Co-host of the 2017 Musculoskeletal Education Day, Dr Louise Warburton helps healthcare professionals understand the difficulties in diagnosing inflammatory arthritis

1. It’s the Keele difference.
Research Institute for Primary
Care & Health Sciences
Keele University
Delivering high quality multidisciplinary research in primary care.

2. Diagnosis of inflammatory
arthritis
Dr Louise Warburton

3. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.

4. It’s the Keele difference.Delivering high quality multidisciplinary research in primary care.

5. The Scope of the Problem
• Health and resource burden
• Rheumatoid arthritis is a common problem and
affects about 1% of the population.
• Rheumatoid arthritis can result in a wide range of
complications for the individual patient, their
carers, the NHS and society in general.
• Spondyloarthritis (Ankylosing spondylitis,
psoriatic, IBD, reactive) accounts for further 1%
• Gout is the commonest inflammatory arthritis in
men.

6. Why is it important to recognise the signs of early
inflammatory arthritis?
• Early referral of patients has been shown to
improve disease outcomes.
• There appears to be a window of opportunity
within the first 12 weeks of the disease (RA)
where commencing disease-modifying therapy
will affect the long term course of the disease.
• Disease –modifying therapy may mean steroids.
• The therapeutic window of opportunity in rheumatoid arthritis: does it ever
close?
• Karim Raza1,2,
• Andrew Filer1,3
• http://dx.doi.org/10.1136/annrheumdis-2014-206993

7. Early treatment
• Treatment for rheumatoid has to be started early in
the disease to prevent disease progression. Patients
who wait over a year from symptom onset to referral
to a rheumatologist, still have a 73% risk of
developing erosive change prior to treatment being
inititiated. (1). Patients with erosive disease have
more progressive disease and greater disability.
• Ref; 1. Irvine S et al. Early referral, diagnosis and treatment of
rheumatoid arthritis: evidence for changing medical practice.
• Ann Rheum Diseases 1999; 58:510-3

8. National clinical audit for rheumatoid
and early inflammatory arthritis
2nd annual report launch

9. For the first time we knew…
• In comparison with the rest of the country
– How quickly patients are referred
– How long they wait for appointments
– How soon they receive treatment
– What impact RA has on patients
– What their experience of care is
– How well units are staffed
– What the relationship is between staffing and
performance

10. Year one headlines
• Most patients
– Wait too long for referral
– Wait too long for rheumatology appointments
– Are usually treated promptly once seen
• Huge variation across NHS
• Prospective outpatient national audits are
feasible but difficult

11. Question
• NICE quality standard One states patients
should be referred within 3 days of
presentation to GP
• What percentage of patients do you think
were referred within 3 days?
• A) 5% B) 11% C) 17% D) 25% E) 30%

12. Answer
• 17 % were referred with 3 days of
presentation

13. Question
• What do you think the median time to referral
was?
• A) 5 days
• B) 7 days
• C) 15 days
• D) 20 days
• E ) 25 days

14. Answer
• 20 days
• Could we do better??

15. NICE Quality Standard 1
• 17% referred by GP within 3 days of
presentation (vs 17% Y1)
• 20% referred by GP within 3 working days
• Median time to referral 20 working days (vs 23
working days Y1)
• One quarter waited more than 3 months
• Wide variation
– Improvement in Wales - median 5 days vs 19 days

16. NICE Quality Standard 2
• Key outcome measure for the audit
• 37% seen in rheumatology within 3 weeks of
referral (vs 38% Y1)
• Median wait 29 days (IQR 16-49) (vs 28 days
Y1)
• Wide variation across regions and Wales

17. NICE Quality Standard 3
• 68% received DMARDS within 6 weeks (vs 53%
Y1)
• 36% received combinations of DMARDs (vs
46% Y1)
• 82% received steroids (vs 86% Y1)
• Coding/ classification issues may account for
some of “improvement”

18. What were the BSR actions from the
audit
• 1. Pay Rheumatologists more?
• 2. Complain to the RCGP?
• 3. Educate GPs?
• 4. Change the Quality standards?
• 5. Get rid of interface MSK clinics?

19. Answer
• 1. Educating GPs was one of the Actions from
the audit.

20. Year 1 – recommendations; BSR audit
• Education to improve early recognition and referral
• Providers to review processes and capacity to
improve waiting times and to allow appropriate
follow up
• Commissioning should take account of best practice
and Quality Standards
• NHS England should develop better outpatient data
systems
• Raise public awareness of early arthritis

21. The Challenge
• How can primary care spot these
patients amongst the huge number
consulting with musculoskeletal
problems? (estimated at 20% of
consultations)
• As we know, patients often DELAY
presenting to their GP
• GP will see one new case every two years

23. A Qualitative Investigation of the Barriers to
Help-seeking Among Members of the Public Presented with
Symptoms of New-onset Rheumatoid Arthritis
Gwenda Simons, Christian David Mallen, Kanta Kumar, Rebecca
Jayne Stack, and Karim Raza
http://www.jrheum.org/content/early/2015/01/27/jrheum.140
913
Methods. Qualitative interviews were conducted with 38
members of the general public (32 women)
without any form of inflammatory arthritis about their
perceptions of RA symptoms and decisions
to seek help were they to experience such symptoms. The
interviews were audio-recorded,
transcribed verbatim, and analyzed using thematic analysis.

