[Music]
I'm going to explain how to examine your own joints and undertake a self-reported
tender and swollen joint count.
Karen Staniland has rheumatoid arthritis and will examine her own joints, whilst I show her how to do it.
[Music] I'll explain why examining your joints
is important, and then show you how to examine all the relevant joints.
Karen and I will then discuss some frequently asked questions.
You can pause the video whenever you wish, and you may want to replay it
before having a go at examining your own joints,
or you can try examining your joints as we go along.
All of the joint examinations are available as separate clips.
We have developed a rheumatoid arthritis tender and swollen joint count model and table.
This is available on the YouTube page where this video is hosted.
You can download and print it to keep a note
of the number of tender and swollen joints, as you go along.
You can tick off swollen and tender joints on the model, or in the table,
and add them up at the end.
These resources are available in the description box below the video.
Assessing the number of tender and swollen joints is really important to
help healthcare professionals calculate your disease activity.
This tells them how active your rheumatoid arthritis is,
and guides treatment. Examining your own joints can be useful for your own
understanding and to enable you to report to your healthcare professional.
The most commonly used score in clinics is the DAS28 score.
D.A.S stands for Disease Activity Score whilst the 28 relates to the number of
joints examined. It's made up of four components
including a tender joint count, a swollen joint count,
a blood test measuring inflammation (CRP or ESR),
and the patient's assessment of
their health over the last week.
The 28 joints included in disease activity scores
are the shoulders, the elbows, the wrists, the knuckles,
the middle joints on the fingers, and the knees. It's not that the other joints
aren't important, especially from a patient point of view,
just that they are not included in the measure.
Joints might appear swollen for lots of reasons.
In rheumatoid arthritis, healthcare professionals are looking for joint
swelling caused by inflamed joint lining. This makes the joints feel
quite soft and squidgy like a grape.
It is really important that only those joints which feel soft and squidgy are counted as swollen.
This kind of swelling can last a long time
or can come and go quite quickly. Joints can be swollen for other reasons
apart from joint inflammation. Osteoarthritis is quite often present
alongside rheumatoid arthritis. Osteoarthritic joints are very hard and
boney, and don't tend to change quickly. Although it will look swollen and can be
tender to touch, this swelling is caused by bone,
so will feel hard and not squidgy.
These hard bony swellings do not count as a swollen joint.
There are other structures around the joints which might make you think they
are swollen, when they are not. Swelling outside the joint
can include pockets of fluid called bursitis.
Bursitis does not count as a swollen joint.
Some people have rheumatoid nodules which are knobbly swellings attached to the skin.
Nodules do not count as swollen joints.
The only type of swelling that counts in rheumatoid arthritis disease activity examinations
is boggy swelling that feels like a grape, due to inflammation in the joint.
In this picture the knuckle joints are swollen.
[Music]
Healthcare professionals use the word tender to describe joints that feel
painful, or sore. Joints may be tender and swollen, just
swollen, or just tender.
You need to press on the joint either until it hurts, or until your fingernails go white.
If your joint is tender to touch you
don't need to press any harder, but you will still need to feel for swelling.
[Music]
When examining the joint, you need to feel for the joint line which is where
the ends of the two bones meet - this is where you'll be able to feel
swelling, if there is any. I'll explain as we go through each joint
where the joint line is and show you on a skeleton first.
It's quite simple once you start having a go.
To examine your own joints it's best to be comfortable.
I usually start with the shoulder working my way down
through to the elbow, and the wrist, the hands and then the knees, but you can
do the examination in any order you like.
Just to show you what a shoulder joint looks like, here's a skeleton.
Here is the ball of the ball and socket joint. And this is where you'll be
feeling for the joint line.
To feel the shoulder joint, if you bring your
hand up to the shoulder joint and feel with your thumb at the front of the
shoulder, and your fingers around the back of the
shoulder, and if you just slightly move your shoulder,
you'll feel it moving underneath your thumb. And that means you're right
in the shoulder joint line so you can feel if there's any swelling
at all, and if it's tender.
How does that feel? [Karen] Okay, I can feel the
space and it's not tender.
[Tricia] Great.
With the elbow joint you can see where the joint line is between these two bones.
To feel the elbow joint, if you bring your thumb
and your fingers up to the elbow joint, and with the elbow
flexed or bent, you can feel around the knobbly bit of the elbow with your
thumb and finger.
[Karen] Yes, I can feel the knobbly bit.
