Approach to diagnosis of arthritis

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Lecture notes for undergraduate medical students and Allied health professionals

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  • Posture, attitude in which they hold and move the symptomatic region or limb, their overall movement and their behaviour. Then continue to examine region by region: examine the whole MSK system and do a general examination: in particular dermatological, neurological, or peripheral vascular
  • Approach to diagnosis of arthritis

    1. 1. APPROACH TO DIAGNOSIS OF ARTHRITIS Lectures Series For Medical Students and Allied Professions
    2. 2. Background Essential orientation... • Musculoskeletal (MS) problems present varied challenges to the clinician • Ease of diagnosis does vary from self-evident to doubtful • The TWO keys to diagnosis of MS complaints are to: 1. take a careful history, and 2. examine the joints carefully ... ... in order to identify the anatomic structure(s) involved
    3. 3. Background ALWAYS be mindful of diversity of aetiologies... • Joint pain can be caused by diverse processes, including: – inflammation, – cartilage degeneration, – crystal deposition, – infection, and – trauma. • This highlights the point: ‘The differential diagnoses of joint pain are generated largely from the history and physical examination’
    4. 4. Background Role for laboratory tests?... • Screening laboratory test results [mostly] serve to confirm clinical impressions – They can be misleading if used without much deductive thinking Goal of clinical enquiry... • The initial aim of the clinical evaluation is to: – localize the source of the joint symptoms, and – to determine the type of patho-physiological process responsible for their presence.
    5. 5. Patho-physiological processes in joint pain 1.Joint pain may arise from structures within or adjacent to the joint or may be referred from more distant sites. 2.Sources of pain within the joint include the joint capsule, periosteum, ligaments, subchondral bone, and synovium, – Determination of the anatomic part responsible for joint pain guides the approach to diagnosis and therapy.
    6. 6. Lecture Objective This lecture aims to teach a standardized approach to the clinical evaluation of patients with joint pain and other musculoskeletal symptoms
    7. 7. Specific Learning Objectives By the end of this lesson, the learner should: 1- Be able to take a relevant history and perform a focused examination of patients with joint pain / other MS problems and elicit diagnostic clues 2-Recognize diagnostic patterns of joint involvement that are helpful in differential diagnosis of various causes of arthritis 3- Be able to apply a screening history and examination as part of a general systemic inquiry on all patients
    8. 8. Evaluation of a patient with arthritis Diagnostic clues from historical features
    9. 9. Precepts Assessment of the musculoskeletal system • Should be approached in the same way as for diseases of any other system – that is by: – careful history taking, – examination, and – use of appropriate investigations • In addition, assess for impact of the condition on physical and mental function of patient
    10. 10. Precepts Understanding Patho-physiologic basis of joint symptoms • TWO DETERMINATIONS serve to focus the history and physical examination of a patient with joint pain: 1.The first is whether the pain stems from the joint or an adjacent structure (e.g., bursa, tendon, ligament, bone, or muscle). 2.The second is whether the pain is referred from elsewhere (e.g., a visceral organ or nerve root).
    11. 11. Precepts Understanding Patho-physiologic basis of joint symptoms (Cont’d) • If the pain is stemming from the joint, THREE broad categories of joint disease must be differentiated: 1.The first is inflammatory arthritis 2.The second category is non-inflammatory arthritis 3.The third category is arthralgia
    12. 12. Precepts Usefulness of signs of inflammation in differential diagnosis of painful joints • Inflammatory arthritis – Is characterized by inflammation affecting joint structures, such as the synovium, synovial cavity, and entheses – With inflammatory joint disease: • Pain is present both at rest and with motion. • Pain is worse at rest than at the end of usage • stiffness is present upon waking and typically lasts 30-60 minutes or longer • joint swelling is related to synovial hypertrophy, synovial effusion, and/or inflammation of peri-articular structures.
