Table 1.1 Descriptors of pain that may be relevant in revealing the in \202 uence of non-o rganic/amplifying \200\230interpretative \200\231 factors on the reporting of pain Organic Non-organic or pain ampli \201 cation Pounding Flickering Jumping Shooting Pricking Lancinating Sharp Lacerating Adults usually accurately localize pain, although there are some situations worth noting in rheumatic disease, where pain can be poorly localized. Pain may be localized, but caused d irectly or indirectly (referred) by a distant lesion, e.g.: \200 Pinching Crushing Hot Searing Tender Splitting Nagging Torturing interscapular pain caused by postural/mechanical problems in the cervical spine; pain from shoulder lesions referred to the area around deltoid insertion in the humerus; lumbosacral pain referred to the area around the greater trochanters; hip joint pain referred (often wi thout pain in the groin) down the thigh, even to the knee. Spreading Piercing Annoying Unbearable Tiring Exhausting Fearful Terrifying Tight Tearing Pain caused by neurological abnormalities, ischaemic pain, and pain referred from viscera a re less easy for the patient to visualize or express, and the history may be given with var ied interpretations. Bone pain is generally constant, despite movement or change in posture . In comparison, muscular, synovial, ligament, or tendon pain tends to alter with movement. Fracture, tumor, and metabolic bone disease are all possible causes. Such constant, local, sleep-disturbing pain should always be considered potentially sinister and investigated. I t is worth noting that certain descriptors of pain (at least in English-speaking patients) have consistently been associated with the in \202 uence of non-organic modi \201 ers of pain, the pain experience, and it \200\231s reporting. These descriptors can be found in a number of pain evaluation questionnaire tools (Table 1.1.) Stiffness Stiffness can be an indication of oedema and/or in \202 ammation. \200 Stiffne ss, however, is not speci \201 c for in \202 ammatory mus- culoskeletal lesions. Musculos keletal stiffness is assumed to be due to accumulation of \202 uid in structures thus oed ema resulting from traumatic or degenerative lesions may produce stiffness in theory. In \202 ammatory-induced stiffness in any musculoskeletal structure often improves with moveme nt. Neurological stiffness (increased tone) can mimic stiff- ness from musculoskeletal lesi ons. It typically occurs in insidiously developing myelopathy, early Parkinson \200\231s Di sease and some other extra-pyramidal disorders, for example. Some patients with in \202 am matory diseases complain about stiffness without pain [e.g. in some patients with ankylosin g spondylitis, in early or mild rheumatoid arthritis (RA)]. Pain in children The assessment of pain in young children is often dif \201 cult. The pres ence of pain may have to be surmised from CHAPTER 1 Clinical assessment of rheumatological disease 3 Multiple musculoskeletal symptoms Multiple symptoms can occur simultaneously or seemingly l inked over time (patterns). Either may be due to a single systemic condition or multiple se parate musculoskeletal lesions. The assessment of symptoms can be complicated by how long p atients have had symptoms (recall bias). The likelihood that each scenario exists depends o n a number of variables including: \200 Case 1.1. A 40-year-old woman presents with 6 months achy pain and stiffness of \201 nger s, both hindfeet and lower legs. No back pain is present. She has had fatigue for 5 years ( diagnosed with ME), mild myositis was diagnosed 2 years previously on clinical grounds and she has had some rashes over the past 10 years, dry, gritty eyes, and xerostomia. Are the s ymptoms from past history linked or separate? The differential diagnosis needs to be wide a nd history taking extensive. Primary care physicians may not have referred her to specialis ts for some of her previous problems. Previous clinical diagnoses may not have been made co gnisant of the possibility that autoim- mune disease can cause periodic symptoms in differe nt body systems. Consideration of her having either an autoimmune connective tissue disease (e.g. lupus or primary Sj gren \200\231s disease), Lyme disease, or chronic sarcoid must be given. Distinction of current symptoms from chronic pain, evidence for pathology at site s of symptoms, and blood tests will be important in deter- mining diagnosis [e.g. compared with \201 bromyalgia (FM)]. The background prevalence of any condition in the reference population. The con \201 gurat ion of the healthcare system particularly the ease or dif \201 culty with which patients c an access specialist care. Individual factors, which may in \202 uence presentation to doc tors (e.g. ethnic or socio-economic factors). Patterns of musculoskeletal symptoms Patterns of musculoskeletal symptoms are recognized in