Assessing Psoriatic Arthritis in your clinic · PDF fileAssessing Psoriatic Arthritis in your...

Assessing Psoriatic Arthritis in your clinic Training manualFor Trainer

Revealing more

This PsA Assessment initiative is led by the UK PsA Assessment Academy and funded by AbbVie Ltd. Date of preparation: October 2015; Job Code: AXHUR151220I

Copies of all the materials mentioned in this booklet and videos on how to conduct assessments are available for download from the Outside In website: www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx

Authored by:Bruce Kirkham, Consultant Rheumatologist, Guy’s Hospital, LondonPhilip Helliwell, Consultant Rheumatologist/Senior Lecturer, Leeds UniversityEleanor Korendowych, Consultant Rheumatologist, Royal National Hospital for Rheumatic Diseases, BathKate Gadsby, Rheumatology Consultant Nurse, AbbVie & Honorary Rheumatology Nurse Specialist, Royal Derby Hospital, DerbyshireSue Oliver, Past Chair RCN Rheumatology Forum and RCN Fellow. Independent Nurse ConsultantLiz Parrish, Past Dermatology Lead Nurse/Matron, East Kent University Hospitals NHS Foundation Trust. Independent Nurse Consultant

This PsA Assessment initiative is led by the UK PsA Assessment Academy and funded by AbbVie Ltd.

http://www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx


Contents

1. Introduction• Why is assessment of psoriatic arthritis so important? .......................................................................................... 5• A new approach to the assessment of PsA ........................................................................................................................ 5

2. Treat to Target (T2T) PsA• T2T Modular Approach for PsA assessment ..................................................................................................................... 7• Outcome measures: Minimal Disease Activity (MDA) and Psoriatic Arthritis Response

Criteria (PsARC) ......................................................................................................................................................................................... 8

3. Standard assessments for rheumatology clinics • Joint count ...................................................................................................................................................................................................... 11• Patient global activity VAS ................................................................................................................................................................ 11• Patient pain VAS ........................................................................................................................................................................................ 12• Dermatology Quality Life Index (DLQI) ................................................................................................................................... 12• Health Assessment Questionnaire (HAQ) ............................................................................................................................ 14

4. Intermediate assessments for rheumatology clinics • 66/68 joint count 17 • Patient and physician global assessments 18

5. Advanced assessments for rheumatology clinics • Leeds Enthesitis Index (LEI) ............................................................................................................................................................. 19• Tender dactylitis count ......................................................................................................................................................................... 20• Psoriasis Area Severity Index (PASI) ........................................................................................................................................ 20• Body Surface Area (BSA) ................................................................................................................................................................... 21

6. Additional tests • Modified Schöbers test ....................................................................................................................................................................... 23• Cervical rotation ......................................................................................................................................................................................... 23

7. Organising assessment training ......................................................................................................................................... 25

8. AppendicesA. 66/68 joint count poster ...................................................................................................................................................................... 32B. 66/68 joint count score sheet ......................................................................................................................................................... 33C. A quick guide to assessing PsA ................................................................................................................................................... 34D. DLQI and score sheet ........................................................................................................................................................................... 35E. HAQ and HAQ score sheet .............................................................................................................................................................. 36F. PASI score sheet ....................................................................................................................................................................................... 37G. Invitation for clinicians .......................................................................................................................................................................... 38

References ................................................................................................................................................................................................................. 40

4

Sectio

n 1Section 1

5

Why is assessment of psoriatic arthritis so important?

Psoriatic arthritis (PsA) is a complex condition that involves many body areas: the skin, fingernails and toenails, peripheral joints, the axial skeleton (the spine, chest and sacroiliac joint), entire digits (dactylitis) and the entheses.

The prevalence of psoriasis in the general population is estimated at 2–3%, with the prevalence of inflammatory arthritis in people with psoriasis estimated at up to 30%.1

At least 20% of people with psoriasis have severe psoriatic arthritis with progressive joint lesions. Psoriatic arthritis is a progressive disorder ranging from mild synovitis to severe progressive erosive arthropathy.1

PsA can progress notably within the first 2 years of disease onset.3 It has been shown that a diagnostic delay of more than 6 months contributes to poor radiographic and functional outcomes in PsA patients.4 It is therefore critical to diagnose and commence treatment early.5

Patients may present to either a dermatology or rheumatology clinic depending on their symptoms. To optimise best practice all patients with psoriasis should be screened for PsA to help prevent irreversible joint damage.

Introduction

This manual provides information on each of the assessments recommended by the PsA Assessment Academy within the Modular Approach, including explanation of how to perform the assessments and score sheets for certain assessments. At the end of the manual there is guidance on how to conduct a training session on assessing PsA in your clinic and the role of the multidisciplinary team in your unit.*

A new approach to the assessment of PsA

The PsA Assessment Academy has devised a Modular Approach for assessing PsA for rheumatology units. This approach details the recommended assessments of PsA at three levels: standard, intermediate and advanced.

This pack has been designed to provide rheumatology clinics with guidance on the approach recommended by the PsA Assessment Academy for the screening and assessment of PsA.

