (MRI) and computed tomography (CT). Ultrasound of joints is increasingly becoming used to assess joints for the existence of synovitis, which aids diagnosis and informs treatment decisions in inflammatory arthritis.

CONCLUSION

Successful clinical diagnosis and management of rheumatological problems in patients requires accurate history taking and examination. Simple screening questions (e.g. red flags) and physical tests (e.g. GALS) can help to establish where further clinical assessment is needed. Rheumatological conditions can present with multi-system and multi-joint involvement. An understanding of the importance of this can help to guide clinical questioning and assessments.

STUDY ACTIVITY

Access the arc-funded Handbook on the Clinical Assessment of the Musculoskeletal System (which comes accompanied by a DVD on regional examination) (http://www.arc.org.uk/arthinfo/documents/6321.pdf) and practise the GALS on a colleague until you can remember the instructions.

ACKNOWLEDGEMENT

The chapter has used the framework of history taking suggested in the Arthritis Research Campaign’s arc handbook of the clinical assessment of the musculoskeletal system, and Professor Paul Dieppe’s original handbook for medical students (1991).

USEFUL WEBSITES

arc-funded handbook on the clinical assessment of the musculoskeletal system (accompanied by a DVD on regional examination) http://www.arc.org.uk/arthinfo/documents/6321.pdf/ (accessed March 2009).

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References and further reading

Doherty M., Dacre J., Dieppe P., et al. The ‘GALS’ locomotor screen. Ann. Rheum. Dis.. 1992;51:1165-1169.

Doherty M., Woolf A. Guidelines for rheumatology undergraduate core curriculum. EULAR standing committee on education and training. Ann. Rheum. Dis.. 1999;58(3):133-135.

Leerar P.J., Boissonnault W., Domholdt E., et al. Documentation of red flags by physical therapists for patients with low back pain. J. Man. Manip. Ther.. 2007;15(1):42-49.

Miedany Y., Ashour S., Youssef S., et al. Clinical diagnosis of carpal tunnel syndrome: old tests-new concepts. Joint, Bone, Spine: revue du rhumatisme. 2008;75(4):451-457.

SIGN, 2003. Management of osteoporosis. guideline 71. Scottish intercollegiate guidelines network. Edinburgh. Available from http://www.sign.ac.uk/guidelines/fulltext/71/index.html/ (accessed 24.01.09.).

Sizer P.B.Jr., Brismée J.M., Cook C. Medical screening for red flags in the diagnosis and management of musculoskeletal spine pain. Pain pract. official J. World Inst. pain. 2007;7(1):53-71.

uul-Kristensen B., Røgind H., Jensen D.V., et al. Inter-examiner reproducibility of tests and criteria for generalized joint hypermobility and benign joint hypermobility syndrome. Rheumatology. 2007;46(12):1835-1841.