Here are the tests and exams doctors use to see if your achy joints are actually RA.
You wake up in the morning and your body isn’t ready to get up and move with you. You’re stiff and achy. You’ve been noticing you’ve been more tired than usual lately, too. So you take out your computer, pull up Google, and type in your symptoms. Wait, could these really be symptoms of rheumatoid arthritis?
What Is Rheumatoid Arthritis?
“Rheumatoid arthritis (RA) is an autoimmune disease, which means the immune system—which is supposed to be your protection against viruses or bacteria—becomes active against your own tissues,” says Ashira Blazer, MD, a rheumatologist at NYU Langone Medical Center.
In RA, the immune system attacks joint tissues, causing chronic inflammation, swelling, and pain in the joints. The most commonly affected joints are knuckles, wrists, elbows, shoulders, hips, and ankles, according to Dr. Blazer.
How Doctors Diagnose Rheumatoid Arthritis
“The first question I always ask patients is, are you stiff in the morning and how long does that last,” says Dr. Blazer. Other causes of arthritis, such as osteoarthritis can cause some morning stiffness as well, but that tends to last no longer than 30 minutes, she says. “When a patient says that they’re stiff for an hour or two hours, maybe all morning long, I start to think about rheumatoid arthritis because that suggests inflammation.”
The diagnostic criteria for rheumatoid arthritis includes:
- Pain and swelling in multiple joints and small (wrists, and certain joints of the hands and feet)
- The same joints on both sides of the body are affected
- Inflammatory markers in the blood
- Morning stiffness for 30 minutes or longer
- Symptoms last for at least six weeks
If a doctor suspects RA based on a patient’s symptoms, they may then refer them to a rheumatologist—a specialist with specific training and skills to diagnose and treat RA. To diagnose RA, the rheumatologist will then conduct a diagnostic work-up, where they’ll learn about the patient’s personal and family history, perform a physical exam, and conduct diagnostic tests.
Tests and Exams that Diagnose Rheumatoid Arthritis
“The first part of a work-up is always asking the history, making sure that the joint pain suggests that there’s inflammation,” says Dr. Blazer. “So that’s looking for some of the symptoms of stiffness, especially in the morning, looking for the symptoms of swelling, along with tenderness.”
During the physical exam, the rheumatologist will examine the patient’s joints by squeezing and pressing on the joints, looking for tenderness, swelling, and painful or limited movement.
When a joint becomes inflamed, the joint capsule (synovium), becomes swollen, which impedes the joint. “It’s sort of like if you shoved a sock in the hinge of a door. So you’ve shoved this inflamed synovium in the joint, and now you can’t move the joint.”
The rheumatologist will also be looking for warmth in the joints. “[Healthy] joints should be cooler than the rest of the body, because there’s no active blood vessels going through the joint,” says Dr. Blazer. “If you’ve got inflammation there, they become very warm.”
Blood tests to diagnose RA measure levels of inflammation and look for biomarkers such as antibodies (blood proteins) that are linked with RA.
Inflammation: There are two tests that measure inflammation: “The ESR, which is the sedimentation rate, and the CRP, which is the C-reactive protein. Those are proteins that are elevated when the immune system is active,” says Dr. Blazer.
A high ESR or CRP does not automatically mean a patient has RA, but when combined with other clues, like antibodies, helps make an RA diagnosis.
Antibodies: “We also look for rheumatoid factor (RF) and anti-cyclic citrullinated peptide (anti-CCP), which are antibodies that the white blood cells produce in RA,” says Dr. Blazer.
Rheumatoid factor is an antibody found in about 80 percent of people with RA. Rheumatoid factor can occur in other inflammatory diseases, so it’s not a sure sign of RA.
Anti-cyclic citrullinated peptide (anti-CCP), however, occurs primarily in patients with RA. While positive anti-CCP test gives a strong clue that it’s RA, anti-CCP antibodies are found in only 60 to 70 percent of RA patients and can exist before symptoms start.
Another important part of an RA diagnosis is getting an imaging test done, such as an X-ray, ultrasound, or magnetic resonance imaging (MRI) scan. “You can make a diagnosis based on the history, the exam, and a lot of the blood tests, so [with an X-ray] we can be pretty sure that a person has rheumatoid arthritis,” says Dr. Blazer.
“[The X-ray] tells us about the health of the bone, and it tells us whether or not RA has started damaging the bones or the joints. So we like to get the x-rays at the start, and we like to get them periodically during treatment to make sure that we’re protecting the bones by preventing inflammation,” says Dr. Blazer.
If no joint damage is found in an imaging test, that doesn’t rule out RA. It may mean that the disease is in an early stage and hasn’t damaged the joints yet.
Many patients find a lot of relief in finding out that they have RA, because the sooner you know, the sooner it can be treated. “Many patients have felt ill for some time and just want their lives back,” says Dr. Blazer. “Having the diagnosis really tells the patient, this is not you, you’re not just tired or lazy, this is an illness that’s affecting you and you’ve got to shift your life in this way.”
Diagnosed with RA? Here are tips for living with rheumatoid arthritis, according to fashion designer and RA patient Michael Kuluva.
Dr. Blazer is a rheumatologist and instructor in the department of medicine at NYU Langone Health.
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The first question I always ask patients
is, are you stiff in the morning,
00:00:06,970 --> 00:00:08,526
and how long does that last?
00:00:08,526 --> 00:00:13,708
00:00:13,708 --> 00:00:17,055
Generally, other causes of arthritis,
such as osteoarthritis,
00:00:17,055 --> 00:00:20,250
can cause some stiffness, but
no longer than 30 minutes.