Many patients with PsA remain undiagnosed. A European study of 1,511 patients with plaque type psoriasis attending a dermatology appointment found that 20.6% had PsA; only 3% of patients had had the diagnosis of PsA established before the study.2

* Copies of all the materials mentioned in this booklet and videos on how to conduct the assessments are available for download from the Outside In website: www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx


66

Sectio

n 2

Section 2

7

A Modular Approach has been developed for PsA assessment which lists the minimum level of assessment through to more advanced assessment for patients at rheumatology clinics. The approach supports clinics to work towards a target of Minimal Disease Activity (MDA), which can be used to support a Treat to Target approach.

As psoriatic arthritis is a complex condition that involves many body areas, in particular the joints and skin, the approach incorporates both skin and joint assessments, as well highlighting that physicians should consider the spine, nails, GI tract and eyes at all times for extra articular manifestations.

The Modular Approach works on the basis of three levels of assessment:

1. Standard – the ‘bronze’ standard of assessment – outlining the minimum assessments that should be performed for each patient regardless of size of the clinic

2. Intermediate – the ‘silver’ standard of assessment incorporating a 66/68 joint count in addition to all the minimum assessments

3. Advanced – the ‘gold’ standard of assessment, incorporating assessments for dactylitis, enthesitis and the skin (psoriasis).

This training manual provides you with all the tools required to use the assessments included within the T2T Modular Approach for PsA assessment.*

Treat to Target (T2T) PsA

Standard (minimum) assessment Intermediate assessment Advanced assessment

Minimal Disease Activity

(MDA) Assessment

• Dactylitis

• Tender entheseal points

• PASI or BSA• 66/68 Joint Count

• Physician Global Assessment (0–5)

• Patient Global Assessment (0–5)

A patient with PsA is in MDA when they meet 5/7 of the following criteria:

Moving Towards a T2T Approach

• Tender joint count (≤ 1)

• Swollen joint count (≤ 1)

• PASI (≤ 1) or BSA (≤ 3%)

• HAQ (≤ 0.5)

• Tender entheseal points (≤ 1)

• Patient pain VAS (≤ 15)

• Patient global activity VAS (≤ 20)

T2T Modular Approach for PsA Assessment

T2T PsA

• Joint Count

• Patient Global Activity VAS*

• Patient Pain VAS*

• DLQI*

• HAQ*

*Patients can complete these prior to the clinic appointment

Remember for psoriatic disease: Spine Nails GI tract Ocular Co-morbidities



8

Section 2

8

As the team become experienced in performing the standard and intermediate assessments, the next level of assessment should be incorporated into the clinical practice (assuming the resources are available in the clinic), so eventually an advanced level of assessment is reached.

All together these assessments allow physicians to assess their patients for a state of minimal disease activity which defines a satisfactory state of disease activities.6

Outcome measures: Minimal Disease Activity (MDA) and Psoriatic Arthritis Response Criteria (PsARC)

Minimal Disease Activity (MDA): An outcome measure for advanced assessment

Minimal disease activity (MDA) is recommended by the PsA Assessment Academy as the optimal outcome measure for the management of PsA patients. By defining a set of criteria to be met for the state of minimal disease activity encompassing all aspects of PsA, the MDA provides a target for the goal of PsA treatment which can be used to support a Treat to Target approach.6

The MDA incorporates the scores from assessments at all levels, and is the key disease activity target at the advanced assessment level; the equivalent ‘gold standard’ of outcome assessment.

A patient is classified as achieving MDA when meeting 5 of the 7 following criteria: 6

• Tender joint count ≤ 1

• Swollen joint count ≤ 1

• Psoriasis Activity and Severity Index ≤ 1 or body surface area ≤ 3%

• Patient pain visual analogue score (VAS) ≤ 15

• Patient global disease activity VAS ≤ 20

• Health assessment questionnaire ≤ 0.5

• Tender entheseal points ≤ 1

The MDA criteria have been validated in two infliximab studies of PsA and a PsA observational cohort study.7,8

Section 2

9

Psoriatic Arthritis Response Criteria (PsARC): An outcome measure for intermediate assessment

At an intermediate level the Psoriatic Arthritis Response Criteria (PsARC) is recommended as an outcome measure. The PsARC is used to assess response to treatment and is generally conducted after 12 weeks of treatment in accordance with NICE recommendations.9,10 It includes an assessment of the joints (66 swollen and 68 tender joints) and the Patient and Physician global scores (PGA). Performing the assessments recommended at an intermediate level allows you to conduct the PsARC.

PsARC defined as improvement in at least two of the following 4 criteria (one of which must be tender joint or swollen joint score) with no worsening of any criteria:11

• 20% or more improvement in physician global assessment of disease activity • 20% or more improvement in patient global assessment of disease activity• 30% or more improvement in tender joint count• 30% or more improvement in swollen joint count

People whose disease has a Psoriasis Area and Severity Index (PASI) 75 response at 12 weeks but whose PsARC response does not justify continuation of treatment should be assessed by a dermatologist to determine whether continuing treatment is appropriate on the basis of skin response.

The joint count scoring sheet (page 17) provides space to record the PsARC.

“Considering all the ways your arthritis affects you, how are you feeling today? ” (Patient)

“Considering all the ways the arthritis affects your patient, how is your patient feeling today? ” (Physician)

543Very good, no symptoms, no

limitations on normal activitiesVery poor, very severe symptoms which are

intolerable, inability to carry out normal activities


Global assessment: Recommended questions:

As part of the PsARC assessment, the patient’s general health is assessed by both the patient and physician. Below are recommended questions for your patient and the physician using a 5-point Likert scale.