    13. 13. Precepts • Usefulness of signs of inflammation in differential diagnosis of painful joints • non-inflammatory arthritis: – Results primarily from alterations in the structure or mechanics of the joint – The joint disease may occur as a result of degenerative, traumatic or mechanical damage – With non-inflammatory joint disease: – Pain occurs mainly or only during motion and improves quickly with rest. – stiffness is experienced briefly (e.g., 15 min) upon waking in the morning or following periods of inactivity. – Swelling results from formation of osteophytes (bony swelling) or from soft tissue swelling related to synovial cysts, thickening, or effusions
    14. 14. Precepts • Usefulness of signs of inflammation in differential diagnosis of painful joints • Arthralgia: – Apart from joint tenderness, no abnormalities of the joint can be identified. – May be due to an early rheumatic syndrome whose clinical signs are not yet apparent
    15. 15. Precepts Differential diagnostic clues from historical features 1. Temporal pattern of arthritis a. ONSET OF SYMPTOMS - Abrupt or insidious • Abrupt onset: – joint symptoms develop over minutes to hours. – May occur in trauma, crystal arthritis, or infection. • Insidious onset: – joint symptoms develop over weeks to months. – This onset is typical of most forms of arthritis, including rheumatoid arthritis (RA) and osteoarthritis.
    16. 16. Precepts Differential diagnostic clues from historical features 1. Temporal pattern of arthritis (cont’d) b. DURATION OF SYMPTOMS - Acute or Chronic • Acute is less than 6 weeks in duration; – – • Inflammatory: e.g., Septic arthritis; Gout Non-inflammatory: e.g., Juxta-articular fracture; Trauma chronic is 6 or more weeks in duration – – Inflammatory: e.g., Septic arthritis; Gout; Rheumatic fever, RA,SLE, and Reactive arthritis Non-inflammatory: e.g., Juxta-articular fracture; Trauma; OA, Haemochromatosis, avascular necrosis, stress fracture
    17. 17. Precepts Differential diagnostic clues from historical features 1. Temporal pattern of arthritis (cont’d) c. PATTERNS OF JOINT INVOLVEMENT • Migratory: inflammation persists for only a few days in each joint (e.g., acute rheumatic fever, disseminated gonococcal infection) • Additive or simultaneous: inflammation persists in involved joints as new ones become affected (systemic rheumatic diseases, e.g., RA) • Intermittent: episodic involvement occurs, with intervening periods free of joint symptoms (e.g., gout).
    18. 18. Precepts Differential diagnostic clues from historical features 2. Number of involved joints • Monoarthritis: involvement of one joint. • Oligoarthritis: involvement of 2-5 joints. • Polyarthritis: involvement of 6 or more joints. 3. Symmetry of joint involvement • Symmetric arthritis: characterized by involvement of the same joints on each side of the body. This symmetry is typical of RA and SLE. • Asymmetric arthritis: characteristic of spondyloarthropathies (e.g., psoriatic arthritis, and reactive arthritis)
    19. 19. Precepts Differential diagnostic clues from historical features 4. Distribution of affected joints • The distal inter-phalangeal (DIP) joints of the fingers are usually involved in psoriatic arthritis, gout, or osteoarthritis but are usually spared in RA. • Joints of the lumbar spine are typically involved in ankylosing spondylitis but are spared in RA. 5. Distinctive types of musculoskeletal involvement • E.g., Spondyloarthropathy involves entheses, leading to: – heel pain (inflammation at the insertions of the Achilles tendon and/or plantar fascia), – dactylitis (sausage digits), – tendonitis, and – back pain (sacroiliitis and vertebral disc insertions).
    20. 20. Precepts Differential diagnostic clues from historical features 6. Extra-articular manifestations • Constitutional symptoms suggest an underlying systemic disorder and are not expected in patients with degenerative joint disease. • Skin lesions may be present and may indicate the specific diagnosis of a number of rheumatic diseases, e.g., SLE, dermatomyositis, scleroderma, psoriasis • Ocular symptoms or signs – Episcleritis and scleritis may be associated with RA or Wegener granulomatosis, – Anterior uveitis with spondyloarthropathies – iridocyclitis with juvenile Idiopathis Arthritis – Conjunctivitis may be caused by reactive arthritis.
