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- So the diagnosis of Rheumatoid Arthritis,
the most important focus for a Rheumatologist
are the clinical symptoms that a patient is presenting with.
By that I mean what is the patient experiencing
is the patient telling us that he or she is experiencing
pain, stiffness, or swelling in the joints?
Are we concerned that there is Arthritis,
which again means inflammation in the joints.
We listen to the patient's story, that is what defines for
us whether we are concerned for Rheumatoid Arthritis or not.
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Two tests that many people are familiar with
is one, a very old test known as Rheumatoid Factor,
and two a rather new test known as Anti-CCP Antibodies.
These tests can help us in confirming the diagnosis
of Rheumatoid Arthritis, but the test by themselves
even if they are positive, will not make the diagnosis
of Rheumatoid Arthritis, what do I mean by that?
Well let's take the first test, Rheumatoid Factor,
Rheumatoid Factor is an age old test that can be positive
in many different conditions just having a positive
Rheumatoid Factor does not define
for me Rheumatoid Arthritis.
But as I said I have to look at Rheumatoid Factor
in the right clinical picture again, the patient
and the patient's symptoms is the key focus.
On the other hand, the newer test Anti-CCP Antibody,
is highly specific for Rheumatoid Arthritis.
What do I mean by that?
I mean that when I see a patient with high levels of
Anti-CCP Antibodies, my concern for Rheumatoid Arthritis
is very high, it's almost as if there's a 99% chance
that somebody with high titres of Anti-CCP Antibodies
will have Rheumatoid Arthritis.
But let's flip the coin, and you may ask me,
does every patient with Rheumatoid Arthritis
have Anti-CCP Antibodies?
The answer to that is again no, as a Rheumatologist
we have to go back to our patient, that patient with
very high titres of Anti-CCP Antibodies do they yet
have joint symptoms or not?
If they have the right joint symptoms, the right Antibody,
yes they have Rheumatoid Arthritis.
There are some other tests that we use,
markers of inflammation and again that people may be
familiar with those, ESR and C-Reactive protein
they're telling us that there's inflammation in the body
and again in the right patient this helps us
make the diagnosis of Rheumatoid Arthritis.
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So I think that's again, something which we are beginning
to understand better, that our patients with
Rheumatoid Arthritis are not just going to come to us
and say I have swollen joints, I have painful joints
but they are going to tell us about more than
just that and they will often tell us,
I'm very tired, I'm very fatigued
and my fatigue is something that I've never experienced
before, this is an unusual tiredness which is,
has nothing to do with what I do in my day.
Some of the other things that patients may be
experiencing may be disturbed sleep as a part of the
inflammation in their body.
They may also experience anxiety, depression,
because of the pain and the stiffness
that they're experiencing.
So I think as physicians it's very important for us
to focus on what else are the patients telling us
besides the symptoms in their joints.
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So a Joint Count means that we examine every single joint
so let's say if I am examining a hand, I am touching,
I am feeling and I am putting some pressure on
what I am trying to understand is number one,
is there tenderness in the joint?
Which means pain in the joint.
Is there swelling in the joint?
Is there deformation, or is there
limited range of motion in the joint?
So using those criteria, we walk through several joints.
The fewer joints that are involved, the better it is
for the patient and that gives us a sense of how active
Rheumatoid Arthritis is, how do we adjust treatment.
Are we happy with the way the patients are doing
at that point or do we need to do more,
to control the inflammation in their joints?
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The new RA criteria basically focuses on four evaluations,
we evaluate the joint, so we examine the joint looking
for tender and swollen joints, we see how many tender
and swollen joints does the patient have
and we give them a particular score for that so that's one.
The second is duration of symptoms, if a patient has
duration of symptoms in their joints, again pain,
stiffness, swelling for more than six weeks
that counts as one score towards the diagnosis
of Rheumatoid Arthritis, the third evaluation is
that of markers of inflammation.
ESR and C-Reactive Protein as we have mentioned before,
if someone has high ESR or C-Reactive Protein that
again goes towards the score for the diagnosis of
Rheumatoid Arthritis and the final evaluation
is that of Rheumatoid Factor and Anti-CCP Antibodies.
We've talked about them, if they are present
or if particularly if they are in high numbers,
that again goes as either one or two scores
for the diagnosis of Rheumatoid Arthritis.
We then add up the score, and a score of six or above
meets the criteria for Rheumatoid Arthritis.
So the only thing that I want people to recognize,
is that on the basis of these four criteria only,
we can make the diagnosis of Rheumatoid Arthritis.
We don't need ultrasound, we do not need MRI,
we do not need evidence of X-ray damage, et cetera.
And the reason this has changed the way we have diagnosed
Rheumatoid Arthritis is because we are diagnosing
Rheumatoid Arthritis much earlier now.
Before the joint damage occurs, before the deformities
occur, before the X-ray damage occurs.
So it has really changed the way and how we are now
diagnosing this disease and early diagnosis means
we can start treating early as well.
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