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12 Articles in Volume 18, Issue #4
A New Frontier in Migraine Management: Inside CGRP Inhibitors & Migraine Prevention
Assessment of Patients with Rheumatoid Arthritis or Osteoarthritis
Biosimilars in Rheumatology: How Popular Will They Be?
Case Studies in Regenerative Cellular Therapy: Tendinopathy and Osteoarthritis
Commentary: Make the Easy Choice for Care
Editorial: The Emergence of Trackable Pill Technology: Hype or Hope?
Editorial: The Practicality of Pain Acceptance
How to Avert Government Scrutiny When Prescribing Opioids
Letters to the Editor: DEA and Prescribing, the War on Statistics, Failing Treatments, Patients' Options
Meet the Migraine Game-Changers
Platelet-Rich Plasma and Stem Cell-Rich Prolotherapy for Musculoskeletal Pain
With concerns over opioids, could novel receptors be useful?

Assessment of Patients with Rheumatoid Arthritis or Osteoarthritis

Case examples are used to detail the optimal evaluation, including disease activity, of patients with probable rheumatoid arthritis or osteoarthritis.
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RA Case #1

A 43-year-old female presented with a four-month history of swelling and pain involving both of her hands, wrists, and feet. She complained of morning stiffness lasting three hours and was exhausted throughout the day. On two occasions she had a low-grade fever and, for the prior few weeks, was unable to go to work. Her past medical history was unremarkable and there was no family history of generalized arthritis disorder. On physical examination, there was swelling, redness, and warmth involving the small joints of both hands and both wrists. Her grip strength was poor. There was a small joint effusion in the right knee. Both feet were very tender around the metatarsal-phalangeal joints. The rest of the examination proved routine.

Initial Assessment

This patient presented with typical symptoms and physical findings suggesting early RA. She had multiple swollen and inflamed joints, including the small joints of the hands and feet as well as one knee. There were systemic symptoms, including fatigue and low-grade fever, characteristic of an immune or inflammatory disease. The fact that her symptoms were present for four months excluded the possibility of conditions such as viral arthritis or Lyme disease. There were no striking extra-articular signs or symptoms to suggest a different systemic immune disease such as systemic lupus erythematosus.

Testing Expectations

As part of the initial evaluation, laboratory tests should include a complete blood count, and acute phase reactants, erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), as well as a rheumatoid factor (RF) or a test for anti-cyclic citrullinated peptide (anti-CCP). Radiographs may be considered optional as they are likely to be unremarkable after only four months of disease. However, they should be obtained in the near future to assist disease activity rather than to help diagnostically.

In this patient, one may expect an elevated level of CRP or ESR as well as a positive RF or anti-CCP antibody. In any patient with inflammatory arthritis involving three or more joints and symptom duration of more than two months, such laboratory tests may be highly suggestive of RA. However, it should be kept in mind that serologic tests are positive in only 70% of patients presenting with early stages of the disease.

Discussion & Follow-Up

This patient should be seen promptly by a rheumatologist to confirm the diagnosis and begin treatment. The role of the primary care physician (PCP) at this point may depend on the ready availability of the rheumatologist as well as the PCP’s expertise in completing the initial evaluation process.

It should be noted that the patient meets the formal criteria for the diagnosis of RA according to the current American College of Rheumatology and European League Against Rheumatism (2010 ACR/EULAR) criteria 1 (see also Table I). These criteria include:

  • presence of inflammatory arthritis in at least one joint
  • absence of an alternative diagnosis
  • achievement of a total score of at least 6 of a possible 10 within four diagnostic domains. These domains include the number and site of involved joints, serological abnormalities, elevated acute phase reactants, and symptom duration of at least six weeks.

Once the diagnosis of RA is confirmed, it is important to evaluate the level and extent of disease activity (either the PCP or rheumatologist may do this). Results may help guide the therapeutic plan and predict individual patient prognosis. The ongoing longitudinal disease evaluation may be further completed and documented with validated core sets of disease activity variables. The clinical parameters that may be used to evaluate disease activity include (see also Table II):

  • number of swollen and tender joints
  • extent of pain and systemic symptoms, such as fatigue and morning stiffness
  • patient and physician global disease activity
  • measures of function and health status.

A pain rating, and a global patient and physician assessment, are typically measured on visual analog scales using horizontal 100 mm lines or numerical scales ranging from 1 to 10. The patient or physician places a mark between 0 mm (no pain) and 100 mm (most severe pain) on the horizontal line. A 28-joint count has become the standard tool for recording the number of swollen and tender joints. 2

Validated composite disease activity formulas are widely available, including online from the American College of Rheumatology. One of the most common forms is the disease activity score 28 (DAS28), which includes an easy-to-use calculator. A simplified disease activity index (SDAI) is more practical and consists of adding together the tender point count and swollen joint count, both using the same 28 joints, the patient global assessment, the physician global assessment and the CRP. A number of instruments have been used for assessing function and health impact, including the Health Assessment Questionnaire (HAQ) and the Short Form-36. 2

RA Case #2

A 65-year-old female with a long-standing history of rheumatoid arthritis presented with elevated cholesterol and exhaustion. She had a 25-year history of RA but had been managing well and, until recently, described being pain-free. Her rheumatologist had gradually reduced her medications and, for the year prior, she had been off all disease-modifying rheumatic drugs after being on methotrexate for 15 years. She continued to take nonsteroidal anti-inflammatory drugs for pain as needed.

However, during the prior six months, she reported increasing generalized muscle aches, fatigue, and sleep disturbances. She also reported feeling depressed at times. She had previously been following a regular exercise routine but because of the exhaustion, she had not been participating in any exercise activity for at least three months.

Initial Assessment

On examination, blood pressure was 148/94 and general physical evaluation was unremarkable. The musculoskeletal examination demonstrated some moderate deformities involving the small joints of the hands and feet but there was no warmth, redness, or tenderness in those joints with otherwise good movement and function. There was generalized soft tissue tenderness around the upper arms, neck, shoulders, and chest wall as well as over the lateral area of the hips. There were no focal neurologic abnormalities. Laboratory data for ESR and CRP were normal; she also had a normal complete blood count and a normal chemistry profile, other than elevated cholesterol (304 mg/dL).

Last updated on: June 8, 2018
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Case Studies in Regenerative Cellular Therapy: Tendinopathy and Osteoarthritis