    21. 21. Summary Differential diagnostic clues from historical features in Clinical Evaluation of a patient with arthritis
    22. 22. PATTERNS OF DIAGNOSTIC IMPORTANCE: Onset, context of pain experience and chronology When did it start and what pattern has followed with time. Example Characteristics of pain… • Gout: rapid onset and extreme pain and tenderness • Bone pain owing to metastatic bone disease is usually persistent day and night • Inflammatory pain: occurs at rest and is associated with stiffness especially in the mornings • Osteoarthritic pain is related to joint use and is associated with short lived stiffness after periods of inactivity • Nerve / neuralgic pain is deep and might be associated with paresthesias
    23. 23. PATTERNS OF DIAGNOSTIC IMPORTANCE: Number of joints involved- Monoarthritis Causes: Causes: 1. 3. Infection – 1. Bone / Cartilage disorder – Bacterial, Viral, Fungal osteonecrosis, Loose body, Inflammatory Arthritis – Rheumatoid Arthritis – Juvenile idiopathic Arthritis – Spondyloarthropathy tumour Crystal – Osteoarthritis, 3. Traumatic – Fracture – Internal derangement – Hemathrosis
    24. 24. PATTERNS OF DIAGNOSTIC IMPORTANCE: Number of joints involved- Polyarthritis Causes: Causes: 1. Rheumatoid Arthritis 3. SLE 2. Seronegative 4. Gout spondyloarthropathies 5. Osteoarthritis – Reactive arthritis /Reiter’s 6. Viral arthritis disease – Psoriatic arthritis – Undifferentiated spondyloarthropathy
    25. 25. PATTERNS OF DIAGNOSTIC IMPORTANCE : Pattern of joint involvement 1. Flitting arthritis – Rheumatic fever 1. Asymmetrical DIP joint involvement – Seronegative arthritides – Osteoarthritis 1. History of attacks in big toe – Gout
    26. 26. PATTERNS OF DIAGNOSTIC IMPORTANCE : Mode of onset ACUTE ONSET: SUB-ACUTE / CHRONIC 1. Viral 1. Rheumatoid arthritis 2. Reactive arthritis /Reiter’s 2. Seronegative disease 3. Crystal arthropathies spondyloarthropathy 3. Chronic Gout
    27. 27. PATTERNS OF DIAGNOSTIC IMPORTANCE : Associated systemic symptoms or extra-articular lesions 1. Connective tissue disorders 1. SLE 2. Dermatomyositis 3. Scleroderma 2. 3. 4. 5. 6. 7. Rheumatoid arthritis Spondyloarthropathies Rheumatic fever Polymyalgia rheumatica Bacterial endocarditis Sarcoidosis
    28. 28. PATTERNS OF DIAGNOSTIC IMPORTANCE : Other Associated problems symptoms 1. Spinal pain – Cervical spine – RA, OA – Low back- spondyloarthropathy (SpA), OA 1. Eye symptoms – Conjunctivitis -(SpA), – Uveitis -(SpA), 1. Urogenital symptoms – Urethral or vaginal discharge -(SpA), 1. Diarrhoea / dysentery – Urethral or vaginal discharge -(SpA),
    29. 29. Evaluation of a patient with arthritis Diagnostic clues from Physical examination
    30. 30. Precepts Assessment of the musculoskeletal system • Should be approached in the same way as for diseases of any other system – that is by: – careful history taking, – examination, and – use of appropriate investigations • In addition, assess for impact of the condition on physical and mental function of patient
    31. 31. Precepts Differential diagnostic clues from the examination • THE MUSCULOSKELETAL EXAMINATION – helps distinguish joint inflammation (e.g., RA) from joint damage (e.g., degenerative joint disease) – It also helps elucidate: • Site of involvement (e.g., synovitis, enthesitis, tenosynovitis, bursitis) and • the distribution of joint involvement.
    32. 32. Precepts Differential diagnostic clues from the examination 1.Signs of inflammatory joint disease – Synovial hypertrophy • This is the most reliable sign of an inflammatory arthritis. • The synovial membrane is normally too thin to palpate. • In a person with chronic inflammatory arthritis, the synovial membrane has a doughy or boggy consistency, – This feature is best appreciated at the joint line or margin.
