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Guide to the Clinical Assessment of Patients with MSK Conditions

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Guide to the Clinical Assessment of Patients with MSK Conditions GUIDE TO THE CLINICAL ASSESSMENT OF PATIENTS WITH MUSCULOSKELETAL CONDITIONS WE ARE 03 Versus Arthritis is dedicated to stopping the 18 MILLION devastating impact that arthritis has on people’s lives. When we talk about arthritis, we include all PEOPLE IN THE musculoskeletal conditions that affect the joints, bones and muscles – including osteoarthritis, UK LIVE WITH A rheumatoid arthritis, back pain and osteoporosis. Although these long-term conditions may be MUSCULOSKELETAL different in pathology, the impact they can have on people’s lives is similar. Pain is the most prevalent CONDITION symptom for people with arthritis, with many experiencing this every day and living with it for THAT’S THREE years or even decades. IN EVERY TEN Musculoskeletal conditions are a costly and growing problem. Their prevalence is expected to continue PEOPLE to increase due to our ageing population, rising levels of obesity and physical inactivity. The role of healthcare professionals in enabling people with The impact of arthritis can be arthritis to live well, to understand their condition, huge as the condition slowly and to have access to the appropriate information intrudes on everyday life, and support to self-manage has never been more affecting the ability to work, important. to care for a family, to move free from pain and to live Versus Arthritis is here to help you. Our education independently. Yet arthritis and training resources for frontline healthcare is often dismissed as an professionals are accessible, relevant and evidence inevitable part of ageing or based. They are designed to support you in shrugged off as ‘just a bit of confidently diagnosing and managing a range of arthritis’. We don’t think that musculoskeletal conditions, as well as honing your this is OK. Building on the skills in providing patient-centred, holistic care. legacies and expertise of both Our ‘Guide to the clinical assessment of patients Arthritis Research UK and with musculoskeletal conditions’ has been Arthritis Care, Versus Arthritis developed as a study guide for medical, nursing is here to change that. and allied health professional students. It takes a step by step approach to assessing people with musculoskeletal conditions to help you become competent and confident in their care. Registered office: Versus Arthritis, Copeman House, St Mary’s Gate, Chesterfield S41 7TD Registered Charity England and Wales No. 207711, Scotland No. SC041156. 01. ABOUT THIS GUIDE 08 BIOGRAPHIES 09 FOREWORD 09 LIST OF ABBREVIATIONS USED 09 TERMINOLOGY 09 ACKNOWLEDGEMENTS 02. INTRODUCTION 12 INTRODUCTION TO MUSCULOSKELETAL ASSESSMENT 12 INITIAL APPROACH 03. THE MUSCULOSKELETAL HISTORY 16 ARE THE SYMPTOMS FROM THE JOINT OR THE SOFT TISSUES? 17 IS THE CONDITION ACUTE OR CHRONIC? 18 IS THE CONDITION INFLAMMATORY OR NON-INFLAMMATORY? 20 WHAT IS THE PATTERN OF AFFECTED AREAS/JOINTS? 22 WHAT IS THE IMPACT OF THE CONDITION ON THE PATIENT’S LIFE? 23 ARE OTHER SYSTEMS INVOLVED? 04. THE MUSCULOSKELETAL EXAMINATION 26 THE MUSCULOSKELETAL SCREEN: ‘GALS’ QUESTIONS AND EXAMINATION 34 PERFORMING A REGIONAL EXAMINATION OF THE MUSCULOSKELETAL SYSTEM ‘REMS’ 05. INVESTIGATIONS 50 IMAGING OF BONES AND JOINTS 51 BLOOD TESTS 51 SYNOVIAL FLUID ANALYSIS 06. CONCLUSION 54 APPENDIX 1: REVISION CHECKLISTS 58 APPENDIX 2: THE CORE SET OF REGIONAL MUSCULOSKELETAL EXAMINATION SKILLS APPROPRIATE FOR A MEDICAL STUDENT AT THE POINT OF QUALIFICATION 59 APPENDIX 3: PGALS AND PREMS 60 BIBLIOGRAPHY 60 ENDORSEMENTS 01. ABOUT THIS GUIDE 08 BIOGRAPHIES 09 FOREWORD 09 LIST OF ABBREVIATIONS USED 09 TERMINOLOGY 09 ACKNOWLEDGEMENTS BIOGRAPHIES Author Medical Editor David Coady is a consultant rheumatologist Mark Lillicrap is a consultant rheumatologist at Sunderland Royal Hospital. He previously at Addenbrooke’s Hospital in Cambridge and held an Educational Research Fellowship Hinchingbrooke Hospital in Huntingdon. His funded by Arthritis Research UK. This focused interest is in medical education and teaching. on identifying the core clinical skills of He is an associate lecturer and curriculum sub- musculoskeletal examination for undergraduates. dean at the University of Cambridge, has led the He produced the REMS videos which have been undergraduate musculoskeletal curriculum in used for teaching since 2001. He maintains a Cambridge, is a lecturer on the Cambridge PGCert keen interest in education, educational research in Medical Education and is the director of the and sailing. undergraduate clinical supervisor programme in Cambridge. Mark has also worked as the director of medical education at Hinchingbrooke and is a postgraduate educational supervisor for rheumatology specialist trainees. DAVID AND MARK HAVE BOTH BEEN CLOSELY INVOLVED IN DEVELOPING PREVIOUS EDITIONS OF THE GUIDE AND HOPE THAT THIS UPDATED VERSION WILL PROVE TO BE A USEFUL RESOURCE FOR EVERYONE INVOLVED IN ASSESSING PATIENTS WITH MUSCULOSKELETAL CONDITIONS. 