Copies of all the materials mentioned in this booklet and videos on how to conduct the assessments are available for download from the Outside In website: www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx


101010

1111

Sectio

n 3

Section 3

The Modular Approach recommended by the PsA Assessment Academy includes a number of assessments for patients who are managed in rheumatology units. This section provides further details on the standard (minimum) recommended assessments.

Joint count

When assessing PsA patients the joints should always be assessed for swelling and tenderness. At an intermediate level the 66 swollen and 68 tender joint count should ideally be performed, as recommended by the British Society for Rheumatology (BSR).12

At a standard level, as a minimum, an overview assessment of the joints should be carried out.

Further information on the 66/68 joint count and for recommendations on how to assess each joint for swelling or tenderness can be found in Section 4 – Intermediate assessments.*

Patient global activity VAS (visual analogue scale)

The patient global activity VAS or patient global assessment of disease activity is a simple VAS which assesses the patient’s general health and the effect of their arthritis at that point in time.

The VAS is scored by measuring from 0 to where the patient marks on the line. The proposed definition of low disease activity is 2.0 (scale 0 –10).13 A Likert style score may also be used such as in the PsARC.

Standard assessments for rheumatology clinics

Example:The patient is asked a question such as “Considering all the ways your arthritis affects you, how are you feeling today?” 12 and asked to mark their score on the VAS line.

0

Very well (best score)

VAS line (10cm/100mm)

100

Very poor (worse score)

Patient score



Section 3

12

Patient pain VAS

The patient pain VAS is a measurement of pain intensity and can be used to assess the presence or absence of arthritis-related pain and its severity. 14 The patient is asked to place a vertical line upon the VAS line at the point that represents their pain intensity, most commonly as experienced within the last 24 hours.

The score is obtained by measuring the distance from 0 to the line drawn by the patient.14

Dermatology Quality Life Index (DLQI)*

The DLQI is a quality of life (QoL) measure that can be used across all skin diseases and measures different aspects of psoriasis to the PASI.

The process of completing a quality of life questionnaire can encourage patients to raise issues that they see as important, but feel the doctor or nurse is not addressing. The DLQI consists of 10 simple questions relating to ways in which skin disease impairs lives. The time frame of the DLQI questions is based on quality of life over the last week.

The questionnaire is designed to be used in a busy clinical setting. The DLQI is provided with a sheet for the healthcare professional with guidance on DLQI calculation and a double sided questionnaire for the patient. The patient completes it without assistance, usually in about two minutes.

Example pain VAS:The patient is asked a question such as “How severe was the pain you have experienced in the last 24 hours?”

The DLQI is calculated by summing the score of each question, resulting in a maximum of 30 and a minimum of 0. The higher the score, the more quality of life is impaired.

The DLQI can also be expressed as a percentage of the maximum possible score of 30.

Meaning of DLQI Scores

0-1 = no effect at all on patient’s life 2-5 = small effect on patient’s life 6-10 = moderate effect on patient’s life

If the DLQI is greater than 10, this represents a skin disease having a very large effect on a patient’s life, meriting intervention.

11-20 = very large effect on patient’s life 21-30 = extremely large effect on patient’s life

0

No pain

VAS line (10cm/100mm)

100

Worst imaginable pain

Patient score

13

Section 3

Healthcare professional pages

Patient pages

Date of preparation: July 2014. Job code: AXHUR140995(1) This PsA Assessment initiative is led by the UK PsA Assessment Academy and funded by AbbVie.

Dermatology Life Quality Index

Calculating the Dermatology Life Quality Index

Very much = 3

A lot = 2

A little = 1

Not at all = 0

Not relevant = 0

1. For each box ticked assign a score as below:

Yes = 3

No = 0

2. Add all the scores together (maximum 30).

The effect on quality of life can beclassifiedasbelow:

0–1 = No effect

2–5 = Small effect

6–10 = Moderateeffect

11–20 = Large effect

21–30 = Extremely large effect

1 Over the last week, how itchy, sore, painful or stinging has your skin been?

Very much A lot A little Not at all

2 Over the last week, how embarrassed or self conscious have you been about your skin?


3 Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden?

Very much A lot A little Not at all Not relevant

4 Over the last week, how much has your skin influenced the clothes you wear?


5 Over the last week, how much has your skin affected any social or leisure activities?


6 Over the last week, how much has your skin made it difficult for you to do any sport?


7 Over the last week, has your skin prevented you from working or studying?

If ‘No’, over the last week how much has your skin been a problem at work or studying?

Yes No

A lot A little Not at all

Not relevant

8 Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives?


9 Over the last week, how much has your skin caused any sexual difficulties?


10 Over the last week, how much of a problem has the treatment for your skin been, for example, by making your home messy, or by taking up time?



The aim of this questionnaire is to measure how much your skin problem has affected your life OVER THE LAST WEEK. Please tick one box for each question.

Hospital No: ______________________

Name: ____________________________

Address: ____________________________________________________________

Date: _________________________

Diagnosis: ____________________Score:

DLQI

DLQI is copyright © A Y Finlay, G K Khan April 1992 at www.dermatology.org.uk.

Please check you have answered EVERY question. Thank you.