    33. 33. Precepts Differential diagnostic clues from the examination 1.Signs of inflammatory joint disease (cont’d) – Joint effusions • Effusions develop in response to: – – – – – synovial inflammation, trauma, anasarca, intra-articular hemorrhage (hemarthrosis), or an adjacent focus of acute inflammation (sympathetic effusion). • Effusions are detected by performing fluid ballottement or cross-fluctuation through the synovial cavity
    34. 34. Precepts Differential diagnostic clues from the examination 1. Signs of inflammatory joint disease (cont’d) – Pain with motion • Pain throughout the whole range of motion is observed in a person with an acutely inflamed joint (Synovitis). • Pain not present throughout the entire range of motion may indicate an extraarticular source, such as tendinitis.
    35. 35. Precepts Differential diagnostic clues from the examination 1.Signs of inflammatory joint disease – Limited range of motion: • In a person with inflammatory joint disease, limitation of motion results from: –the presence of a tense effusion, –markedly thickened synovium, –adhesions, –capsular fibrosis, or –pain.
    36. 36. Precepts Differential diagnostic clues from the examination 1. Signs of inflammatory joint disease (cont’d) – Erythema and warmth • Erythema of the joint is restricted to acute inflammatory forms of arthritis, such as gout, septic arthritis, or acute rheumatic fever. Rare in persons with RA and psoriatic arthritis. • Warmth of the joint is a sensitive sign of inflammatory arthritis – It can be detected by passing the hand back and forth from the joint to a neutral area distal or proximal. Differences in warmth can also be detected by comparing the same joint on each side of the body.
    37. 37. Precepts Differential diagnostic clues from the examination 1.Signs of inflammatory joint disease (cont’d) – Joint tenderness • This is a sensitive sign of joint disease, – However, it is not specific for inflammatory arthritides • In an acutely inflamed joint, tenderness can be elicited over the entire joint. • Focal tenderness may indicate a focus of inflammation outside the joint, such as tendinitis, osteomyelitis, or fracture.
    38. 38. Precepts Differential diagnostic clues from the examination 2.Signs of degenerative/mechanical joint disease – Bony overgrowth of the joints (osteophytes): • In hands: those located at the distal interphalangeal joints are called Heberden nodes, while those located at the proximal interphalangeal joints are called Bouchard nodes. – Limited range of motion: In persons with degenerative/mechanical joint disease, the limitation of motion may result from: • intra-articular loose bodies, • osteophyte formation, or • subluxation.
    39. 39. Precepts Differential diagnostic clues from the examination 2.Signs of degenerative/mechanical joint disease (cont’d) – Crepitus during active or passive range of motion • A palpable or audible grating sensation is produced during motion of the joint. • Soft, fine crepitus may be felt (or heard with a stethoscope) in a rheumatoid joint when the cartilage surface is no longer smooth. • Coarse crepitus or grating may be felt in joints severely damaged by long-standing rheumatoid or degenerative arthritis.
