Musculoskeletal Clinical Examination Research Articles

Ultrasound prevalence of wrist, hand, ankle and foot synovitis and tenosynovitis in systemic sclerosis, and relationship with disease features and hand disability

In systemic sclerosis, few studies have shown that hand and wrist ultrasound is more sensitive than clinical examination in the detection of synovitis and tenosynovitis. Even fewer studies have investigated ankle and foot involvement with ultrasound. Our objectives were to investigate ultrasound prevalence of wrist, hand, ankle and foot synovitis and tenosynovitis in patients with systemic sclerosis classified with ACR/EULAR 2013 criteria, and to study their relationship with disease features and hand disability. Consecutive patients with systemic sclerosis, classified with ACR/EULAR 2013 criteria, were included in a monocentric cross-sectional study. They underwent standardized musculoskeletal clinical examination and hand, wrist, ankle and foot ultrasound. Clinical, biological and imaging data were also collected. Fifty-five patients were included. Ultrasound was more sensitive than clinical examination to detect at least one synovitis (respectively 52% versus 25%, P=0.025) and at least one tenosynovitis (respectively 16% versus 4%, P=0.009); 18% of patients had ankle tenosynovitis and 29% had ankle and/or foot synovitis, mostly located at metatarsophalangeal joints (25.5%). Having at least one ultrasound hand synovitis was associated with higher Cochin hand functional disability scale (mean 25±3 versus 12±2, P=0.003) and diffuse cutaneous subset (P=0.038). Our study shows that ultrasound is more sensitive than clinical examination to detect synovitis and tenosynovitis in systemic sclerosis. The foot involvement is less frequent than hand involvement, mainly localized at metatarsophalangeal joint. Finally, having at least one synovitis of the hand is associated with diffuse cutaneous subset and higher hand disability.

Migraine Awareness in Italy and the Myth of "Cervical Arthrosis".

The primary aim of this study was to assess the degree of awareness migraine patients had of their condition. The secondary aims were to evaluate the frequency of an incorrect diagnosis of "cervical arthrosis" in patients unaware of having migraine and to compare the clinical features, diagnostic investigation, and treatment strategies between the 2 subgroups of migraineurs, that is, those with and without the incorrect diagnosis of "cervical arthrosis." Patients, between 18 and 65 years, were consecutively referred to 5 Headache Centers in 2 Italian regions for a first visit. They fulfilled the diagnostic criteria for migraine (with/without aura, episodic/chronic) and were enrolled in this cross-sectional study. Each patient underwent a specific cranial/cervical musculoskeletal clinical examination. A total of 117/250 subjects (46.8%) were unaware that they suffered from migraine. In these unaware subjects, the most frequently reported diagnosis was "cervical arthrosis" in 34/117 (29.1%), followed by tension-type headache in 23/117 (19%). The cervical region was the most common site of pain onset in the so-called "cervical arthrosis" group (52.9%, P<.0001), where also more pericranial (58.8%; P=.041) and neck (70.6%; P=.009) muscle tenderness, restricted range of cervical vertical (47.1%; P<.001), and lateral (29.4%; P=.040) movements were reported. More "cervical arthrosis patients" had been referred to an Emergency Department (88.2%; P=.011) and had undergone more cervical spine radiography (23.5%; P=.003) and magnetic resonance imaging (20.6%; P=.044). While they had used fewer triptans (11.8%; P=.007) and received less pharmacological prophylaxis (2.9%; P=.004). In our sample, there were high misdiagnosis rates for migraine sufferers in Italy. The most common misdiagnosis, that is, "cervical arthrosis," led to misuse of healthcare facilities and had a negative impact on the migraine treatment.

Clinical findings from 104 cases of calving paralysis in dairy cows from Gippsland, Australia

ABSTRACTCase History: Dairy cows recumbent following calving on farms in South Gippsland, Australia were examined during two 3-month seasonal calving periods in 2011 and 2012 as part of a larger study of 218 recumbent cows. A cohort of 104 cows diagnosed with calving paralysis following dystocia was derived from the larger group, which were examined with 3 days of becoming recumbent. A thorough medical and musculoskeletal clinical examination was performed on each cow including flexor-withdrawal and patellar reflex tests, and postural assessment in the lifted position, unless the facilities were not available. Cows were diagnosed with one or more neurological syndromes: sciatic, tibial paresis, obturator or femoral, based on clinical findings consistent with damage to these peripheral nerves or their nerve roots.Clinical Findings: Evidence of sciatic syndrome was found in 100/104 (96.2%) cows and 146/172 (84.9%) affected hind limbs either as the sole neuropathy or in combination with tibial paresis, obturator or femoral syndromes. Pelvic damage was also present in 3/104 (2.8%) cows. Obturator syndrome was diagnosed in 30/104 (29%) cows and 45/172 (26.2%) affected hind limbs but not apparently as the sole reason for the recumbency. Femoral syndrome occurred in 16/104 (15.4%) cows and 21/172 (12.2%) affected hind limbs and was the only syndrome recorded in one cow.Clinical Relevance: Sciatic syndrome was the most common neurological syndrome observed in cows with calving paralysis. The other major nerves arising from the lumbo-sacral plexus were also affected and the various syndromes associated with damage to these nerves or their ventral nerve roots occurred in many combinations. Calving paralysis should be thought of as a paresis or paralysis resulting from damage to the ventral nerve roots of the lumbo-sacral plexus as any of the nerves originating from this plexus can be damaged during dystocia either individually or in combination with other nerves from the plexus.