3

3

3

3

3

3

3

3

3

3

3

1 Over the last week, how itchy, sore, painful or stinging has your skin been?


2 Over the last week, how embarrassed or self conscious have you been about your skin?


3 Over the last week, how much has your skin interfered with you going shopping or looking after your home or garden?


4 Over the last week, how much has your skin influenced the clothes you wear?


5 Over the last week, how much has your skin affected any social or leisure activities?


6 Over the last week, how much has your skin made it difficult for you to do any sport?


7 Over the last week, has your skin prevented you from working or studying?

If ‘No’, over the last week how much has your skin been a problem at work or studying?

Yes No

A lot A little Not at all

Not relevant

8 Over the last week, how much has your skin created problems with your partner or any of your close friends or relatives?


9 Over the last week, how much has your skin caused any sexual difficulties?


10 Over the last week, how much of a problem has the treatment for your skin been, for example, by making your home messy, or by taking up time?



The aim of this questionnaire is to measure how much your skin problem has affected your life OVER THE LAST WEEK. Please tick one box for each question.

Hospital No: ______________________

Name: ____________________________

Address: ____________________________________________________________

Date: _________________________

Diagnosis: ____________________Score:

DLQI

DLQI is copyright © A Y Finlay, G K Khan April 1992 at www.dermatology.org.uk.

Please check you have answered EVERY question. Thank you.

3

3

3

3

3

3

3

3

3

3

3

16

A Y Finlay, G K Khan. April 1992. Available at www.dermatology.org.uk. Last accessed May 2014.



14

Section 3

Health Assessment Questionnaire (HAQ)

The HAQ is patient-oriented outcome assessment tool for measuring overall health status. It was developed as a comprehensive measure of outcome for patients with a wide variety of rheumatic diseases, and is designed to capture the long term influence of multiple chronic illnesses. The HAQ is available as a short 2 page version and a full 5 page version; the most frequently used and cited version is the 2 page version which assesses the extent of a patient’s functional ability.15,16

The 2-page HAQ contains the:

• HAQ Disability Index (HAQ-DI) – assessing a patient’s level of functional ability• HAQ visual analogue (VAS) pain scale – assessing the presence or absence of arthritis-

related pain and its severity• HAQ VAS patient global health scale – assessing overall quality of life

The HAQ is usually self-administered, but can also be asked by a trained receptionist or a healthcare professional in a clinical setting. The 2-page HAQ takes around five minutes to complete.

15

Section 3

Scoring of the HAQ

There are two disability indices that can be calculated from the HAQ-DI: 16

1. The Standard HAQ-DI, the preferred method, which takes into account the use of aids/devices.2. The Alternative Disability Index, which does not.

For either indices the patient must have a score for at least six of the eight categories (e.g. dressing and grooming, eating, walking) to calculate the score.

Calculating the Standard HAQ-DI Score (with aids/devices):

1. The four response options ‘Without any difficulty’, ‘With some difficulty’, ‘With much difficulty’ and ‘Unable to do’ are scored 0-3 respectively.

2. A score for each category is calculated by using the highest sub-category score from the category. For example, in the category ‘Arising’ there are three sub-category items. If a patient responds with a 1, 2 and 0, respectively; the category score is 2.

3. The scores are then adjusted for use of aids/devices and/or help from another person when indicated. The table below identifies the aid/device companion variable for each HAQ-DI category.

When an aid/device is indicated the scores are adjusted as follows:• For a category score of zero or one – increase to a two • For a category score of two or three – no increase

4. Divide the total category scores by the number of categories answered (must be a minimum of 6) to obtain a HAQ-DI score of 0-3 (3=worst functioning).

The HAQ VAS pain scale and HAQ VAS patient global health scale are scored by asking the patient to score their pain and health from 0-100 on a 100mm horizontal VAS line. Zero represents the lowest score e.g. no pain and 100 the highest e.g. severe pain. The score is obtained by measuring the distance from 0 to the line drawn by the patient.

Companion Aids/Devices Items for HAQ-DI Categories

HAQ-DI Category Companion Item

Dressing & Grooming Devices used for dressing (button hook, zipper pull, long handled shoe horn etc.)

Arising Built up or special chair

Eating Built up or special utensils

Walking Cane walker, crutches

Hygiene Raised toilet seat, bathtub seat, bathtub bar, long handled appliances in bathroom

Research Long handled appliances for reach

Grip Jar opener (for jars previously opened)



16

17

Sectio

n 4

Section 4

In addition to all the assessments performed as a minimum level of assessment, a full 66/68 joint count and patient and physician global assessment should be performed at the intermediate level.

66/68 joint count

When assessing PsA, the British Society for Rheumatology (BSR) recommends the use of a 66 swollen and 68 tender joint count.12 Research suggests that using anything less than a 66/68 joint count may result in the patient’s disease severity being underestimated and, as a consequence, the patient not being treated appropriately.17 Once experience is gained in using the 66/68 joint count it can be performed in 3 minutes, so this doesn’t need to be time consuming.

Recommendations on how to assess each joint for swelling or tenderness can be found on the next page.

The accompanying joint count scoring sheet* can be used to record the joint count scores; the joint count

scoring sheet also provides space to calculate the PsARC as discussed earlier in this manual.

Intermediate assessments for rheumatology clinics

The diagram on the right represents how often particular joints are affected in PsA. This diagram illustrates the importance of conducting a 66/68 joint count in patients with PsA rather than a 28 joint count.