    40. 40. Precepts Differential diagnostic clues from the examination 2.Signs of degenerative/mechanical joint disease (cont’d) – Joint deformity • Several types must be distinguished as follows: – Restriction in the normal range of motion, e.g., lack of full joint extension that results in a flexion deformity – Mal-alignment of the articulating bones, such as ulnar deviation of the fingers or valgus deformity of the knee – Alteration in the relationship of the two articulating surfaces, such as subluxation and dislocation
    41. 41. Precepts DIAGNOSTIC CLUES FROM THE EXAMINATION Look at 1. The affected joint, and the contra-lateral joint 2. Skin and nails – – – – – – Psoriasis Rash of SLE Nodules, tophi Erytherma marginatum Pits / ridges on nails Etc 3. Eyes – – – Conjunctivitis Uveitis Dryness 3. Genitalia – – – Ulceration Balanitis Discharge 3. Mouth – Ulceration
    42. 42. Precepts Schema for MS examination • SYSTEMATIC & SEQUENTIAL – LOOK – FEEL – MOVE • ACTIVE & PASSIVE • Starting with the symptomatic region or limb, examine the whole MSK system and do a general examination: in particular dermatological, neurological, or peripheral vascular
    43. 43. Precepts Schema for MS examination LOOK (at rest and during movement) for gait, posture/attitude, swelling, deformity, range, muscle wasting, skin changes, FEEL for tenderness, swelling, deformity, muscle spasm, crepitus with movement, and temperature MOVE (actively, then passively, and against resistance). Assess range and stability, presence of pain. Test FUNCTION and STRENGTH
    44. 44. Summary: Physical Examination of a patient with arthritis • Be organized, systematic and thorough • Do a GENERAL examination – Start by looking at the whole person • Then examine the symptomatic joint or region • Continue to examine region by region from the head downwards • Compare the contra-lateral side with the symptomatic one
    45. 45. Evaluation of a patient with arthritis Diagnostic clues from Laboratory and other tests
    46. 46. Precepts Assessment of the musculoskeletal system • Should be approached in the same way as for diseases of any other system – that is by: – careful history taking, – examination, and – use of appropriate investigations • In addition, assess for impact of the condition on physical and mental function of patient
    47. 47. Investigations for Joint Disorders There are three main types of investigations: 1. Blood tests, 2. Imaging of bones and joints, and 3. Synovial fluid analysis and/or synovial biopsy.
    48. 48. Precepts Diagnostic clues from Laboratory tests 1. Screening blood tests for all types of inflammatory arthritis – Erythrocyte sedimentation rate (ESR): an elevated ESR supports the presence of an inflammatory arthritis. – C-reactive protein (CRP): This test is an alternative to obtaining the ESR. – Rheumatoid factor and cyclic citrullinated peptide (CCP): A rheumatoid factor test should be obtained when rheumatoid arthritis (RA) is at least moderately possible in the patient. Measuring antibodies to CCP is a new test for RA; it has higher specificity but lower sensitivity than rheumatoid factor.
    49. 49. Precepts Diagnostic clues from Laboratory tests 1. Screening blood tests for all types of inflammatory arthritis (cont’d) – ANAs: ANA tests are commonly obtained in patients with arthralgias or arthritis as a screening test for SLE or another connective-tissue disorder. • More than 95% of patients with SLE have ANAs; thus, a negative ANA result is a strong indicator that SLE is not present. • However, a positive ANA result lacks specificity and may occur in persons with other connective-tissue diseases or certain medical illnesses. • The diagnostic yield of the ANA test is increased substantially when the patient has features that suggest a diagnosis of SLE or another autoimmune disease in addition to joint pain.
    50. 50. Precepts 2. Diagnostic clues from imaging studies 1. Plain radiography: • The least expensive imaging modality • Most useful for clarifying the nature of joint abnormalities already noted during the physical examination, e.g., – swelling [bony vs soft tissue], – loss of motion [bony vs soft tissue], – instability [ligamentous vs destruction of articular surface], – focal bony tenderness [fracture vs osteomyelitis] • Joint appearance on plain radiographs is often distinctive for various forms of arthritis. However these characteristic changes may not be apparent early in the disease course. • Plain radiographs are useful for monitoring the progression of chronic arthritides (eg, osteoarthritis, RA).
    51. 51. Precepts 2. Diagnostic clues from imaging studies (cont’d) 2. CT scan: • This technique obtains cross-sectional images of skeletal structures. • It is most useful for: – assessing trauma of the spine and pelvis, – evaluating arthritis in axial joints (e.g., sacroiliac, atlantoaxial, sternoclavicular), – evaluating pain in complex joints in which overlying structures obscure plain radiography views (e.g., ankle, wrist, temporomandibular joints), and – evaluating degenerative disc disease of the spine and possible disc herniations.
    52. 52. Precepts 2. Diagnostic clues from imaging studies (cont’d) 3. MRI: • Is best for assessing soft tissue and spinal cord elements. • It is of greatest use for assessing: – – – – – – – rotator cuff tears, spinal stenosis, ligamentous or meniscal abnormalities of the knee and wrist joints, osteonecrosis (ie, avascular necrosis of bone), stress fractures, osteomyelitis, and subchondral bone injury in osteoarthritis or meniscal tears.
