A Step-by-Step Guide: Evaluating Patients with Arthritis in Long-Term Care

by Steven Levenson, MD, CMD

Diagnosis and management of arthritis in long-term care residents should reflect an effective care process, including adequate evaluation and thoughtful treatment selection. Instead, there is often a tendency towards drawing conclusions and prescribing treatments based on superficial examination and inadequate consideration of causes.

Despite the limitations on obtaining historical information in nursing home patients, it is possible to manage individuals with arthritis more effectively. Since many nursing home patients either do not or cannot provide such a history--and since x-rays and other diagnostic tests are not routinely done in nursing homes--nurses and other staff should make and document sufficiently detailed observations to allow practitioners to define the presenting problem. For example, a determination must be made as to whether the condition is osteoarthritis, an acute flare-up of rheumatoid arthritis, or perhaps not arthritis at all,but rather bursitis or tendonitis.

The following is a guide to assist in the diagnosis and evaluation of arthritis in long-term care patients.

History

The staff should gather pertinent information related to musculoskeletal complaints, including the following:

• Duration and intensity of pain.
• Current treatment.
• Functional status related to the body part of concern.
• Recent medical, surgical, and trauma history.

Pertinent observations would include observations of pain and stiffness related to efforts to perform activities of daily living (ADLs), joint swelling, and lack of mobility.

When questioning a patient who is able to respond appropriately, the physician or nurse should allow the person to describe symptoms, but should guide the flow of information. Before proposing or adjusting treatment, the provider should understand the nature and context of the problem. The most relevant, lowest-risk interventions may then be offered.

For the purposes of differential diagnosis, it is important to be aware of specific medical disorders that could have a significant impact on or association with a joint complaint, including: diabetes with neuropathic or septic joints, or osteomyelitis; endocrinopathies such as hypothyroidism (carpal tunnel syndrome, myopathy), and fracture, dislocation or gout. It should be noted that it is particularly difficult to distinguish chronic gout in older people from rheumatoid arthritis, since gout in this population can occur in a number of joints.

A complete medication list is important, as well as an inquiry into prior medications. A number of medications may be associated with myalgia (muscular pain or discomfort).

History of rheumatic diseases As much as possible, staff should identify factors such as the mode of onset, inciting events, duration , and pattern and progression of the musculoskeletal complaints. For example, acute onset is consistent with infectious, crystal-induced (for example, gout), or traumatic origin. It can also occur in the setting of a connective tissue disorder. Chronic complaints are seen with rheumatoid arthritis, Reiter's syndrome, and osteoarthritis, or the chronic sequelae of traumatic or back problems.

Pattern of joint involvement Knowing the pattern of joint involvement helps to define the type of joint disorder. Symmetric involvement of multiple small joints of the hands and feet is typical of rheumatoid arthritis. Osteoarthritis typically affects the small joints first, including the joints of the hands and feet. More than one joint usually is affected, and symptoms often appear bilaterally, but not symmetrically. Symptoms are usually worse in the morning or after rest.

Location, characteristic, and associated findings These factors assist in diagnosis. For example, acute metatarsophalangeal joint inflammation is characteristic of gouty arthritis. Sudden onset of low back pain in lifting or bending with associated radiating pain down the lateral leg is a common presentation for a disk herniation with sciatica. Pain in the shoulder or upper arm occurring after repeated lifting or moving the extremity may reflect tendonitis. Subcutaneous rheumatoid nodules appear in about one-quarter of cases. Nodules are firm, pea-sized masses made up of inflammatory byproducts and scar tissue.

Severity of disease This should be assessed in conjunction with a patient's ability to carry out ADLs--for example, if the person needs assistance in personal care, or uses a cane, crutches, or wheelchair.

Functional ability The focus here is on the ability to transfer, ambulate, and perform personal care.

Overview of prior management Document--including benefits and liabilities--the history of medications used in the past and present along with a record of patient compliance, history of therapeutic exercise programs, and any surgical procedures on joints.

