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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.

RHEUMATOID ARTHRITIS (RA)

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).

The patient fit the category of long-standing rheumatoid arthritis, which seemed to be inactive. She had structural deformities in the hands and feet, but the absence of any swelling or inflammation indicated that the RA was no longer active. Laboratory testing further substantiated this diagnosis as acute phase reactants (eg, ESR and CRP) were normal. She met current criteria for clinical remission in RA. 3 These criteria include:

  • swollen and tender joint count of less than one
  • patient global assessment of less than one
  • CRP of less than 1 mg/dL.

Discussion & Follow-Up

In contrast to the initial diagnosis, the patient’s recent fatigue, generalized muscle tenderness, and multiple areas of muscle/soft-tissue tenderness are suggestive of fibromyalgia (FM) rather than an exacerbation of RA (see Table III). Recent onset of depression and inability to exercise are also consistent with FM. With this in mind, the patient need not restart medication for RA and should be reassured that her RA is still in remission.

Fibromyalgia symptoms may be treated with low dose medication, such as amitriptyline, which may also improve the patient’s sleep disturbances, or with a medication such as duloxetine or pregabalin. She should be encouraged to return to her exercise routine and be as active as possible.

The primary physician should evaluate and treat any cardiac risk factors, including the patient’s elevated blood pressure and hyperlipidemia. Rheumatoid arthritis patients have a significant increased risk of comorbid cardiovascular disease—approximately 60% higher than in the general population. 4 Patients with RA over age 50 years are also encouraged to undergo a yearly electrocardiogram; if symptoms of possible coronary artery disease are present, pharmacologic stress testing and cardiology referral may be further recommended. The provider may also recommend bone mineral densitometry since any patient with long-standing arthritis is at increased risk for osteoporosis.

OSTEOARTHRITIS (OA)

OA Case #1

A 62-year-old male complained of increasing right knee pain over the prior 3 years. He reported the pain as being especially bothersome when walking or during prolonged standing and he was having difficulty going down stairs. He also complained of pain at the base of both thumbs and increased stiffness and loss of motion in his neck and lower back.

He reported that these symptoms have been present for a number of years and had been slowly getting worse.

Initial Assessment

The general physical examination was unremarkable except for being moderately overweight and a blood pressure of 140/90 mmHg. Joint examination demonstrated bony hypertrophy involving both hands, primarily at the distal interphalangeal (DIP) joints and tenderness and pain on movement at the base of both thumbs at the carpal-metacarpal (CMC) joint. He had difficulty fully flexing or extending the right knee but there was no joint effusion or warmth found. There was bony crepitus on moving the right knee and evidence of quadriceps muscle weakness of the right leg compared to the left. Laboratory tests included a normal complete blood count, normal chemistry profile, and a normal ESR.

Discussion & Follow-Up

This patient presents with classic features of generalized osteoarthritis (OA).5 These criteria include (see also Table IV):

  • age greater than 50
  • joint involvement in the hands, most common in the DIP joints and CMC joints
  • slowly progressive joint stiffness and pain.

The physical examination demonstrated no evidence of joint inflammation but rather bony hypertrophy in the finger DIP joints (Heberden’s nodes) and crepitus with diminished range of motion in the most symptomatic joint, the right knee. Patients with widespread, generalized OA may have more arthritis in weight-bearing joints, including the hip and knees. For example, a recent study found that the number, severity, and symmetry of DIP osteoarthritis (Heberden’s nodes) correlated with the progression of knee osteoarthritis.6

Differentiating OA from RA

Although there are no formal guidelines for the diagnosis of generalized OA, the signs and symptoms noted with this case, in combination with the patient’s normal acute phase reactants, provide an accurate diagnosis of generalized OA and may be helpful in differentiating it from rheumatoid arthritis. See Table V.

In contrast to RA, there are no standardized disease activity assessment tools for generalized OA. There are also no disease biomarkers, such as serological abnormalities, or acute phase reactants. Therefore, the clinician may simply document the level of pain and stiffness, and assess physical function and activity levels.