    53. 53. Precepts 2. Diagnostic clues from imaging studies (cont’d) 4. Arthrography: • Is of greatest use for defining abnormal communication between the synovial space and adjacent bursae and soft tissue, e.g., – popliteal cysts, – rupture of rotator cuff with communication between glenohumeral joint space and subacromial bursa.
    54. 54. Precepts 2. Diagnostic clues from imaging studies (cont’d) 5. Radionuclide bone scanning: • It is most useful for assessing: – osteomyelitis, – stress fractures, and – bony metastasis. • It may be used to exclude skeletal disease in patients with diffuse musculoskeletal pain.
    55. 55. Precepts 3. Diagnostic clues from Synovial fluid studies – Synovial fluid (SF) analysis • This test is used to broadly characterize the type of arthritis: – E.g., to identify crystals, and to establish the diagnosis of septic arthritis and crystal-induced synovitis. • Synovial fluid types are classified as: – – – – – normal, Non-inflammatory, inflammatory, septic, or hemorrhagic.
    56. 56. Precepts 3. Diagnostic clues from Synovial fluid studies – Synovial fluid (SF) analysis (cont’d) • Normal SF: Characteristics include: – clear to pale yellow colour, transparent clarity, WBC count of less than 200/µL with less than 25% PMN leukocytes, and very high viscosity. • Non-inflammatory SF: Characteristics include: – pale yellow colour, transparent clarity, WBC count of 200-2000/µL with less than 25% PMN leukocytes, and high viscosity. It typifies osteoarthritis, traumatic arthritis, and an early or resolving stage of an inflammatory arthritis.
    57. 57. Precepts 3. Diagnostic clues from Synovial fluid studies – Synovial fluid (SF) analysis (cont’d) • Inflammatory SF: Characteristics include: – yellow-to-white colour, translucent-to-opaque clarity, WBC count of 2000-50,000/µL with more than 70% PMN leukocytes, and low viscosity. It typifies RA and other chronic inflammatory arthritides • Septic SF: Characteristics include: – a white-to-cream colour, opaque clarity, WBC count of more than 50,000/µL with more than 90% PMN leukocytes, and very low viscosity. It typifies bacterial arthritis, but it also may occasionally be seen in crystalline arthritis and flares of RA. • Hemorrhagic SF: Characteristics include: – a hemorrhagic colour and opaque clarity. Fat globules should be sought in hemorrhagic fluids by centrifuging the synovial fluid. A supernatant of fat is indicative of a juxta-articular fracture.
    58. 58. Precepts 4. Diagnostic clues from Synovial biopsy – Synovial Biopsy – In the majority of patients with rheumatic diseases, an accurate diagnosis can be established without performing a synovial biopsy. – For certain conditions, histopathologic findings in the synovium are either pathognomonic or highly specific. These include: • various granulomatous arthritides, e.g., tuberculous, sarcoidosis • amyloidosis, • synovial tumors
    59. 59. Precepts Prudent use of laboratory & other Investigations 1. Most useful diagnostic tests for specific rheumatic diseases – Septic arthritis: Order a Gram stain and culture of synovial fluid – Gout or pseudogout: Use polarized light microscopy to examine a drop of synovial fluid for intracellular urate (gout) or calcium pyrophosphate dihydrate (pseudogout) crystals – Ankylosing spondylitis: Obtain sacroiliac joint radiographs to demonstrate bilateral sacroiliitis
    60. 60. Precepts Prudent use of laboratory & other Investigations 1. Most useful diagnostic tests for specific rheumatic diseases (cont’d) – Osteoarthritis: Obtain radiographic images of the affected joint – Systemic lupus erythematosus (SLE): Screen with an antinuclear antibody (ANA) test. • If positive, test for Smith (Sm) and double-stranded DNA antibodies. These antibodies are more specific for SLE but are present in only 30-60% of patients with SLE, respectively.