Identification of the psychosocial consequences of disease Note anxiety, depression, insomnia, and other related consequences.

Emotional or physical stress Note stressors that may affect the development or exacerbation of musculoskeletal disorders.

Review of Systems

Many types of arthritis show signs of joint inflammation: swelling, stiffness, tenderness, redness, or warmth. These joint symptoms may be accompanied by weight loss, fever, or weakness. When symptoms last for more than two weeks, the cause may be inflammatory arthritis, such as rheumatoid arthritis. Unlike osteoarthritis--the most common type of arthritis, in which joint inflammation is not a prominent feature--rheumatoid arthritis is often associated with other diseases and systemic disorders related to rheumatic complaints and diseases of connective tissue.

In individuals with inflammatory joint complaints, it is important to inquire about and to recognize a possible association with:

• Eye disease (iritis, uveitis, conjunctivitis, dryness).
• Mouth disorders (dryness, mouth sores, tightness).
• Gastrointestinal problems (problems with swallowing, reflux symptoms, abdominal pain).
• Diarrhea (with or without blood, constipation).
• Genitourinary complaints (including dysuria, urethral discharge, hematuria).
• Skin disorders (painful rash, nodules, ulcers, or ischemic changes).

The presence of constitutional symptoms is also important, including complaints of weight loss, fatigue, fever, chills, night sweats, and weakness.

Physical Examination

In order to assess the nature and causes of symptoms, and the effectiveness of and need to continue current treatment, both nurses and physicians may need to selectively examine the patient. For example, tenderness on direct pressure over the joint and stress pain produced when the joint, at the limit of its range of motion, is nudged a little farther are important findings of inflammation. Deformity may be caused by bony enlargement, dislocation, or complete loss of joint motion in abnormal positions.

In order to clarify the situation, there are five relevant aspects of the physical examination to be employed: gait, spine, muscles, upper extremities, and lower extremities. The examiner should inspect and palpate problematic areas, and ask the individual to move them. Inspection, palpation, and movement of joints may reveal swelling, tenderness, temperature and color changes over the joint, and deformity.

Gait Describe the gait, and note a limp or use of cane or crutches. Clinically important gaits include antalgic gait, which is characterized by a short stance phase on the painful side; short-leg gait, which has signs of pelvic obliquity and flexion deformity of the opposite knee; coxalgic gait, an antalgic gait with a lurch toward the painful hip; and metatarsalgic gait, in which the patient tries to avoid weight bearing on the forefoot.

Alignment of lower extremities Examine for flexion deformity of knees, genu varum (bow legs), or genu valgum (knock-knees).

Position of ankles and feet Observe for varus or valgus heels, flat feet, inversion or eversion of the feet.

Check back motion on forward bending Check lateral flexion to each side, and hyperextension, if possible. Additional investigations may include the following.

Seated Position

Useful maneuvers in a seated position If the individual complains of shoulder pain, for example, the nurse or physician should have the individual attempt to elevate both arms from zero degrees along the sides of body to 180 degrees straight above the head. The patient should then be assisted in abducting arms to the normal maximum of 90 degrees. Restrictions in range of motion on either side should be noted.

Fingers, thumbs, and wrists Although the pain is not generally as intense as it is in the weight-bearing joints, hand-joint pain can be debilitating in severe cases. If arthritis of the wrist or hands is suspected, palpate wrists and examine finger joints by inspection and palpation for soft tissue swelling and bony enlargement. Quantify grip by noting the patient's maximum strength in grasping two fingers of the examiner.

Bone spur growth may give the affected finger joint a deformed, "bumpy" appearance. Pain is most common when the finger joint is in use. With osteoarthritis, pain in the thumb usually occurs as the joint begins to perform an action. The pain diminishes while using the joint, but returns for a while accompanied by stiffness, once the joint is at rest. Like the thumb, the arthritic wrist tends to hurt most when starting or after finishing a task.