As noted in the first RA Case, pain rating and patient/physician global assessment are best recorded on simple visual analog scales (0 to 10 or 100). For this OA patient, the right knee is the only joint that is adversely affecting his function and quality of life. The extent of limited function should be documented. Radiographs of both knees should be obtained as well, followed by referral to an orthopedic surgeon. The patient is a likely candidate for knee replacement. It may also be appropriate to discuss efforts toward weight reduction and increased non-weight-bearing exercises with potential referral to a dietitian or obesity specialist.

OA Case #2

A 55-year-old female complained of worsening pain in the right hip along with generalized pain and increasing exhaustion over the prior 12 months. Radiographs of the right hip showed modest joint space narrowing with no other abnormalities. She had consulted with two orthopedic surgeons, one who suggested that she undergo an immediate hip replacement and the other who recommended weight reduction, exercise, and analgesic medications to manage pain.

During the year prior, she had discontinued her regular walking program because of the increased pain and subsequently gained 25 pounds. She also complained of increasing generalized soreness and stiffness, persistent fatigue, and feeling unwell all the time.

Initial Assessment

The physical examination demonstrated an anxious, overweight female in obvious pain despite minimal movement. The joint examination revealed no swelling, inflammation, or deformities involving the hands, wrists, elbows, knees, ankles, or feet. Examination of the right hip demonstrated pain on full rotation with tenderness over the lateral hip at the trochanteric bursa. There was also diffuse soft tissue tenderness in the neck, shoulders, and back. Laboratory studies, including a normal ESR, were unremarkable.

Discussion & Follow-Up

The diagnosis of right hip osteoarthritis was confirmed via x-ray, in which modest joint space narrowing was apparent. However, the level of the patient’s symptoms—in the hip as well as her widespread pain and fatigue—were not consistent with a diagnosis of OA. Osteoarthritis does not cause generalized muscle pain, widespread soft tissue tenderness, or exhaustion. Although there were localizing symptoms in the hip, tenderness was observed over the greater trochanter rather than hip joint. This distinction raised the possibility of a different chronic pain disorder, such as FM, complicating the hip arthritis.

Differentiating OA from Fibromyalgia

There is an increased prevalence of FM in both rheumatoid arthritis and osteoarthritis. As in this patient, whenever symptoms such as chronic widespread pain and exhaustion do not fit well with the current activity of the underlying arthritis, the clinician may consider concurrent fibromyalgia. Polymyalgia rheumatica (PMR) may also be considered, but generalized pain and soft tissue tenderness are not typical of PR and the ESR in this particular case was normal.

Radiographs may be misleading in OA diagnosis. Patients with significant knee OA on x-ray may have minimal symptoms, while some patients who have quite severe knee pain show minimal changes on radiographs.7

Fibromyalgia symptoms should be documented and discussed with the patient and her orthopedic surgeon. The presence and severity of FM symptoms, including widespread pain, fatigue, and mood disturbances have correlated with poor outcome following joint replacement in patients with OA.8 FM survey criteria may be used to help guide treatment decision-making in this patient (see Table VI).9

As noted in the previous case, weight reduction may be an important management plan to help lessen progression of hip OA.10 It is advised that this patient not be treated with opioid medications as there is no evidence for improved pain-related function with opioids in hip or knee OA,11 and there is evidence that this medication class may have an adverse effect in FM.12

Conclusion

The optimal evaluation of any new patient with suspected rheumatoid arthritis or osteoarthritis always begins with making an accurate diagnosis. Although there are formal guidelines for the diagnosis of RA, in general, both RA and OA have distinct signs and symptoms. An elevated ESR or CRP is typically present in patients with RA but not in those with OA. Plain x-rays or imaging tests may not be helpful in initial evaluation. It is advised that a disease activity assessment, however, be part of the initial evaluation and at each subsequent patient visit. Levels of pain, associated symptoms, such as fatigue and impact on activities of daily living and function, should be documented. Healthcare providers would benefit from understanding that fibromyalgia commonly complicates rheumatoid- and osteoarthritis. Therefore, when pain is out of proportion to objective disease findings, central pain sensitivity may be suspected. Primary care providers and pain specialists may apply the fibromyalgia diagnostic criteria shown in Table IV when suspecting that disorder.
Last updated on: April 12, 2019
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Case Studies in Regenerative Cellular Therapy: Tendinopathy and Osteoarthritis
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