    61. 61. Summary Differential diagnostic clues from laboratory tests in patients with arthritis •The are NO pathognomonic laboratory tests... •Screening laboratory test results [mostly] serve to confirm clinical impressions – They can be misleading if used without much deductive thinking
    62. 62. Background Role for laboratory tests?... • Screening laboratory test results [mostly] serve to confirm clinical impressions – They can be misleading if used without much deductive thinking Goal of clinical enquiry... • The initial aim of the clinical evaluation is to: – localize the source of the joint symptoms, and – to determine the type of patho-physiological process responsible for their presence.
    63. 63. Routine screening history and examination for musculoskeletal problems
    64. 64. An essential screening history and examination to be applied as part of a general inquiry in all encounters with patients to identify those with musculoskeletal problems
    65. 65. Core concepts in evaluating MS disease This section teaches three concepts key in the logical sequence required for evaluation of MS disorders: 1.‘Asking’ Screening questions for musculoskeletal disorders 2.Performing a Screening examination for musculoskeletal disorders- The ‘GALS’ 3.Performing a regional examination of the musculoskeletal system (‘REMS’)
    66. 66. Screening for disorders of the musculoskeletal system (MSS) • An assessment of the MSS should be incorporated into your routine clerking of all patients – just as you would for the cardiovascular or other systems. • This is achieved through the use of screening questions and a screening examination, both of which have been developed specifically for musculoskeletal disorders.
    67. 67. 1. Screening questions for musculoskeletal disorders Screening questions for MS disorders-Rationale • The main symptoms arising from disorders of the MSS are pain, stiffness, swelling, and associated functional problems. • The screening questions have been designed to directly address these aspects Screening questions for MS disorders 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 steps/stairs without any difficulty?’
    68. 68. Screening questions for disorders of the musculoskeletal system (MSS) • Interpretation of screening questions and a screening for musculoskeletal disorders. – A positive response to one or more of the screening questions should be followed up by taking a more detailed history and by carrying out the screening examination. – Similarly, an abnormal finding in the screening examination should lead to a more detailed regional examination and a review of the patient’s history.
    69. 69. Screening questions for musculoskeletal disorders: Interpretation • If the patient has no pain or stiffness, and no difficulty with dressing or with climbing stairs it is unlikely that s/he suffers from any significant musculoskeletal disorder. • If the patient does have pain or stiffness, or difficulty with either of these activities, then a more detailed history should be taken.
    70. 70. 2. Screening examination for musculoskeletal disorders- The ‘GALS’ • • • • A brief screening examination, which takes 1–2 minutes, has been devised for use in routine clinical assessment. It is highly sensitive in detecting significant abnormalities of the MSS. It involves inspecting carefully for joint swelling and abnormal posture, as well as assessing the joints for normal movement. This screening examination is known by the acronym ‘GALS’, which stands for Gait, Arms, Legs and Spine.
    71. 71. ‘GALS’ Screening Examination Gait • Observe gait • Observe patient in anatomical position Arms • Observe movement – hands behind head • Observe backs of hands and wrists • Observe palms • Assess power grip and grip strength • Assess fine precision pinch • Squeeze MCPJs Legs • Assess full flexion and extension • Assess internal rotation of hips • Perform patellar tap • Inspect feet • Squeeze MTPJs Spine • Inspect spine • Assess lateral flexion of neck • Assess lumbar spine movement
    72. 72. ‘GALS’ Screening Examination GAIT (Ask the patient to walk a few steps, turn, and walk back) 1.Observe the patient’s gait for symmetry, smoothness and the ability to turn quickly 2.With the patient standing in the anatomical position, observe from behind, from the side, and from in front for: 1. 2. 3. 4. 5. 6. bulk and symmetry of the shoulder, gluteal, quadriceps and calf muscles; limb alignment; alignment of the spine; equal level of the iliac crests; ability to fully extend the elbows and knees; popliteal swelling; abnormalities in the feet (see Figure 2).