0-9%Frequency

10-19%20-29%30-39%40-49%50-59%60-100%

Joint involvement in PSA



18

Section 4

The ‘A quick guide to PsA Assessment’ provides information on how to assess each of the joints in the 66/68 joint count. Also available as the joint scoring poster.*

Patient and physician global assessment

As within the PsARC, the patient and physician global assessments are recommended at an intermediate level to assess the patient’s general health. The following questions are recommended for the patient and physician using a 0–5-point Likert scale.

The accompanying joint count scoring sheet* also allows to capture this information (as recommended in the minimum assessments).

Joint Assessment

Pale green dots represent joints also assessed in DAS28. For

additional information on scoring these joints, please refer to the

Standardising DAS28 poster.

1

2 3

4

5

7

6

8

9

Temporomandibular Joint (TMJ)The line of the temporomandibular joint can easily be found by placing the tips of two fi ngers immediately in front of the tragus of the ear. As the patient opens their jaw the mandibular condyle moves forwards anda depression can be felt.

1

Sternoclavicular Joint (SCJ)To palpate the SCJ fi nd the manubrial notch at the top of the sternum. Move your fi ngers laterally to the medial end of the clavicle. To check position ask the patient to shrug their shoulders upwards.

2

Acromioclavicular Joint (ACJ)Move the fi ngers laterally along the clavicle until where the end of the clavicle meets the acromium. The position of the joint line can be checked by asking the patient to shrug their shoulders. This is usually the site that thebra strap sits on women.

3

Distal Interphalangeal Joints (DIPs)IP of thumb, PIPs and DIPs are all assessed using the interlocking “C” technique. With index fi nger and thumb on each hand make a “C” shape. Position one Canteriorly/posteriorly over the joint line and the other one laterally. Then in turn squeeze the fi ngers over the joint line. If there is an effusion within the joint you will feel the fl uid moving below your fi ngers. This technique iscalled “ballotting”.

4

HipThe hip joint is too deep seated to palpate, hence 66 swollen versus 68 tender. Therefore only tenderness is assessed. Tenderness of the hip is classifi ed as pain on movement when fl exing and rotating the hip.

5

AnklePlace both index fi ngers on the medial and lateralmalleoli and place both thumbs on the midline of the ankle joint. Ask the patient to plantar fl ex and dorsifl ex the ankle to ensure you are on the joint line.

6

Mid TarsalFrom the ankle joint, move both thumbs down themidline of the foot to a point half way between the ankle and the MTPs. Palpate laterally from the midline with both thumbs for swelling and tenderness.

7

Metatarsophalangeal Joints (MTPs) of FeetPalpate each MTP joint in turn, both for tendernessand swelling, by squeezing both thumbs on the plantar aspect and both thumbs on the dorsal aspect ofthe foot.

8

Proximal Interphalangeal Joints (PIPs) of FeetThese are done in the same way as assessing the DIPs of hands, although it is a little more diffi cult to get yourfi ngers into the spaces between toes.

9

Joint Count 66/68

Assessing Tender JointsJoint tenderness should be assessed by pressing on the joint using the thumb and index fi nger. A general guide to the amount of pressure required is press until it causes ‘whitening’ of the examiner’s nail bed.

Assessing Joint SwellingJoint swelling is typically soft and boggy and not hard or bony.

XXXXXX_Outside In_A5 leaflet_PRINT_v8.indd 2 11/08/2014 17:39

Joint Assessment


additional information on scoring these joints, please refer to the Standardising DAS28 poster.

1

2 3

4

5

7

6

8

9

Temporomandibular Joint (TMJ)The line of the temporomandibular joint can easily be

found by placing the tips of two fi ngers immediately in front of the tragus of the ear. As the patient opens their

jaw the mandibular condyle moves forwards anda depression can be felt.

1

Sternoclavicular Joint (SCJ)To palpate the SCJ fi nd the manubrial notch at the

top of the sternum. Move your fi ngers laterally to the medial end of the clavicle. To check position ask the

patient to shrug their shoulders upwards.

2

Acromioclavicular Joint (ACJ)Move the fi ngers laterally along the clavicle until where

the end of the clavicle meets the acromium. The position of the joint line can be checked by asking the patient to

shrug their shoulders. This is usually the site that thebra strap sits on women.

3

Distal Interphalangeal Joints (DIPs)IP of thumb, PIPs and DIPs are all assessed using the

interlocking “C” technique. With index fi nger and thumb on each hand make a “C” shape. Position one C

anteriorly/posteriorly over the joint line and the other one laterally. Then in turn squeeze the fi ngers over the joint

line. If there is an effusion within the joint you will feel the fl uid moving below your fi ngers. This technique is

called “ballotting”.

4

HipThe hip joint is too deep seated to palpate, hence 66

swollen versus 68 tender. Therefore only tenderness is assessed. Tenderness of the hip is classifi ed as pain on

movement when fl exing and rotating the hip.

5

AnklePlace both index fi ngers on the medial and lateral

malleoli and place both thumbs on the midline of the ankle joint. Ask the patient to plantar fl ex and dorsifl ex

the ankle to ensure you are on the joint line.

6

Mid TarsalFrom the ankle joint, move both thumbs down the

midline of the foot to a point half way between the ankle and the MTPs. Palpate laterally from the midline with

both thumbs for swelling and tenderness.