association with certain rheumatic conditions. Patterns are not usually speci \201 c, but help in forming a working diagnosis. Patterns can be interpreted from either the simultano us presentation of symptoms given their distri- bution or from a presumed link between symp toms over time (common originsee Case 1.1). The latter, of course, is the most dif \201 cu lt situation to unravel. Some examples of patterns include: \200 Case 1.2. An 80-year-old lady known to have type 2 dia- betes (20-year history) complicated by CKD3 (renal im- pairment) and hypothyroidism presents with bilateral shoulder and wrist pain, pain in 2nd and 3rd \201 ngers, swollen knees, and collapsed (valgus) painful swol len hind- feet. She is used to being ill, does not present to doctors early, and many sympt oms are long-standing. The time of onset of each symptom cannot be determined accurately. L ate-onset RA, gout, or CPPDD arthritis might be single causes of all her symptoms; however, it would be wise to initially consider some combination of separate, but common conditions , which could be contributing to her predicament. Conditions might include: osteoar- thriti s (e.g. knee), carpal tunnel syndrome, Charcot ar- thritis or diabetic osteolysis (e.g. sub talar joints), adhe- sive capsulitis (diabetes-associated), and subacromial impingement (e. g. 2nd to a rotator cuff lesion). The situation may be complicated by any diabetic cheirar- thropathy in her hands, peripheral neuropathy or cardiac failure (swollen ankles), and her ability to tolerate symptoms (in \202 uencing the reporting of symptoms) perhaps influenc ed by fatigue from diabetes and (undertreated) hypothyroidism! Simultanous symmetrical small joint in \202 ammation in the hands and wrists [e.g. RA or c alcium pyrophosphate dihydrate disease (CPPDD) polyarthritis or pseudo-RA psoriatic arthrit is]. Simultanous asymmetric, lower limb pains associated with in \202 ammatory low back pa in 4 weeks after Salmonella infection (e.g. reactive arthritis). A history of acute, but al so previously recurrent monoar- ticular, peripheral joint, symptoms over many years (e.g. g out or the pseudogout form of CPPDD arthritis/ disease). Recurrent \200\230tennis elbow \200\231 and episodic inflammatory back pain symptoms \200\223 both for many years, recalc itrant bilateral plantar fasciitis 5 years previously in a patient known to get recurrent b outs of psoriasis presenting now with a single swollen knee (psoriatic arthritis). Separate co-prevalent conditions Musculoskeletal conditions are common, particularly in the elderly. It is common for the elderly to present to specialists infrequently and/or late, and have a consider- able amount of symptoms. In the elderly, both over- and under-diagnosi s of unifying conditions are quite easy mistakes to make given the problems in assessment ( see Case 1.2). Common \200\230degenerative \200\231 and other lesions giving (either chron ic variable or persistent) symptoms are: \200 \200 Evaluating a history of illness in children and young people A musculoskeletal disorder wil l affect a growing, developing child differently to an adult. Children with in \202 ammato ry disorders, as in adults, will be affected systemically by their illness. Non-musculoskel etal symptoms associated with musculoskeletal disease can occur in children. In addition, s peci \201 c aspects of a child \200\231s life should be addressed. \200 Osteoarthritis. Crystal-induced in \202 ammation or accelerated degeneration of joints and other structures. Rotator cuff degeneration/arthropathy. Radicular symptoms (usually nerve root exit foramen stenosis in spinal canal lateral recess). Frank lumbar spinal stenosis. Mild myopathy (e.g. chronic hypovitaminosis-D). Various contributors to back pain [osteoart hritis (OA) facet joints, degenerative disc disease, osteoporotic fracture]. Development. Is the young child meeting normal devel- opmental milestones? Is walking delay ed or has it regressed in any way? Are they keeping up with their peers in toddler groups o r nursery? Appetite and growth. Is the child eating normally and gaining weight? Do they ha ve a record of weight and height with them (red book in the UK)? Does it show good growth o r a falling through the centiles? Older children are not often weighed, but you can ask if the clothes \200 \200 \200 RHEUMATOLOGY HISTORY TAKING 4 ability, either in disease deterioration or improvement with treatment has been questioned. Other tools for RA. Some generic measures do include assessment of features of disability in RA and have been applied as such (Stanford Health Assessment Questionnaire, Nottingham H ealth Profile, Short Form-36). have become loose. Also, is there any change in bowel or bladder function? Energy levels. Y oung children who are normally described as \200\230 \200 into everything \200 \200\231 , or \200\230 \200 you can \200\231t take your