How is the ultrasound in rheumatology used, implemented, and applied in Latin American centers? Results from a multicenter study

This study aimed to perform an overview of how ultrasound (US) is being used, implemented, and applied in rheumatologic centers in Latin America (LA). A retrospective, multicenter 1-year experience study was undertaken. Eighteen centers from eight countries were involved. The following information were collected: demographic data, indication to perform an US examination, physician that required the examination, and the anatomical region required for the examination. A total of 7167 patients underwent an US examination. The request for US examinations came most frequently from their own institution (5981 (83.45%)) than from external referral (1186 (16.55%)). The services that more frequently requested an US examination were rheumatology 5154 (71.91%), followed by orthopedic 1016 (14.18%), and rehabilitation 375 (5.23%). The most frequently scanned area was the shoulder in 1908 cases (26.62%), followed by hand 1754 (24.47%), knee 1518 (21.18%), ankle 574 (8.01%), and wrist 394 (5.50%). Osteoarthritis was the most common disease assessed (2279 patients (31.8%)), followed by rheumatoid arthritis (2125 patients (29.65%)), psoriatic arthritis (869 patients (12.1%)), painful shoulder syndrome (545 (7.6%)), connective tissue disorders (systemic sclerosis 339 (4.7%), polymyositis/dermatomyositis 107 (1.4%), Sjögren's syndrome 60 (0.8%), and systemic lupus erythematosus 57 (0.8%)). US evaluation was more frequently requested for diagnostic purposes (3981 (55.5%)) compared to follow-up studies (2649 (36.9%)), research protocols (339 (4.73%)), and invasive guided procedures (198 (2.76%)). US registered increasing applications in rheumatology and highlighted its positive impact in daily clinical practice. US increases the accuracy of the musculoskeletal clinical examination, influence the diagnosis, and the disease management.

FRI0229 High Prevalence of Subclinical Ultrasonographic Synovitis in Patients with Inflammatory Bowel Disease

BackgroundUltrasonography has proved more sensitive than physical examination to detect synovitis in rheumatoid arthritis, so we believe it can be useful to identify subclinical joint involvement in patients with Inflammatory...

SAT0183 High Prevalence of Ultrasonographic Enthesopathy in Patients with Inflammatory Bowel Disease without Clinical Signs or Symptoms of Spondyloarthritis

Background10-62% of Inflammatory Bowel Disease (IBD) patients have musculoskeletal manifestations, characterized by the appearance of peripheral arthritis, axial disease and enthesitis, mainly. Ultrasonography is more sensitive than physical examination to...

Capturing the Combined Clinic: Inter-Professional Multimedia Musculoskeletal Examination as a Teaching Resource

Background: Inter-professional education (IPE) and training to encourage collaborative teamwork in healthcare and medical teams has been widely advocated. Objectives: The aim of the study was to evaluate post-graduate students’ perceptions of the value of IPE and videos modelling good practise on multi disciplinary team (MDT) work and skill acquisition. Method: Four sports injury assessment educational videos were prepared that model high level IPE team working in the ‘Combined Clinic’ (a MDT clinic for complex patients). These were used to educate 26 doctors and physiotherapists on musculoskeletal clinical examination (MCE). The participants were then surveyed, and a sample of the group took part in semi-structured interviews that were audio-recorded and analysed by thematic content analysis.\ Results: There was an 85% response rate to the survey, with 46% of the group describing their competence in MCE as ‘developing skills,’ and 50% as having ‘some experience’. Attitudes towards IPE and MDT work were positive, acknowledging their benefits as learning tools. Thematic analysis of the interview data revealed an appreciation; of the real-time approach with expert instruction of multiple perspectives and perceived behavioural changes of improved MCE technique and enhanced interactive skills. Conclusion: This study provided evidence that an inter-professional approach can promote learning amongst postgraduate students, resulting in clinical skill acquisition. Further, the videos served to improve students’ appreciation of IPE, teamwork, and awareness of other disciplines.