7

Metatarsophalangeal Joints (MTPs) of FeetPalpate each MTP joint in turn, both for tenderness

and swelling, by squeezing both thumbs on the plantar aspect and both thumbs on the dorsal aspect of

the foot.

8

Proximal Interphalangeal Joints (PIPs) of FeetThese are done in the same way as assessing the DIPs

of hands, although it is a little more diffi cult to get yourfi ngers into the spaces between toes.

9

Joint Count 66/68

Assessing Tender JointsJoint tenderness should be assessed by pressing on the joint

using the thumb and index fi nger. A general guide to the amount of pressure required is press until it causes ‘whitening’ of the

examiner’s nail bed.



“Considering all the ways your arthritis affects you, how are you feeling today? ” (Patient)

“Considering all the ways the arthritis affects your patient, how is your patient feeling today? ”


limitations on normal activitiesVery poor, very severe symptoms which are

intolerable, inability to carry out normal activities


Patient (PtGA)

Physician (PGA)

A Quick Guide to Assessing PsAErythema

1 = light red

2 = red, but not dark red

3 = dark red

4 = very dark red(changing to purple)

Severity Score Erythema Scaling Induration

0 – None No redness No scaling No elevation

1 – Mild Light red Predominantly fi ne scaling Slight, but covering part of the lesion defi nite elevation; typically edges indistinct or sloped

2 – Moderate Red, but not Fine to rough scaling Moderate dark red covering a large part of elevation with the lesion rough or sloped edges

3 – Severe Dark red Rough, thick scaling Marked covering a large part of elevation; the lesion typically with hard or sharp edges

4 – Very severe Very dark red Very rough, very thick Very marked (changing to purple) scaling totally covering elevation; the lesion typically with hard, sharp edges

Scaling

Scaling

1 = predominantly finescaling covering part of the lesion

2 = fine to rough scalingcovering a large part of the lesion

3 = rough, thick scalingcovering a large part of the lesion

4 = very rough, very thickscaling totally covering the lesion

About PASIPASI is derived from skin assessment of the body in four regions: head and neck, arms, trunk (including groin and axillae) and legs (including buttocks). The assessment of the severity of the symptoms erythema, scaling and induration is performed separately for each region. The extent to which each of the four regions of the body is affected by psoriasis is also assessed.

Extent score Grade

0 None

1 1% to 9%

2 10% to 29%

3 30% to 49%

4 50% to 69%

5 70% to 89%

6 90% to 100%

Erythema

Erythema

Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

Erythema

Scaling





Scaling

Scaling





Scaling

Scaling





Scaling

Extent Total Area score extent

Head x 0.1 & Neck

Arms x 0.2

Trunk x 0.3

Legs x 0.4

SeverityExtent

Example of nail pitting.

Total extent x Erythema Scaling Induration Total severity total severity

Head + + = & Neck

Arms + + =

Trunk + + =

Legs + + =

PASI = extent x severity /72

(0-4)(0-6) (0-4) (0-4)

This PsA Assessment initiative is led by the UK PsA Assessment Academy and funded by AbbVie Ltd. Date of preparation: February 2013 AXHUR111119b

With AbbVie

DLQI At a minimum, the Dermatology Life Quality Index (DLQI) should be completed. If the score is ≥5 or if the patient has evidence of active psoriasis, the patient should be referred to a dermatology clinic for assessment. Nails should be assessed visually for pitting.

PASI and BSA The skin should be assessed using either the PASI (Psoriasis Area Severity Index) or the BSA (Body Surface Area). PASI is an assessment of the body in four regions: head and neck, arms, trunk (including groin and axillae) and legs (including buttocks). The assessment includes the severity of specific symptoms, and the extent the regions are affected by psoriasis. BSA is assessment of the percentage of area of the body covered by psoriasis.

Skin Assessment

“Considering all the ways your arthritis affects you, how are you feeling today?

”

Patient and Physician global assessments – recommended questionsAs part of the PsARC assessment, the patient’s general health is assessed by both the patient and physician. Below are recommended questions for your patient and the physician using a 0–5-point Likert scale.

About PsARC NICE guidelines require the use of PsARC as a criteria for continuation of anti-TNF treatment. This assessment is only needed at 12 weeks. However to conduct a PsARC, baseline scores at 0 weeks as well as scores at 12 weeks are required. The following assessments should therefore be performed on all patients commencing anti-TNF treatment:

• 66 swollen joint score• 68 tender joint score• Patient global assessment (PtGA)• Physician global assessment (PGA)

Definition of the criteria: Response = improvement in ≥ 2 of the 4 tests:

• One of which must be the joint tenderness or swelling score

• No worsening in any of the four measures

• Improvement is defined as a decrease ≥ 30% in the swollen or tender joint score and ≥1 in either of the global assessments

PsARC Outcome Assessment

“Considering all the ways the arthritis affects your patient, how is your patient feeling today?

”

Very good, no symptoms,

no limitations on normal activities

Very poor, very severe

symptoms which are intolerable,

inability to carry out normal activities

5 024 3

For further information on the assessments mentioned in the modular approach please refer to the PsA Assessment Academy materials available at https://www.psoriatic-arthritis.co.uk/healthcare-professionals-psa.aspx

Patient (PtGA)

Physician (PGA)

1

An alternative outcome assessment if the patient has not undergone all the assessments within the MDA Assessment is the PsARC (PsA Response Criteria)

Basic (minimum) assessment Intermediate assessment Advanced assessment


(MDA) Assessment

• Dactylitis









• PASI (≤ 1) or BSA (≤ 3)

• HAQ (≤ 0.5)




Psoriatic arthritis is a complex condition that involves many body areas, in particular the joints and skin.