eyes off her for a minute \200 \200\231 may become \200\230 \200 well behaved \200 \200\231, and \200\230 \200 now plays quie tly in one place \200 \200\231 Establish, therefore, if the child is abnormally fatigued? Is there weakness? The things the child used to do independently like brushing hair, cuttin g up their own food, may be lost. Hobbies. What do they enjoy doing? Have they had to stop doing any activities? Is there anything they want to do, but can \200\231t? School. How muc h school has been missed? Are they keeping up with their peers at school, both in terms of physical activity and academically? Is there any deteriora- tion in handwriting? Vision. Ha s there been any deterioration in vision? Those <10 \200\22311 years old often do not notic e if the sight in one eye has deteriorated. WOMAC The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) has been u sed to assess disability in OA since 1982. \200 WOMAC utilizes a 24-question proforma including domains on pain, disability, and stiffness in regard of knee and hip OA. For its purpose WOMAC has been extensively validated in clini cal practice and research settings, is quickly com- pleted, is reliable and responsive to c hange. It has been translated into >60 language forms. The most recent version of WOMAC (WO MAC \204 3.1 Index) is a joint-targeted version of the index. Rheumatology Questionnaire tools Most rheumatologists use some questionnaire tools to asses s different aspects of disease in certain (validated) situations. Tools can be used in clin ical practice or, in certain examples, to grade outcome in research. Bath Ankylosing Spondylitis Functional Index (BASFI) Devised over 15 years ago, this self-a ssessed questionnaire has been validated in measuring Ankylosing spondylitis (AS) disabilit y in different populations and in early and late disease. Its strength is its simplicity. \200 BASFI is done by the patient. There are 10 questions and responses are on a visual analog s cale. Eight questions cover AS-relevant functional issues and 2 questions refer to overall effects of disability. BASFI has not been extensively validated over the long- term in the context of immunotherapy for AS. There is some concern that, with the short-term variation of effects from anti-TNFA therapies, BASFI may be over- responsive on a single assessment. Alternative functional indices for AS include The Dougados Functional Index; HAQ-S (HAQ ada pted for spondylarthropathies). Some questionnaire tools used in assessing rheumatological disease \200 \200 \200 \200 Health Activity Questionnaire. Short form 36 (SF36). Bath Index Questionnaires (AS). Qualit y of Life Questionnaires (RAQoL, ASQoL etc.). Hospital Anxiety and Depression Scale (HADS). Child Health Assessment Questionnaire (CHAQ). \200 For more detail on disease-speci \201 c assessment tools, see relevant chapter on that dis ease. The Child Health Assessment Questionnaire (CHAQ) The CHAQ is a disease-speci \201 c measur e of functional status that comprises two indices, disability, and discom- fort. Both indic es focus on physical function. Disability is assessed in eight areas with a total of 30 ite ms with dif \201 culty rated 0 \200\2233. Pain is measured on a 100 mm visual analog scale . \200 \200 Measuring disability: questionnaire tools Many questionnaire tools exist that are used to s core disability in speci \201 c diseases. Usually, a tool has been devel- oped to measure disability in a speci \201 c population for a speci \201 c reason. Some tools have been w ell validated for that purpose. It is also true that disability tools get adopted to use in other scenarios in the same disease (e.g. early as opposed to late arthritis or in differe nt countries or cultures), but also adopted/applied in other diseases. The degree to which a tool is validated in situations other than which it was devised for (and by implication a pplicable to), is variable (examples listed below). The reliability and validity of the tool are excellent. It takes an average 10 min to compl ete, and can be completed either by a parent or the older child, since the two raters corre late well. The CHAQ is now commonly used in juvenile idiopathic arthritis (JIA) randomized control trials (RCTs) and is helpful in clinic to monitor response to treatments. Health Assessment Questionnaire (HAQ) Self-assessment questionnaire originally developed an d validated in hospital populations of RA patients to measure functional disability. \200 Additional (non-musculoskeletal) symptoms When are non-musculoskeletal symptoms relevant to making (or not making) a diagnosis of a musculos- keletal condition (see Table 1.2)? The d iagnostician will need to: \200 Easy and quick to complete for patients, the scoring is weighted and a little complicated t o summarize for assessors. Has been extensively validated in different scenarios in RA popu lations over the last 25 