[Tricia] And if you just slightly move the elbow
as well, then you'll know that you're right in the joint line.
[Karen] Yes, I can feel it moving.
[Tricia] Great.
Looking at the wrist joint, you can see the two bones
and where they meet, the small bones of the wrist.
Where the wrist bends, is where the joint line is.
To examine the wrist, if you have your hands resting on the pillow and
with your hand come over to the top of the wrist
with your fingers and you can feel down past the two bony lumps of your wrist.
If you look at what I'm doing with my fingers,
I'm bringing them across the wrist joint with the thumb underneath,
with the two fingers to examine the wrist joint. And then if
you bend your wrist slightly, you'll feel that you're right in the joint line.
So you can feel if there's any swelling at all.
[Karen] Yes, it feels quite squishy.
And I think it's a bit swollen.
[Tricia] Okay, so does that feel like a grape?
[Karen] Yes. Yes, it does. Like a squishy grape.
[Tricia] Thank you.
With the knuckles, the joint line is where the two bones meet
and the joint bends.
To examine the knuckles, these are known as the MCPs for short, we're going to feel
across from the thumb across to the index finger
and then the other fingers. So if we start with the
thumb joint, and you're coming to
just try and bend the thumb slightly, and put your
thumb and first finger over the joint, and you'll feel it moving
underneath your fingers, and then you'll know you're in the joint line.
[Karen] That's a little tender.
[Tricia] Okay, and if you come across down to
the index finger knuckle and again
those fingers are slightly bent.
[Karen] Yes, that's a little bit swollen there.
[Tricia] And moving your hands across to feel the other joints.
You'll know you're in the joint line
because you can feel a space. [Karen] Yes.
[Tricia] Okay.
With the finger joint you can see that the two joints bend
and that's where the joint line is.
So let's examine the middle finger joints, which are also known as the PIP joints.
The distal interphalangeal joints, or the DIP joints, we don't examine
in rheumatoid arthritis. So you could start with the thumb again
and using two fingers and a thumb
just gently feel around that joint. Feeling for any swelling
or tenderness, and moving across to the index finger.
And again with the finger slightly bent or even moving underneath your fingers,
you'll be able to feel that you're actually in the joint line,
and feeling for any swelling or tenderness.
[Karen] I can feel that all my finger joints are tender and swollen at the moment.
So I don't need to press very hard.
On the skeleton you can see the knee joint is a hinge joint.
And this is where the joint line is,
where the two bones meet.
The knee joint is a hinge joint, and so therefore when we're feeling the knee
joint what we're feeling for is the joint line where the
two bones meet together. Now there's a lot of soft tissue around the knee joint,
so you have to be aware of that when you're feeling the joint for any
swelling or tenderness. So if you have your fingers behind the
knee and your thumbs around the knee joint, you'll feel for
these two dips
either side of the kneecap. [Karen] Yes.
[Tricia] And then you can feel, if there's any swelling in there at all,
so if it feels boggy to the touch and if there's any tenderness at all.
[Karen] That feels fine. [Tricia] And it's good to keep your knee relaxed
as well so the muscles at the top of the leg are
relaxed, because it's so much easier then to examine the knee.
[Karen] How do you know, whether you're in the right place?
[Tricia] So this becomes much easier with time and the more you examine your joints
the more you'll know you're in the right place,
but it is particularly where you find the joints are moving underneath your
fingers when you're examining your joints.
[Karen] Why do I get swollen palms? [Tricia] Swelling occurs in places other than
the joints in rheumatoid arthritis. It can occur in the palms, on the backs
of the hands, and it's important to make note of it,
but it doesn't count when we're doing a disease activity score.
[Karen] I often get swelling in one shoulder or one hand,
but not the other. Is this normal? [Tricia] So rheumatoid arthritis is always
described as being symmetrical, but it's perfectly normal to have just one joint
inflamed at a time.
[Karen] Do nodules stay forever?
[Tricia] Nodules do stay for a long time, but sometimes they respond to treatment,
so they may well go away.
[Karen] Please explain why feet aren't included
in the scoring. If you've got no tender and swollen joints anywhere else, but you
have in your feet, why are they not included?
[Tricia] So the joints that are used in the disease activity score
are reliable for assessing disease activity,
but that doesn't mean to say the feet aren't important.
They are affected in rheumatoid arthritis and therefore it is really
important that when you do see your healthcare professional you do tell them
that you have problems with your feet, and that they can then have a look at them.
[Music]