A modular approach has been developed that lists the minimum level of assessment through to more advanced assessment for each patient at every clinic visit. The advanced assessment is aspirational for all clinics to work towards to be able to target Minimal Disease Activity – which can be used to support a Treat to Target approach.


T2T PsA

• Joint Count



• DLQI*

• HAQ*


Remember for psoriatic disease: Nails Spine GI tract Ocular Co-morbidities

Revealing more

This PsA Assessment initiative is led by the UK PsA Assessment Academy and funded by AbbVie. Date of Preparation: July 2014. Job code: AXHUR141093(1)

Section

2

Section 2

7

A Modular Approach has been developed for PsA assessment which lists the minimum level

of assessment through to more advanced assessment for patients at rheumatology clinics.

The approach supports clinics to work towards a target of Minimal Disease Activity (MDA),

which can be used to support a Treat to Target approach.

As psoriatic arthritis is a complex condition that involves many body areas, in particular the joints and

skin, the approach incorporates both skin and joint assessments, as well highlighting that physicians

should consider the spine, nails, GI tract and eyes at all times for extra articular manifestations.

The Modular Approach works on the basis of three levels of assessment:

1. Basic – the ‘bronze’ standard of assessment – outlining the minimum assessments that

should be performed for each patient regardless of size of the clinic

2. Intermediate – the ‘silver’ standard of assessment incorporating a 66/68 joint count in addition

to all the minimum assessments

3. Advanced – the ‘gold’ standard of assessment, incorporating assessments for dactylitis,

enthesitis and the skin (psoriasis).

This training manual provides you with all the tools required to use the assessments included within

the T2T Modular Approach for PsA assessment.

Treat to Target (T2T) PsA



(MDA) Assessment

• Dactylitis









• PASI (≤ 1) or BSA (≤ 3)

• HAQ (≤ 0.5)





T2T PsA

• Joint Count



• DLQI*

• HAQ*


Remember for psoriatic disease: Spine Nails GI tract Ocular Co-morbidities

Revealing moreA Quick Guide to Assessing PsA


PASI and BSA The skin should be assessed using either the PASI (Psoriasis Area Severity Index) or the BSA (Body Surface Area). PASI is an assessment of the body in four regions: head and neck, arms, trunk (including groin and axillae) and legs (including buttocks). The assessment includes the severity of specifi c symptoms, and the extent the regions are affected by psoriasis. BSA is assessment of the percentage of area of the body covered by psoriasis.

Skin Assessment


”




Defi nition of the criteria: Response = improvement in ≥ 2 of the 4 tests:


• No worsening in any of the four measures• Improvement is defi ned as a decrease ≥

30% in the swollen or tender joint score and ≥1 in either of the global assessments



”






5 024 3Erythema

1 = light red


3 = dark red




1 – Mild Light red Predominantly fine scaling Slight, but covering part of the lesion definite elevation; typically edges indistinct or sloped 2 – Moderate Red, but not Fine to rough scaling Moderate dark red covering a large part of elevation with the lesion rough or sloped edges



Scaling

Scaling





About PASIPASI is derived from skin assessment of the body in four regions: head and neck, arms, trunk (including groin and axillae) and legs (including buttocks). The assessment of the severity of the symptoms erythema, scaling and induration is performed separately for each region. The extent

Extent score Grade

0 None

1 1% to 9%

2 10% to 29%

3 30% to 49%

4 50% to 69%

5 70% to 89%

6 90% to 100%

Erythema

Erythema

Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

Erythema

Scaling





Scaling

Scaling





Scaling

Scaling





Scaling


Head x 0.1 & Neck

Arms x 0.2

Trunk x 0.3

Legs x 0.4

Severity Extent

Nails should be assessed for any sign of disease. Typical indicators include: 1. Pitting2. Beau’s lines3. Onycholysis4. Subungual hyperkeratosis.

Total severity Erythema Scaling Induration Total severity x total extent

Head + + = & Neck

Arms + + =

Trunk + + =

Legs + + =

PASI = severity x extent /72

(0-4) (0-6)(0-4)(0-4)

1 2 3 4

This PsA Assessment initiative is led by the UK PsA Assessment Academy and funded by AbbVie. Date of preparation: July 2014. Job code: AXHUR141094(1)


Patient (PtGA)

Physician (PGA)

1




(MDA) Assessment

• Dactylitis






Moving ToToT wards a T2T Approach



• PASI (≤ 1) or BSA (≤ 3)

• HAQ (≤ 0.5)







T2T PsA

• Joint Count



• DLQI*

• HAQ*



Revealing more



19

Sectio

n 5

Section 5

Assessing enthesitis and dactylitis

Entheseal inflammation and dactylitis are common in patients with PsA. Entheseal inflammation is a typical feature of PsA and is one of the features which distinguishes it from RA.3 Dactylitis occurs in 16–24% of patients and is characterised by diffuse swelling of a digit which can become painful.18

Leeds Enthesitis Index (LEI)*

The LEI examines tenderness at six sites: 2 sites at each of the lateral epicondyles of the humerus, medial condyles of the femur and the insertion of the Achilles tendon.