years. Although responsive to change (usually deterioration) in RA when used extensively some years ago, the tool \200\231s ability to respond to less overt changes in functional Have a broad knowledge base of general medical and musculoskeletal conditions. Have an in-d epth understanding of systemic conditions with musculoskeletal features (see p 47 \200\2231 04). Be aware of the potential of some chronic conditions to have relapsing features. CHAPTER 1 Clinical assessment of rheumatological disease 5 Be suspicious of previous diagnoses if based on incom- plete or erroneous evidence. This wo rks both ways in that previous symptoms can be ascribed to the chronic rheumatological cond ition or may have been inappropri- ately ascribed to another diagnosis. Secondary gain Patients may knowingly or unknowingly look for \200\230gain \200\231 from a consultation, in addition to the process of getting a diag- nosis or advice about treatmen t. Gain, anticipated or not, can imply different things for different people and can affect the way in which a history is provided. \200 Reporting styles No two patients ever seem to give the same account, even for the same cond itions! Experienced rheumatologists will recognize a number of characteristic patterns of h istory accounts for some conditions, however. How a history is given can be in \202 uenced by a number of factors. \200 Whether the patient is verbose or reticent. \200 Anticipa ted gain from the consultation. \200 Interpretative styles. These aspects are discussed b elow. We do not aim to pro- vide solutions. A detailed discussion is beyond the scope of th is text. We aim to provide a framework for further thought and discussion about the issues. The simplest form of gain is reassurance. Some aspects of the history can be overlooked if not perceived by the patient as currency in obtaining reassurance. Symptom emphasis. The pa tient \200\231s (usually conscious, but not always) objective is that speci \201 c symptom recogni- tion and acknowledgement of its \200\231 severity by the doctor is important to c ondone a predicament (such as absence from work, social support application, etc.). Thus, p arts of the history are emphasized. Often \202 orid adjectives are used. Interpretative styles Many patients have thought about why they have symp- toms and will re adily tell you their beliefs. This can be helpful or distracting, and sometimes amusing. \200 Verbosity or reticence The skill in history taking with verbose patients is in steering the conversation back to the relevant points. It is impor- tant to accept, however, that the v erbose historian often requires time initially to explain things in their own way. They may otherwise feel cheated and uncomfortable with a (perceived) shortened consultation. Thus, \200\230free rein before reining in \200\231 should be your maxim. Most people will have little concept of autoimmune or in \202 ammatory disease \200\223 i llness with no basis in trauma. Patients often try to be \200\230helpful \200\231 by linki ng the onset of their symptoms to events \200\223 often physical trauma or activities \200\223 which they regard as important. This can be distracting. A previous diagnosis can lead to any new symptoms being interpreted by a patient as secondary to that diag- nosis. F or example prolonged fatigue put down to \200\230ME \200\231 ( \201 bromyalgia), but p otentially due to primary Sj gren \200\231s syndrome or chronic sarcoid, for example. Wher e there has been \200\230investment \200\231 in a previous diagnosis, even if it is Reticence on the part of the patient may have a reason or be an intrinsic characteristic. S uch consultations often require more closed questioning. Reticence is often associated with stoicism. It \200\231s not always right to believe or conclude little is wrong if little i s complained about. Table 1.2 Non-musculoskeletal symptoms associated with musculoskeletal diseases Non-musculoskeletal symptom For example: possible causes/associations Infection, SLE \200 or other AICTD*, Adult Stills Diseasedisease, periodic fevers, post-st reptococcal conditions, reactive arthritis Fever Dry eyes Sj gren \200\231s, sarcoid Xerostomia Sj gren \200\231s, sarcoid Giant cell arteritis, neck disorders, migraine (SLE \200 or AP LS**). Headache Mucocutaneous ulcers AICTDs, Beh et \200\231s, Reactive arthritis Dysphagia Scleroderma Serositis (SLE \200 ), pericarditis (AICTDs*) Sharp chest pains Cough Sarcoid, AICTDs* Dyspnoea Interstitial lung disease, pulmonary hypertension, pericarditis (AICTDs*) Abdominal pain Crohn \200\231s disease [enteropathic spondylarthropathy (ESpA)]; Diarrhea Crohn \200\231s disease (ESpA); Reactive arthritis Skin burning Peripheral neuropathy or mononeuritis (AICTDs)* SLE \200 UV skin sensitivity Parasthesias Radiculopathy, entrapment neuropathies, neuropathy secondary to AICTD* Fatigue Can be associated with many