24. This exploration of the views held by members
of the general public without RA revealed a
number of potential barriers to and drivers of
help-seeking for symptoms of RA.
These can be summarized by 5 overarching
themes:
• perceived cause of symptoms;
• presentation, location, and
• experience of symptoms;
• perceived effect of symptoms on
daily life;
• planned self-management of symptoms;
and
• GP-related drivers and barriers.

25. An important challenge to the development of an
effective public health campaign for RA relates to the
multiple different symptoms that herald the onset of
RA and that can occur in varied combinations.
Qualitative research involving patients with
seropositive arthralgia at risk of RA or with new onset
RA found that besides joint pain, swelling, warmth,
and stiffness, patients experienced a range of other
symptoms including weakness, loss of motor control,
fatigue, sleeping difficulties, and depressive symptoms
early in their disease

26. Angela
• Angela was in her mid forties and came to surgery
complaining of aches and pains. She is well known to you as
her husband was killed in a road traffic accident three years
previously and she has two teenage children. You have
already supported her through the trauma of this
bereavement . She has a job as a carer which involves driving
around and helping people in their own homes.
• She describes a history of joint pains which have been getting
worse for about six months
• What sort of questions would you ask Angela about
these joint pains?

27. Questions to ask
• It is useful to ask Angela if she has had any joint
swelling as this would point towards and
inflammatory disorder.
• How long has it been going on?
• Ask her what time of day the joint pain is worse:
morning pain and stiffness lasting more than 30
minutes is very suggestive of an inflammatory
disorder.
• Joint pains which are worse at the end of the
day suggest a mechanical aetiology such as OA

28. Questions
• Ask about family history ; there may be a
family history of rheumatoid arthritis
• Ask about previous episodes of joint pain and
swelling. Patients often forget about previous
instances of joint swelling which happened a
few months or even years ago
• (Palindromic onset)

29. Questions
• Ask about what analgesics Angela has
tried and if they have had any effect.
• Ask questions to screen for depression.
(Previous bereavement)
• Ask about sleep. Loss of sleep may be
due to pain or depression .

30. Moving on
• Would you like to examine Angela?
• What would you be looking for?

31. Question
• Which one of the following is a sign of
inflammatory arthritis?
• Heberdens nodes
• Bony swelling
• Petechiae
• Boggy synovial swelling
• Bouchards nodes

32. Answer
• Boggy synovial swelling
• Signs of inflammation and synovitis

33. Examination findings
• Any evidence of joint swelling?
• Swelling can be bony and suggests OA ( eg
Heberdens nodes), or synovial which suggest
inflammation and will feel soft and there may be
an effusion which will feel 'squidgy'
• Is the tenderness on squeezing the joints?
Tenderness may indicate inflammation .
• Observe Angela's gait which can give clues
about stiffness and which joints are affected

34. Examination findings
• Is there any loss of range of movement in
Angela's joints or stiffness?
• Ideally all the joints should be checked, but in
reality with time limited, an examination of joints
which feel painful or are symptomatic will suffice.
Does Angela's pain appear to come from joints or is to more
widespread and felt in muscles and soft tissues?
• A more widespread presentation of pain can suggest a chronic pain
syndrome such as fibromyalgia.

35. Angela
• Examination findings with Angela were non specific.
There was no evidence of real joint swelling . The
joints in her hands (mcps and pips) were tender when
squeezed.
• She complained of pain in her hands, knees and
shoulders.
• She appeared to move stiffly . She was stiff in the
morning for about 30 minutes and was struggling
with the physical aspects of her job.
• What investigations would you perform?