00:00:20,250 --> 00:00:23,530
But when a patient says that they're
stiff for an hour or two hours,
00:00:23,530 --> 00:00:27,460
maybe all morning long, I start to think
about rheumatoid arthritis because that
00:00:27,460 --> 00:00:29,470
00:00:29,470 --> 00:00:33,520
The diagnostic criteria for
rheumatoid arthritis involves pain and
00:00:33,520 --> 00:00:35,600
swelling in multiple joints.
00:00:35,600 --> 00:00:36,840
00:00:36,840 --> 00:00:40,980
It's associated with increased
inflammation or inflammatory markers
00:00:40,980 --> 00:00:45,250
in the blood, and it needs to be
persistent for at least six weeks.
00:00:45,250 --> 00:00:48,830
If a doctor suspects the patient has RA,
the next step would be to refer them to
00:00:48,830 --> 00:00:53,100
a specialist, where a diagnostic
workup would take place.
00:00:53,100 --> 00:00:55,880
The first part of a workup is
always asking the history, so
00:00:55,880 --> 00:01:00,110
making sure that the joint pain
suggests that there's inflammation.
00:01:00,110 --> 00:01:04,340
So that's looking for some of the symptoms
of stiffness, especially in the morning,
00:01:04,340 --> 00:01:08,690
looking for the symptoms of swelling,
along with the tenderness.
00:01:08,690 --> 00:01:11,630
So the first thing we look for
is range of motion.
00:01:11,630 --> 00:01:14,860
When a joint becomes inflamed,
the capsule of the joint, or
00:01:14,860 --> 00:01:17,880
the synovium, becomes very swollen.
00:01:17,880 --> 00:01:20,629
So that actually physically
impedes the joint.
00:01:20,629 --> 00:01:23,594
So it's sort of like if you shoved
a sock in the hinge of a door,
00:01:23,594 --> 00:01:26,926
you wouldn't be able to move the door
as well, similar with a joint.
00:01:26,926 --> 00:01:30,270
So you've shoved this inflamed
synovium in the joint, and
00:01:30,270 --> 00:01:32,040
now you can't move the joint as well.
00:01:32,040 --> 00:01:34,150
We also look for tenderness.
00:01:34,150 --> 00:01:35,670
So when we squeeze the joint,
00:01:35,670 --> 00:01:40,380
when we press on the lining of the joint,
does that cause the patient discomfort?
00:01:40,380 --> 00:01:44,710
And then warmth, so the joints should
be cooler than the rest of the body
00:01:44,710 --> 00:01:47,590
because there's no active blood
vessels going through the joint.
00:01:47,590 --> 00:01:51,270
But when you've got inflammation there,
they become very warm and hot.
00:01:51,270 --> 00:01:53,490
So we look for that as well.
00:01:53,490 --> 00:01:57,179
When we draw a blood sample for
rheumatoid arthritis we're looking for
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levels of inflammation.
00:01:58,541 --> 00:01:59,831
And then, we're looking for
00:01:59,831 --> 00:02:02,900
antibodies that tend to go along
with rheumatoid arthritis.
00:02:02,900 --> 00:02:04,000
There are two tests.
00:02:04,000 --> 00:02:07,615
The ESR, which is a sedimentation rate,
and the CRP,
00:02:07,615 --> 00:02:09,664
which is a C reactive protein.
00:02:09,664 --> 00:02:14,410
And those are proteins that are elevated
when the immune system is active.
00:02:14,410 --> 00:02:19,100
And we also look for
rheumatoid factor in CCP,
00:02:19,100 --> 00:02:24,050
which are antibodies that the white blood
cells produce in rheumatoid arthritis.
00:02:24,050 --> 00:02:27,340
Another important part of
diagnosis is getting xrays.
00:02:27,340 --> 00:02:30,630
That tells us about the health of
the bone, and it tells us whether or
00:02:30,630 --> 00:02:35,120
not rheumatoid arthritis has started
damaging the bones or the joints.
00:02:35,120 --> 00:02:37,921
So we like to get the xrays at the start.
00:02:37,921 --> 00:02:41,545
And we like to get them periodically
during treatment to make sure that we're
00:02:41,545 --> 00:02:44,630
protecting the bones by
00:02:44,630 --> 00:02:48,170
You can make a diagnosis
based on the history and
00:02:48,170 --> 00:02:50,300
the exam, a lot of the blood tests.
00:02:50,300 --> 00:02:54,770
And so, we can be pretty sure that
a person has rheumatoid arthritis.
00:02:54,770 --> 00:02:56,900
There's a lot of relief in knowing.
00:02:56,900 --> 00:03:00,985
Many patients have felt ill for some time,
and just want their lives back.
00:03:00,985 --> 00:03:03,342
So I think that people tend to be happy.
00:03:03,342 --> 00:03:07,754
And having the diagnosis really
tells the patient, this is not you,
00:03:07,754 --> 00:03:12,622
you're not just tired or lazy, this is
an illness that's affecting you and
00:03:12,622 --> 00:03:15,380
you've got to shift your life in this way.
00:03:15,380 --> 00:03:21,684
Rheumatoid Arthritis Diagnosis. Arthritis Foundation. (Accessed on June 7, 2018 at https://www.arthritis.org/about-arthritis/types/rheumatoid-arthritis/diagnosing.php
Rheumatoid Arthritis. NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases. (Accessed on June 7, 2018 at https://www.niams.nih.gov/health-topics/rheumatoid-arthritis)