severe/chronic musculoskeletal or autoimmune diseases Dyspareunia or genital discharge Reactive arthritis Polyuria/nocturia Hypercalciuria (Primary hyperparathyroidism) AICTD: autoimmune connective tissue diseases. \200 SLE: systemic lupus erythematosus. **AP LS: antiphospholipid syndrome. RHEUMATOLOGY HISTORY TAKING 6 illness (e.g. severe stroke) or because they are critically ill (e.g. ventilated in an inte nsive care facility). \200 erroneous, attempts by you to develop the notion of a different diagnosis, through your que stions, can be per- ceived as a threat. Questioning needs to be circumspect. Predicting the situation in your clinic can reduce the problems associated with communicati ng with severely ill patients. The main barrier to achieving a valuable assessment is often lack of time. Usually the main carer will attend the clinic. The patient \200\231s compreh ension may be \201 ne, but their language compro- mised; however, directing all questions to the carer is impolite. Don \200\231t exclude the patient! Obtaining previous medical re cords will be helpful in many cases. This can be a key issue if you \200\231re being asked the diagnosis of a critically patient on the intensive (critical) care unit (ICU). In the s ituation of a ventilated or sedated ICU patient it may be important to actively seek relati ves and contacts of the patient to establish the history of the current, and if necessary p revious, illness. The most important account may not come from relatives, but the person wh o has seen the patient most, recently. History from others: assent and necessity There are four main scenarios whereby people othe r than the patient may be involved in providing all or part of the history. \200 \200 \200 \200 The elderly with communication impairment. Linguistic barriers. Those who are too ill to gi ve a history. Pediatric history taking. The elderly History taking from an elderly patient can be challenging. Consultations can, a nd often should, take time. The most appropriate approach to take is important to determine early on. For example, knowing whether there are intran- sigent fears about being admitted to hospital or undergo- ing surgery can be important in determining where a consultation g oes. \200 Pediatric history taking Talking with children and adolescents Children are not small adult s and their assessment should be different to that in adults. Concepts of pain may be well developed, but of stiffness and swelling not. You will need to obtain a history both from t he child and a carer. \200 It may be appropriate to aim for pragmatic solutions without necessarily basing therapeutic choices on invasive investigations. History taking should be tailored accordingly (and, th us, often needs to be more comprehensive and carefully taken compared with normal). Symptom reporting and its location is not always exact or in an expected distribution in the elder ly. For exam- ple, co-prevalent pathology can complicate the report of speci \201 c sympto ms (e.g. the report of pain in feet where dependent oedema and small \201 bre peripheral neuropa- thy have been present for a long time). Be aware of multiple, often age-related, p athologies. Talking with the carer who spends most time with the young child is ideal. If the child is in full-time childcare, reports from nursery and childminder can be useful. Picture clues a re often helpful in obtaining information from young children. For example, showing a range of facial expressions (happy to very sad) and asking which picture re \202 ects their exp erience regarding pain (of a speci \201 c joint, for example) has been shown to help ( \200\230Faces \200\231 rating scale). The parent can clarify. Obtaining a history from adol escents can be challenging. Have a well thought-out strategy, but note the presence of a pa rent doesn \200\231t always help: \200 Linguistic barriers There are two aspects to communication. The \201 rst is gen- eral com prehension and communication given the language barrier. The second aspect is an ability of a language to adequately explain medical symptomology (for your pur- poses) \200\223 blun ted either because of the intrinsic properties of their language and/or socio-ethnic in \202 uences. \200 some teenagers \200\231 communication habits with their parents can impair a consultation; it is often best, once trust has been established (may be several consultations), to see th e young person alone \201 rst, then with the parent \200\223 talk to the teenager \201 rst or you risk alienating them, even if they are reticent; try not to allow the parent to \200\230jump in \200\231 too quickly; clari \201 cation of history with the parent is im portant, but probably later in the consultation and with the teenager present; in the rare circumstance when you think its necessary to speak with the parent alone, obtain consent fr om the young person \201 rst; they, like