36. Which of the following investigations
are useful in diagnosing RA?
• A) protein level
• B) anti CCP
• C) vitamin D level
• D) uric acid
• E) Ferritin

37. Answer
• B ) anti-CCP antibodies
• The sensitivity and specificity of anti-CCP
reactivity for the diagnosis of rheumatoid
arthritis (RA) were 66.0% and 90.4%,
• This compared with the sensitivity and
specificity of RF for RA at 71.6% and 70%

38. Investigations
• Blood tests can give useful information about whether this is
an inflammatory condition.
• Check FBC : normochromic, normocytic anaemia can indicate
a chronic disease.
• ESR and CRP : low grade increase in inflammatory markers is
seen in many conditions such as viral illnesses and OA?
• A significant rise such as ESR over 20 should alert suspicions of
an inflammatory condition.
• A very high ESR may suggest poly myalgia rheumatica with
these symptoms

39. Rheumatoid factor
•
• Rheumatoid factor: this is positive in about 80% of
patients with RA.
• Low positive titres are very common and do not
mean that the patient has rheumatoid arthritis .
• NICE guideline 79 : management of RA in adults
suggests referring patients on clinical signs and not
waiting for the results of blood tests.
• There is new evidence that having a negative
rheumatoid factor delays the referral of
patients with RA

40. • A negative rheumatoid factor can lead to a delay in referral for those patients
subsequently diagnosed with RA
• “Patients whose RF test was negative were not referred as promptly as those
with a positive test. Their referral was typically 45 days later, generally taking a
total of 67 days. The consequences of this delay can be serious. When treatment
is not given within a 12 week window of opportunity following the disease onset,
it is more likely that there will be subsequent damage to joints and other organs,
reduced function and lower likelihood of disease remission.
• “Lead researcher Anne Miller said: “It is important that rheumatoid factor tests
are not used to rule out possible rheumatoid arthritis in primary care, and that
patients with symptoms suggestive of inflammatory arthritis are referred for
specialist assessment without delay.”
• ABSTRACT BSR 2016

41. Anti CCP
anti- citrullinated C Peptide
• Anti CCP if available ; in some areas GPs can
request anti CCP which is a more specific test
for RA.
• Having a high titre positive RF and anti CCP
can indicate a worse prognosis.
• Can pre-date the onset of RA by years

42. Imaging
• Plain X ray (useful?)
• Ultrasound
• MRI

43. Connective tissue disorders
• Question; which of the following tests should be
requested if a connective tissue disorder is
suspected?
• A. anti-CCP
• B. Ferritin level
• C. Immuoglobulins
• D. Anti-nuclear antibody (ANA)
• E. Vitamin D level

44. Answer
• ANA
• In addition
• Extractable nuclear antigens (ENAs)
• Anti Ro, anti La, SMP, scl-70
• Anti ds DNA
• Complement levels C3/C4

45. CT disorders
• Raynauds phenomenon (20 % of cases will be
associated with a CT disease)
• Rashes; butterfly, sun-sensitivity, vasculitis
• Pericarditis, pleurisy, glomerulonephritis
• Blood abnormalities such as leucopaenia,
thrombocytopaenia
• Arthritis and joint pain

46. Angela;
• Angela had a slightly raised ESR of 35; CRP 20
• Rheumatoid factor negative
• Anti CCP negative
• Would you refer her?
• Would you refer her if ESR and CRP were
normal?

47. Angela
• Ultrasound examination confirmed synovitis
of her MCPs
• Diagnosed with early inflammatory arthritis
• Sero-negative

48. Kate
• 23 year old college student ; you have seen in
her a couple of times to prescribe the pill
• Presents with a sore toe

49. Questions
• What questions would you like
• to ask Kate?

50. Question
• Which of the following are NOT useful
questions?
• 1. Any trauma?
• 2. Previous episodes of toe swelling?
• 3. History of psoriasis
• 4. History of eczema?
• 5. Arthritis in relatives?

51. Answer
• History of eczema is not useful as this is not
usually associated with inflammatory arthritis.

52. Questions
• Trauma?
• Previous episodes
• Other joint swelling or pain or stiffness ,
including the back
• Any other medical problems or skin diseases?
• Sexual health history
• Bowel problems?

53. Inflammatory vs mechanical
• New criteria for inflammatory back pain
• Age at onset <40 years
• Insidious onset
• Improvement with exercise
• No improvement with rest
• Pain at night (with improvement on getting up)
• - See more at: http://www.arthritisresearchuk.org/health-
professionals-and-students/reports/hands-on/hands-on-
spring-2010.aspx#sthash.A3cDInJk.dpuf

54. What would you examine?
• Which joints?
• Which parts of the body?

55. Spinal examination

56. Kate
• Kate has dactyli
• Previously had swollen left knee when 16
years old and saw Orthopaedic surgeons but
no diagnosis reached
• Mother has psoriasis
• Would you refer?
• What is the likely diagnosis?

57. Spondyloarthropathies
• Group of diseases associated with HLA B27
• Reactive arthritis; usually chlamydia associated
• Psoriatic arthropathy (14% of patients with psoriasis
will have arthritis)
• Axial Spondyloarthropathy; radiographic (ankylosing
spondylitis) or non-radiographic
• Arthritis associated with inflammatory bowel disease
; Crohns and UC
• Juvenile arthritis

58. • Diagnosing
• PSA

60. It’s the Keele difference.
Any Questions?
The End