    73. 73. ‘GALS’ Screening Examination ARMS • Ask the patient to put their hands behind their head. – • • • Assess shoulder abduction and external rotation, and elbow flexion. (These are often the first movements to be affected by shoulder problems.) With the patient’s hands held out, palms down, fingers outstretched, observe the backs of the hands for joint swelling and deformity. Ask the patient to turn their hands over. Look at the palms for muscle bulk and for any visual signs of abnormality. Ask the patient to make a fist. Visually assess power grip, hand and wrist function, and range of movement in the fingers. • • • Ask the patient to squeeze your fingers. Assess grip strength. Ask the patient to bring each finger in turn to meet the thumb. Assess fine precision pinch. While watching the patient’s face for signs of discomfort, gently squeeze across the MCP joints to check for tenderness suggesting inflammatory joint disease.
    74. 74. ‘GALS’ Screening Examination LEGS (With the patient lying on the couch) • • • • • Assess full flexion and extension of both knees, feeling for crepitus. With the hip and knee flexed to 90º, and while holding the knee and ankle to guide the movement, assess internal rotation of each hip Perform a patellar tap to check for a knee effusion. From the end of the couch, inspect the feet for swelling, deformity, and callosities on the soles. While watching the patient’s face for signs of discomfort, Squeeze across the MTP joints to check for tenderness suggesting inflammatory joint disease.
    75. 75. ‘GALS’ Screening Examination SPINE (With the patient standing) • Inspect the spine from behind for evidence of scoliosis, and from the side for abnormal lordosis or kyphosis. • Ask the patient to tilt their head to each side, bringing the ear towards the shoulder. • Assess lateral flexion of the neck. (This is sensitive in the detection of early neck problems.) • Ask the patient to bend to touch their toes. This movement can be achieved relying on good hip flexion, so it is important to palpate for normal movement of the vertebrae. – Assess lumbar spine flexion by placing two or three fingers on the lumbar vertebrae. – Your fingers should move apart on flexion and back together on extension
    76. 76. 3. Performing a regional examination of the musculoskeletal system (‘REMS’) • Regional examination of the musculoskeletal system (REMS)refers to the more detailed examination of the MSS • REMS: – should be carried out once an abnormality has been detected either through the history or through the screening examination (GALS) – involves the examination of a group of joints which are linked by function – may also require a detailed neurological and vascular examination.
    77. 77. Performing a regional examination of the musculoskeletal system (‘REMS’) • There are five key stages which need to be completed during an examination of the joints in any part of the body: 1. 2. 3. 4. 5. Introduce yourself. Look at the joint(s). Feel the joint(s). Move the joint(s). Assess the function of the joint(s). • LOOK for attitude, swelling, range, deformity, muscle wasting, skin changes, at rest and during movement • FEEL for tenderness, swelling, deformity, and crepitus with movement and temperature • MOVE actively, then passively and against resistance to see if different. Look for pain, range and stability.
    78. 78. Some useful terms and definitions
    79. 79. 1. Definitions / rheumatological jargon A. Relating to names of joints / joint areas • MCP: Metacarpophalangeal • MTP: Metatarsophalangeal • PIP: Proximal inter-phalangeal • DIP: Distal Inter-phalangeal
    80. 80. 1. Definitions / rheumatological jargon B. Relating to joint size • Large joints: Hips, knees, ankles, shoulders, elbows, and wrists. • Small joints: MCP, MTP, and phalangeal joints of hands and feet.
    81. 81. 1. Definitions / rheumatological jargon C. Relating to pattern of joint involvement • Monarticular: affecting one joint • Polyarticular: affecting more than five joints. • Pauciarticular: affecting five or less joints. • Bilateral: Affecting the same joint on both sides of the body. • Symmetrical: Affecting the same joints to the same extent on both sides of the body.
    82. 82. 1. Definitions / rheumatological jargon D. Relating to mode of joint involvement • Episodic: Two or more attacks of arthritis with periods of complete remission between them. • Migratory: Arthritis moving from joint to joint, the first affected joint becoming normal when the second is involved. • Simultaneous: Arthritis affecting a number of joints, all of which are affected from the beginning of the illness. • Additive: Arthritis moving from joint to joint, the first affected joint persisting with the involvement of the second and subsequent joints.

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