all of us, wish to be treated with dignity and r espect. Linguistic barriers to obtaining a history can be lowered by predicting and addressing cert ain situations. Alerting patients or clinic staff of the need to arrange an inter- preter t o attend the consultation (and also the need to establish whether it should be male or fema le); providing written material about how your clinic works in (the appropriate) language, etc. Consider provision of access to a female doctor for women from certain ethnic backgrou nds. Know the likely regard that certain ethnic groups have for \200\230a doctor \200\231. The success of a consultation may stem from following a patient \200\231s certain perceive d ideals about the role you, as a man or woman, follow in conducting the consultation. Be a ware of likely family/social interactions in relevant situations. History giving from a rel ative may be in \202 u- enced by established communication patterns within a family or gro up (even if another is not present), and there may even be barriers to the patient advocati ng a role for their relative in such situations. Pattern recognition Localized or diffuse pain There is merit and utility in considering ini tially whether the child is well or unwell, and then discriminating whether any condition i s local or widespread. \200 Localized pain in a well child might be due to soft-tissue injuries, oligoarticular JIA, gr owing pains, and perhaps bone tumors. If unwell, but pain and other symptoms localized, con sider septic arthritis or osteomyelitis. The ill patient There will be a need occasionally to assess either a patient who cannot com municate because of previous serious CHAPTER 1 Clinical assessment of rheumatological disease 7 Widespread pain in a well child might be secondary to hypermobility or pain syndromes. Unwe ll children with widespread symptoms are the group most likely to have serious pathology, i ncluding leukemia, systemic JIA and AICTDs. Children with hypermobility can have recurrent quite widespread symptoms, but there is no accepted de \201 ni- tion of hypermobility in c hildren. Growing pains are common and are a frequent reason for parents to consult, as symp toms, although short- lived, can appear severe and can cause children some distress. Typical features of growing pains \200 \200 \200 \200 \200 \200 \200 \200 Occur age 3-11 years old. The child is systemically well. Growth and motor milestones are n ormal. Activities not limited by symptoms. Pains are usually symmetrical in the legs. Pains never occur in the morning after waking. The child does not limp. The examination is norma l. RHEUMATOLOGICAL EXAMINATION 8 Rheumatological examination Setting and resources An ideal examination environment requires certain basic facilities an d some relevant equipment. For children it is necessary to have a selection of differ- ent age-appropriate toys to kee p them (or their siblings) occupied and content during the consultation. Principles of musculoskeletal examination What is normal? With some experience it is possib le to develop a good appreciation of what is within the boundaries of a normal examination. Age, gender, and ethnicity can all in \202 uence the range of normal \201 ndings both i n appearance and move- ment of musculoskeletal structure. \200 Place In addition to the general requirements of privacy and comfort then rheumatological e xamination can be com- pleted almost anywhere. \200 It is essential to have suf \201 cient space to examine gait and lower limb/foot biomechan ics when the patient is walking. Patients will need to be barefoot so a hard but clean \202 oor is required. Space is also important. Shoulder and spine examination is best done with the patient standing. A couch that is height-adjustable with an additional adjustable back-rest is essential. An area for joint and other connective tissue injections, which is kept clean (although strict sterile conditions are not generally needed). There should be a controlled facility to dispose of human waste material (e.g. synovial \202 uid after joi nt aspirate), and a wash-basin with antibacterial gel and soap. There is wide variation in musculoskeletal features, many of which cannot be classed as \200\230abnormal \200\231 and never cause problems. Other features, however, might be withi n the range of \200\230normality \200\231, but do increase the risk of subsequent abnormal ity. Both types of features are often inherited. Some common examples of the normal variati on in mus- culoskeletal features that dictate differences in skeletal appearance: \200 \200 \200 \200 \200 limb length; protracted (sloping) shoulders; lumbosacral lordosis/pelvic tilt; femoral neck ante or retroversion; \202 at feet (but with ability to re-form longitudinal plantar arc h when non-weight bearing). Kit There are only a few necessary pieces of equipment. Ideally, the following should be