Shoulder and elbow joint Note any grinding sensations in the shoulder along with reduced range of motion. As arthritis of the elbow joint progresses, the joint can become very difficult to straighten and bend. The joint may grind and swelling often occurs.

Supine Position

Evaluation of low back pain should include inspection, palpation, range-of-motion assessment, and a straight leg-raising test to screen for lumbosacral nerve root symptoms. Evaluation of the knees should include inspection and palpation, noting the position and mobility of the patellae. Assessment of the ankles and feet should distinguish synovial soft tissue swelling of ankles from periarticular edema and fat pads. Inspection of the toes should note alignment and deformity, including hammertoes, claw toes, and hallux valgus.

Osteoarthritis: Key Points

In evaluating osteoarthritis, typical symptoms that should be noted include the following.

• Sore joints (either while using the joints or, in advanced arthritis, at rest).
• Changes in joint shape (due to the formation of bone spurs, or osteophytes).
• Inflammation (a symptom of advanced osteoarthritis).
• Loss of joint mobility.
• Stiffness in the morning that lasts up to thirty minutes.
• Cracking or grinding noises in the joint.

The joints that are affected most often are those that bear the body weight. Unlike rheumatoid arthritis, osteoarthritis is located in only one or a few joints. In fact, osteoarthritis is probably most often confused with rheumatoid arthritis if it affects multiple joints in the body.

Patients present with pain or brief morning stiffness in one or more hand joints or in a single weight-bearing joint. Symptoms can be diffuse in distribution , mildly inflammatory, and associated with significant, if slowly progressive, deformity and disability. The joint distribution typically involves the first carpometacarpal joint of the thumb, first metatarsophalangeal joint, the distal and proximal interphalangeal joints of the hands, hips, knees, and the cervical and lumbar spine.

On physical examination, joints may be tender to the touch, especially if swelling and warmth (synovitis) are present. Or, there may be tenderness without signs of inflammation. Pain on weight bearing may be present without pain on passive range of motion.

In later disease stages, there may be crepitus, gross deformity, and subluxation (joint dislocation caused by cartilage loss, collapse of subchondral bone, bone cysts, and gross bony overgrowth). Limitation of motion increases as disease progresses,perhaps caused by joint surface incongruity, muscle spasms and contracture, capsule contracture, or mechanical blockage.

Other disorders that may coexist with osteoarthritis but are important to identify include tendonitis and bursitis.

Bursitis

Localized pain is the presenting complaint, with radiation into the involved limb as an occasional feature. Local swelling is also common. Erythema may be present and does not necessarily indicate sepsis. Tenderness is always present. Pain is usually elicited when the patient is asked to execute a maneuver that stresses the involved motor unit--for example, abduction of the hip against gravity will cause pain in trochanteric bursitis.

Tendonitis

The classic sign of inflammation within the tendon or tendon sheath is pain on motion, especially with passive stretch or contraction of the affected motor tendon unit against resistance. Local swelling, warmth, and tenderness are usually present. Tenderness may be palpated along the course of the tendon. On deep structures, such as the supraspinatus or gluteus medius tendons, deep-point tenderness in a specific and reproducible location may be felt.

Since most tendons cross joints, tendonitis must be distinguished from acute inflammatory or septic arthritis. In the latter case, range of motion will be more severely restricted. Systemic signs may be present.

Conclusion

Arthritis is a common condition in long-term care residents, and is also a common source of pain. It is important to distinguish the various kinds of arthritis, as well as to distinguish arthritis from other sources of musculoskeletal and joint symptoms. This enables individualized treatment and reduces the risk of inappropriate or excessive treatment with undesired side effects. A pertinent history focused on the musculoskeletal system and psychosocial consequences of disease, followed by an appropriate physical examination with a detailed musculoskeletal and joint evaluation, remain the important clinical basis for diagnosis and individualized management of rheumatic disease.

Dr. Levenson is a Multi-Facility Medical Director in Baltimore, MD, and Chair of Caring's Editorial Board.

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