One of the things I get asked to talk about most often to Physiotherapy audiences is recognition of Rheumatology conditions, specifically the systemic inflammatory arthropathies such as Rheumatoid Arthritis and the Inflammatory Spondyloarthropathies. There are many good reasons to recognise the symptoms of these conditions if they appear in the clinic not least of which is that delay to diagnosis is directly related to poorer long-term outcomes.
The development of posts such as First Contact Practitioners and the increase in self-referral to Physiotherapists is likely to increase the presentation of this cohort in our clinics as they will not have been screened by a GP or secondary care consultant prior to referral. There are issues with recognition here as well but targeted campaigns by groups such as NASS and NRAS have targeted GP surgeries and secondary care departments to increase awareness of the clinicians as well as their attending cohorts of patients. There have to date been less high-profile campaigns targeted towards Physiotherapists.
My usual starting point is that if these conditions are not in your differential diagnosis or you are unaware how they present then they are going to slip the net. I have seen other conditions across social media pushed forwards as part of the reasoning process, most noticeably in my mind Cervical Artery Dysfunction for cases of neck pain. Of course, not every person attending your clinic will have a serious medical condition and we know from our red flags research that not even every person with those will have a serious underlying condition, but still it is our duty to be diligent and rule things out or refer onwards appropriately.
The first step is recognition that something is a little different, so below I have outlined how to recognise systemic inflammatory symptoms in the quagmire of variation that walks through our clinic doors.
The onset of systemic inflammatory arthropathies is quite often insidious, but can be related to viral illness such as gastro-enteritis or a sexually transmitted infection. The onset of symptoms peaks between 20-40 years of age for the Spondyloarthropathies and 30-60 years of age for Rheumatoid Arthritis, but onset outside of these ranges is not uncommon.
Worse on waking
With inflammatory arthropathies, symptoms (joint pain and stiffness) are often at their worst first thing in the morning, lasting for over 30 minutes and improving after being up and about. The time frame is important, Osteoarthritis for example is commonly aggravated in the morning but usually for less than 15 minutes. If the stiffness is “self-reported” i.e. the patient volunteers the descriptive word, this is prognostic of inflammatory symptoms.
As students we are all taught that night pain can be a red flag but the details of this are of vital importance. In the world of Rheumatology, onset of pain in the second half of the night (after 2am say) is what we are looking for, especially if the individual has to get out of bed and move around to ease the symptoms.
Unlike the more typical types of musculoskeletal problems which present in clinic, inflammatory arthropathy symptoms tend to better with activity and worse with rest. Look for clues such as worse when working at a desk or during car journeys, much better when just “keeping active” or no symptoms when in the gym.
Better with Anti-Inflammatories
Unsurprisingly, inflammatory arthropathy symptoms are often improved with anti-inflammatories, look for those individuals that can’t cope without regular doses of ibuprofen or naproxen.
Swelling without trauma either transient or prolonged of the synovial joints is another clue that there might be something inflammatory going on. Especially looking for redness, heat and multiple joints affected particularly of the hands and/or feet can lead you down a path to ask more questions.
This list is by no means exhaustive, it is a starting point to begin recognising inflammatory symptoms. Inflammatory Arthropathies may present with any combination of these symptoms and it is important that we use these as a springboard to ask other questions which would raise the index of suspicion for these conditions such as family history and other associated co-morbidities.
I have created a tool which can help your clinical reasoning process for recognising Rheumatoid Arthritis, I run CPD sessions and talk at conferences on Recognition and Management of Rheumatology conditions in a lot more detail.
Here is a google drive with lots of references and materials to get your teeth into if this has wet your Rheumatology appetite.
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