pr ovided: \200 Tape measure for measuring: limb circumference and leg-length; chest expansion at nipple he ight [for chest restriction in ankylosing spondylitis (AS)]; Sch ber \200\231s test (lumba r spine forward \202 exion range in AS); span (3rd \201 nger tip to opposite 3rd \201 nger with patient \200\231s arms outstretc.hed) in assessing for Marfan syndrome. Neurolog y kit: tendon hammer, 128 Hz frequency tuning fork, sensory skin testing pins, and cotton w ool. Ophthalmoscope (signs of vasculitis). Goniometer for joint angle measurement. Diagnost ic injection kit (1): 1% lidocaine 5- or 10-ml vials, 5-ml syringes, and a range of hypoder mic needles [21, 23, and 25 gauge, ideally long (40 mm/1.5 \200\231)] for injections. Injec tion therapy kit (2): long-acting glucocorticoid for joint and intramuscular injection (e.g . triamcinolone acetonide 40 mg/ml vials); hydrocortisone vials for super \201 cial connec tive tissue, tendon, enthesis and small joint injections (25 \200\22350 mg); alcohol swabs; plasters; a variety of syringe sizes and needles. General medical examination: for assessi ng cardiac and lung function in patients with autoimmune joint or connective tissue disease , a stethoscope, peak flow meter and blood pressure sphygmomanometer are important. Shirmer \200\231s tear test strips (Sj gren \200\231s, see p. 256). Multistix for urinalysis is i mportant. Screening for renal disease in SLE, vasculitis and RA starts with testing for blo od and protein on a simple urine dipstick analysis. Diagnostic ultrasound (US) in the clini c is common- place in many centers and is a highly desirable facility used in conjunction w ith musculoskeletal exami- nation. Ideally, there should be facility to use Doppler with it to gauge the vascularity of thickened soft-tissue/ synovium. Children are far more \202 exible than adults and usually girls more \202 exible than b oys. This underscores the dif \201 - culty in coming to a consensus as to what constitutes (mild or moderate) hypermobility in children. Generally, women retain greater \202 exibi lity than men as they age. Greater muscle bulk and tension may deter- mine more resistance of \200\230end-feel \200\231 at the extreme of range of passive joint movement. People of South Asian descent often show greater \202 exi- bility in joint movement, and connective tissue \202 exibility than Caucasians and Afro-Caribbeans. \200 \200 Symmetry The vast majority of people start off life broadly symmetrical (left to right)! De velopment of dominant right- or left- sided function can change symmetry slightly, and cert ainly previous disease or injury can lead to obvious asymmetry. Examining both sides when p resented with unilateral loco- motor symptoms is important to orientate the examiner as to what is \200\230normal \200\231 for the person being examined. Important examples include: \200 Shoulder movement range. Subtle degrees of shoul- der restriction can accompany rotator cuf f lesions. There is, however, a variation in normal shoulder movements in the population. I t is always important to examine a patient \200\231s good shoulder \201 rst. Subtle degre es of loss of knee joint movement can be missed. It within the accepted \200\230normal \200\231 range to have a little extension at the knee. The conclusion that a \200\231fully straight \200\231 knee on the couch is normal would therefore be erroneous, without testing for extension in the symp- tomatic and unaffected knee. Similarly, given that early loss o f hip movement is often only appreciated from restriction of hip extension, it is important to examine patients with hip symptoms while \200 CHAPTER 1 Clinical assessment of rheumatological disease 9 How (whether) is your hand is shaken. Does the patient sit skew (?unilateral back/hip pain) ? they are lying prone. Extension range of the hip, how- ever, is sometimes hard to interpret given the tendency for additional pelvis tilt and back arching when the leg is lifted. Com pare sides. Gait Antalgic A limp can be obvious and accentuates the indication of pain a patient may be getting from a weight-bearing joint. The period of stance phase of the gait is reduced on the affected side. Look to see if any walking aid is being used correctly. For a right-side d knee or foot problem a stick will be most helpful used in the left hand, for example. Examining the proximal moving part There is a tendency for musculoskeletal lesions around c ertain joints to present with relatively few symptoms at that joint but present with referr ed pain to more distal structures. Examples: \200 Neck lesions causing referred pain into the arm (sepa- rate to radicular distribution senso ry symptoms and pain from any nerve root lesion). Rotator cuff lesions causing referred pai n to the area around the deltoid insertion. Hip lesions causing pain and stiffness in the a nterior thigh and knee. Occasionally, you might