High prevalence of ultrasonographic synovitis and enthesopathy in patients with psoriasis without psoriatic arthritis: a prospective case-control study

To investigate the presence of synovitis, tenosynovitis and enthesitis with power Doppler (PD) ultrasonography (US) in patients with psoriasis without musculoskeletal diseases as compared with controls with other skin diseases without musculoskeletal disorders. A total of 162 patients with plaque psoriasis and 60 age-matched controls with other skin diseases, all without musculoskeletal diseases, were prospectively recruited at 14 centres. They underwent dermatological and rheumatological assessment and a blinded PDUS evaluation. Clinical assessment included demographics, comorbidities, severity of psoriasis, work and sport activities and musculoskeletal clinical examination. PDUS evaluation consisted of the detection of grey scale (GS) synovitis and synovial PD signal in 36 joints, GS tenosynovitis and tenosynovial PD signal at 22 sites, and GS enthesopathy and entheseal PD signal in 18 entheses. US synovitis and enthesopathy were significantly more frequent in psoriatic patients than in controls (P = 0.024 and 0.005, respectively). The percentage of joints with US synovitis was 3.2% in the psoriasis group and 1.3% in the control group (P < 0.0005). US enthesopathy was present in 11.6% of entheses in the psoriasis group and 5.3% of entheses in the control group (P < 0.0005). Entheseal PD signal was found in 10 (7.4%) psoriatic patients, whereas no controls showed this finding (P = 0.05). Among demographic and clinical data, having psoriasis was the only significant predictive variable of the presence of US synovitis [odds ratio (OR) 2.1; P = 0.007] and enthesopathy (OR 2.6; P = 0.027). Psoriatic patients showed a significant prevalence of asymptomatic US synovitis and enthesopathy, which may indicate a subclinical musculoskeletal involvement.

Evaluation of an interprofessional multimedia musculoskeletal examination teaching resource: a qualitative study

BackgroundInterprofessional education (IPE) has been used more frequently in the last thirty years to encourage collaborative teamwork within healthcare.ObjectivesThe aims of this study were primarily to assess the impact of...

Joint examination skills: are rheumatology specialist registrars adequately trained? Reply

Mistlin’s survey is a timely reminder that the well-known problem of poor confidence in musculoskeletal examination skills is not confined to medical students [1], general practitioners [2, 3] or general physicians [4], but is present also in rheumatology specialist registrars. This problem has been generally overlooked and has a number of possible causes. There has historically been little or no agreement on what to teach students [5], with resulting diversity of student experience [6] and lack of confidence and use of such skills [7]. With this background, most clinicians have developed their own examination techniques and routines, which may in turn affect their confidence to teach others. Specialist registrars may regard their own lack of confidence as a personal failure, not realizing that it is shared by others, and therefore feel diffident about asking for such teaching and revealing their lack of skill. There has been a lack of easily available teaching resources for self-directed learning [8]. The evidence base for many of the examination techniques used is poor. Once the problem is identified, there are a number of possible solutions. Increased specific teaching, as Mistlin suggests, is one answer, but this does not address a number of the points raised above. We had identified this concern in medical students [1], and, in a project funded by the Arthritis Research Campaign, have obtained a national, multispecialty consensus on the core set of musculoskeletal clinical examination skills that a student should learn by the time they qualify [9]. Supporting educational materials are being produced and the medical student learning guide,

The attitudes and beliefs of clinicians involved in teaching undergraduate musculoskeletal clinical examination skills

The aim of this study was to explore which regional musculoskeletal examination skills medical students should learn and be examined on. A qualitative research study was undertaken, and six focus groups were formed involving 36 consultants from four chosen specialties. The feeling was that greater emphasis should be placed on the functional assessment of a patient. Students should be able to discern through examination what the patient can and cannot do with his/her affected limb/joint. It was felt that many of the traditional eponymously named special tests (e.g.Thomas’ test, Trendelenburg’s test) should be dispensed with along with traditional descriptions such as varus, valgus, swan neck and Boutonniere deformities. It was felt these were often a cause of confusion for medical undergraduates. A broad view and diversity in opinions was detected with differences between specialties. The strongest theme to emerge by far was the desire to simplify and standardize the regional examination as much as possible.

Joints: if relevant. Do available textbooks contain adequate information about musculoskeletal examination skills for medical students?

The objective was to determine whether routinely available textbooks describe the core musculoskeletal examination skills for medical students. Textbooks were evaluated for content against a list of 27 core examination skills as perceived by rheumatologists, orthopaedic surgeons and general practitioners. The study took place in Newcastle upon Tyne, libraries of the rheumatology department, teaching hospital and medical school. The main outcome was the inclusion of a description of examination skills by available textbooks. Median score for each textbook was only 19 (range 1–24) of a possible 27 core skills. Screening examination was not included in general texts. General principles were well covered but detail was insufficient, particularly in texts aimed at students taking final examinations. It is not easy for students to access adequate information about core items of musculoskeletal examination from textbooks readily available to them. This may reflect a general view of the lack of importance of musculoskeletal clinical examination skills.