09 FOREWORD FOREWORD Dr Pippa Watson List of abbreviations used Consultant Rheumatologist CMC(J) carpometacarpal (joint) and Honorary Senior Lecturer CT computerised tomography University Hospital of DEXA dual-energy x-ray absorptiometry South Manchester DIP(J) distal interphalangeal (joint) ESR erythrocyte sedimentation rate GALS gait, arms, legs and spine I’m delighted to introduce the updated Versus Arthritis MCP(J) metacarpophalangeal (joint) ‘Guide to the clinical assessment of patients with MRI magnetic resonance imaging musculoskeletal conditions’. I remember using this MTP(J) metatarsophalangeal (joint) guide during my training and finding it to be a clear NSAIDs non-steroidal anti-inflammatory drugs and useful resource. A few years later I find myself OA osteoarthritis using it again when teaching medical students. I PIP(J) proximal interphalangeal (joint) look forward to using this updated version – I think it RA rheumatoid arthritis brilliantly achieves its aim of demystifying examination REMS regional examination of the musculoskeletal of the musculoskeletal system, an area which students system have previously reported finding difficult. The guide includes the ‘GALS’ (Gait, Arms, Legs, Terminology Spine) screening examination developed by It could be argued that the term ‘arthritis’ should Professors Paul Dieppe and Mike Doherty. For patients only be used to describe inflammatory disorders who report symptoms or have positive findings on of the joint whilst ‘arthropathy’ should be used to the GALS screen it offers Regional Examination describe non-inflammatory disorders of the joint. of the Musculoskeletal System (REMS). The core However, the term ‘arthritis’ is in such widespread skills included in REMS are based on a consensus use to describe any disorder of the joint that, for the reached across a broad spectrum of UK clinicians in a purpose of this guide, it will be used in that sense. study led by Dr David Coady. Regional examinations Acknowledgements are structured using the look/feel/move/function We remain indebted to Professor Paul Dieppe – his approach making them easy to recall and perform. earlier version of this guide has been widely referred This new edition focuses on examination, but also to by medical students in the UK since 1991 and his includes tips on history taking and investigations text remains influential in this new edition. that will assist in making a diagnosis. It also includes We would like to thank David Coady and Mark paediatric examination incorporating work led by Lillicrap for their considerable time and commitment Professor Helen Foster which led to the development in updating the content, Pippa Watson for her of paediatric versions pGALS and pREMS. feedback and additional support during the filming These are based on the adult examinations with of the video material, and all those who took the additions to improve detection and identification of time to comment on the previous edition and early musculoskeletal problems in school-aged children. drafts of the new guide – Onebieni Ana, Ivan Cheuk I hope you will enjoy it and find it useful too. Over to Li, Nathan Ng, Jamie Nicholson, Sarah-Jane Ryan, you – time to get reading and then practising! Sophia Wakefield, Louise Warburton and Anita Williams. 02. INTRODUCTION 12 INTRODUCTION TO MUSCULOSKELETAL ASSESSMENT 12 INITIAL APPROACH 12 INTRODUCTION TO MUSCULOSKELETAL ASSESSMENT MUSCULOSKELETAL TO INTRODUCTION INTRODUCTION TO INITIAL MUSCULOSKELETAL APPROACH ASSESSMENT It is estimated that musculoskeletal disorders Before considering a diagnosis, it is useful to try to account for approximately 30 per cent of a GP’s broadly categorise the symptoms and signs (from workload (Department of Health, 2006) and are the history and examination) by answering the the most common cause of repeat consultations in following key questions: primary care. About 30 per cent of those with any • Are the symptoms from the joint itself or the soft physical disability, and 60 per cent of those with a tissues (tendons/muscles)? severe disability, have a musculoskeletal disorder as • Is the condition acute or chronic? the primary cause of their problems. • Is the condition inflammatory or non- Clinical assessment skills – i.e. history taking and inflammatory? examination – are the key to making an accurate • What is the pattern of affected areas/joints? diagnosis and appropriately managing any patient • What is the impact of the condition on the presenting with a musculoskeletal problem. This patient’s life? guide aims to introduce you to the methods you • Are other systems involved? might use during the initial
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