come across patients deny having groin or h ip area pain at all. Trendelenberg Leaning over on a painful or weakened hip might indicate a Trendelenberg effe ct. Normally, gluteus medius and mini- mus, which arise from the ileum and insert on the gr eater trochanter, isometrically contract when weight is put on their side to stabilize (abd uct) the femur against the pelvis. This prevents the pelvis sagging on the other side when the leg is lifted on that other side for the swing phase of the gait. If gluteus medius is weak or denervated, or there is reduced lever-arm capacity of abduction (shortened femo- ra l neck, hip instability, pain, etc.) the pelvis can sag on the other side and there is dif \201 culty swinging the leg through on walking. The patient can compensate by leaning over the affected side to reduce the (lever arm effect or ground reaction force) needed to stab ilize the pelvis \200\223 a compen- sated Trendelenberg gait. Passive vs active examination When patients move their own joints (active movement) structu res can move differently compared with when an examiner moves them (passive). This is a key issue appreciated well by physical therapists and musculoskeletal physicians, and develope d initially by Cyriax. \200 Pain elicited by passive examination (which usually is, although may not be, present during active movement of the same structure) suggests an intra-articular lesion. The proviso her e is that your patient \200\231s peri- articular tissues are completely relaxed for your ex amination. Patient-initiated painful movement of the joint (active movement), which lessens or disappears on passive joint examination, suggests involvement of extra-articular tissue s that have a moment of force around that joint (e.g. ligament or tendon). The integrity of systems of joint prime movers and secondary stabilizers can only be examined actively (alt hough isolated speci \201 c lesions can be complex and signs are often not speci \201 c). Physiotherapists refer to weight bearing leg examination as \200\230closed chain \200\231 . Knowledge of the stabilizers (e.g. isometrically operating muscles) around certain joints is essential for Rheumatologists (e.g. the role of short hip abductors in stabilizing the pelvis and avoiding a Trendelenberg gait). Myopathic A myopathic gait is most obvious when there is signi \201 cant quadriceps weakne ss. The dif \201 culty in lifting the legs is compensated for by leaning back slightly and tilting the pelvis forward. Gait can be high stepping if associated with signi \201 cant weakness of tibialis anterior or peroneal muscles, and can be associated with a Trendelenbe rg lurch if associated with hip abductor muscle weakness. High-stepping or foot slap gait The leg is lifted high on swing phase of gait because the a bility to actively dorsi \202 ex and evert the foot to prevent the toe dragging on the gro und is compromised by muscu- lar weakness. Most often due to peroneal nerve damage or compr omise (e.g. L5/S1 radiculopathy). The poor dorsi- \202 exor control can results in the fo ot slapping down. The adult \200\230GALS \200\231 screening examination The locomotor system is complex and dif \201 cult to examine. The gait, arms, leg, and spine (GALS) examination is a selective clinical process to detect important locomotor abnormalities and functional disability. It is based on a tested \200\230minimal \200\231 history and examination system with a simpl e method of recording. The screen is fast and easy to perform, and includes objective obser vation of functional movements relevant to activities of daily living. The GALS screen has been well validated and accepted into the core undergraduate curriculum in UK Medical Schoo ls, and has been taught as a quick and pragmatic screening assessment for use in general pr actice. Functional assessment An assessment of the musculoskeletal (locomotor) system requires an e xamination of moving parts. Functional anat- omy and regional functional assessments are in cluded in Chapter 5. General function is dealed with here. General observation Observing patients even before they enter the consultation room can be helpful in the functional examination. \200 Body habitus/posture. Check for patient walking stooped with kyphosis (intervertebral disc disease or osteoporosis). Does the patient walk bow-legged or with dif \201 culty, what wa lking aids are used, what shoes are being worn, who is accompanying them and what is their role in helping the patient? Is the patient accommodating or protecting painful areas? For example, how does the patient rise from the waiting room chair or do they depend on others to help movement? How is the coat is taken off (?shoulder pain)? Screening history If patients answer \200\230no \200\231 to the following three questions then there is unlikely to be any signi \201 cant musculoskeletal abnormality or disability . \200 