Analysis and evaluation of the joint examination by the Rheumatology Group of the National University of Colombia

One of the major problems in the practice of rheumatology and patient care is joint pain. This pain may be classified into two groups: arthralgias or arthritis (mono, oligo or polyarthritis), based on these two categories, patients are separated into different groups, in accordance with their medical record and a joint examination that should be performed pursuant to the guidelines of the Universidad Nacional work group, led by Professor Yimy Medina.¹ In accordance with the focus of the medical record and the joint examination, four broad classification categories are established:

• A

  Inflammatory diseases.

• B

  Diseases associated with joint wear-and-tear (osteoarthrosis).

• C

  Metabolic diseases (osteoporosis, osteomalacia, diabetes and dyslipidemias).

• D

  Functional diseases (neurosis, stress).

Once the rheumatologist is aware of the type of joint pain, has completed the physical examination and the joint examination to identify symptoms – arthralgia or polyarthralgia – it is then possible to determine the presence of arthritis. This is the key role of the rheumatologist: to conduct the joint examination. This involves studying each individual joint by applying pressure and then determining their sensitivity and swelling to finally complete the swollen and tender joint count. However, in order to make a diagnosis, the diagnostic criteria for rheumatoid arthritis (RA) established in 1987 by the American College of Rheumatology (ACR) and used until 2010 should be followed. The new criteria were adopted in 2010, through a joint effort between the ACR criteria and the EULAR (European League Against Rheumatism) criteria; the primary objective of this joint effort was the early identification of rheumatoid arthritis and the determination of established disease.² Before these criteria were developed, the first approximation to standardize the joint examination was suggested by Richie et al.³ they analyzed the behavior of arthritis and defined the initial clinical and laboratory criteria. However, due to the complicated examination, such criteria were simplified into what we now call activity criteria.

Few studies are published on the examination of the joints in different rheumatology journals in Colombia and the world. One of those publications worth mentioning is the work led by professor Medina of the Universidad Nacional de Colombia, on the “Variation in the definition of the joint examination for rheumatoid arthritis clinimetrics”. This study reviews the survey administered to a group of 92 rheumatologists participating in the General Assembly of the Colombian Association of Rheumatology during the 2018 congress held in Bucaramanga. The questionnaire comprised 30 questions, divided into 4 topics:

• 1

  Joint pain during the RA activity examination (questions 1–3).

• 2

  Joint swelling (questions 4–6).

• 3

  General examination (questions 7–10).

• 4

  Individual joint examination (questions 11–27) and general questions (28–30).

Before administering the survey, a pilot test with 5 rheumatologist, representing different geographical areas of the country, was conducted in order to adequately structure the questions.

The most significant results of the investigation were: 1) 99% completed the survey; 2) in terms of the general questions, the rheumatologist agreed on the need for a consensus; 3) with regards to joint pain, 78% considered that all the topics covered in the questions were relevant (passive motion, tenderness at palpation of the joint, inter alia); and 13% said that palpation of the joints was very important. Moreover, 53.8% agreed with the assessment of passive motion, whilst 62.6% were interested in doing the thumb pressure test: thumb technique to assess joint swelling – which was considered an important objective of the study.

The most relevant conclusions were: with regards to marking of the joint margin, 55% agreed with joint swelling (swelling, joint effusion, and altered range of motion); 54% disagreed with exploring first the inflammation in each joint and then pain; with regards to the patient’s position for examination, 83.5% preferred to examine the upper body in a sitting position, and then have the patient lie down to examine the lower body. There was no major disagreement about the examination technique, except with regards to the hip examination.

Among other conclusions of the study, the investigators argue that there are differences in terms of the concepts involving the joint examination technique, which could affect clinimetrics; therefore they suggest implementing a consensus. The strongest disagreement was about the joint examination concept for defining swollen of tender joints; the proposal is to adopt standardization as a sound option.

It should be highlighted that this type of exercise had never been conducted in the Colombian Association of Rheumatology, and probably in many of the rheumatology societies, with the exception of clinimetrics testing.

Finally, we should recognize the outstanding work by Professor Yimy Medina and the group of rheumatologists and residents of the Rheumatology Group of the Universidad Nacional de Colombia. The level of quality of this work is rarely achieved in Latin America.