LEI examination points:

• Lateral epicondyle, left and right

- This examination is performed with the patient’s arm flexed at 90°

- The thumb is pressed on the lateral epicondyle with the fingers underneath for support. Pressure, sufficient to blanch the nail is exerted and the enthesis examined for tenderness

• Medial femoral condyle, left and right

- Find the joint line of the knee. Move the fingers approximately 2.5 cm (1 inch) proximal to this to locate the bony diffuse swelling on the medial femoral condyle

- The thumb is pressed on the medial femoral condyle, sufficient to blanch the nail and the enthesis examined for tenderness

• Achilles tendon insertion, left and right

- The Achilles tendon insertion can be located by following the Achilles tendon down until it inserts

- Place the thumb on the insertion site with pressure sufficient to blanch the nail and assessed for tenderness.

When examining the entheses, pressure should be exerted at the enthesis sufficient to blanch the finger nail of the examiner. In addition the presence of soft-tissue swelling at the enthesis should also be assessed. For each entheseal site, assessment is made of the adjacent joint in terms of tenderness and soft-tissue swelling.

Careful attention should be made to try and distinguish swelling and tenderness separately at the joint and the juxta-articular enthesis.

The LEI score range is 0-6.

Advanced assessments for rheumatology clinics



20

Section 5

Tender dactylitis count

The tender dactylitis count is a simple count based on the presence or absence of tender joints. 20 digits are assessed as entire digits, looking for signs of tender dactylitis (the joints of any digits with dactylitis are not scored separately for the purposes of the 66/68 joint count). Dactylitis is defined as a uniform swelling of the digits where the joints cannot be defined.

The hands and feet should be visually assessed side by side.

Psoriasis Area Severity Index (PASI)*

Assessing the skin is an important part of managing patients with PsA. Although the Psoriasis Area Severity Index (PASI) is generally performed by a dermatologist or in a dermatology clinic it is an important part of the assessment for PsA, and forms part of the assessment for minimal disease activity for psoriatic arthritis.

The PASI is an index used to express the severity of psoriasis. It combines the severity (erythema, induration and desquamation) and percentage of affected area. The PASI is the main test used in the clinic to assess total body area affected by psoriasis and to monitor both the patient’s psoriasis and their progression and response to treatment over time. The PASI is used to help decide the most appropriate treatment

Each is assigned a score to reflect extent of affected area, (see appendix F for extent score gradings on the PASI score sheet) with 0 indicating no skin affected and 6 indicating all skin affected. Severity of psoriasis is assessed with scores assigned to each of redness, thickness and scale (0 = least severe, 4 = most severe).

The scores are then used to calculate the PASI.

The body is assessed in four regions:

• Head and neck• Arms

• Trunk (includes groin and axillae)• Legs (includes buttocks).

For each body section (head, arms, trunk and legs) specify:

• The percentage of area of skin involved

• The severity of three clinical signs (erythema, induration and desquamation) on a scale from 0 to 4 (from none to maximum).

21

Section 5


Head + + = & Neck

Arms + + =

Trunk + + =

Legs + + =

PASI = severity x extent

Example of a PASI calculation

On examining the patient’s arms the percentage of the area affected was estimated to be 35% which gives an extent score 3. The total extent for the arms is 3 x 0.2 = 0.6.

The severity of the plaques on the arms was calculated as 3 for erythema (the plaques were dark red in colour), 2 for scaling (moderate scaling) and induration as 2 (moderate elevation with rough or sloped edges).

The calculation of the PASI for this patient is shown below. There was no psoriasis on the head and neck, trunk or legs.

A PASI meter is available from your AbbVie representative. The PASI stick provides guidance in assessing the extent and the severity of erythema, scaling and induration.

Body surface area (BSA)

The body surface area (BSA) is an estimation of the percentage of the body affected by psoriasis. The surface of palm plus five digits is generally assumed to be approximately equivalent to 1%19 allowing calculation of the BSA. It should be noted that the palm has been found to be slightly less than 1% in some studies,19,20 and for the most accurate estimation, the patient’s hand should be used as a measure.19

Scoring:21

• <3% mild case of psoriasis • 3-10% moderate case of psoriasis • >10% severe case of psoriasis

SeverityExtent

(0-4)(0-6) (0-4) (0-4)

The severity for the arms was calculated as 3+2+2 = 7

The total extent multiplied by total severity for the arms is 0.6 x 7 = 4.2

3 0.6 3 2 2 7 4.2

4.2/72


Head x 0.1 & Neck

Arms x 0.2

Trunk x 0.3

Legs x 0.4



22

Modified Schöbers test*

The modified Schöbers test assesses the amount of lumbar flexion. To perform this assessment:1. Mark the lumbosacral junction by locating the dimples of Venus and mark on each side and then

mark a line between the two points2. Measure upwards from this line 10cm (superior) and also below this line 5cm (inferior) and mark

each point3. Ask the patient to lean forward to touch their toes holding the tape measure close to the skin.

As the patient flexes the spine as far as possible, measure and record the distance between the superior and inferior marks

4. A normal modified Schöbers is 5cm or above.

Cervical rotation*

Cervical rotation can be measured using a goniometer. To perform this assessment:1. With the patient seated, place the goniometer on the top of the patient’s head and line up with the

patient’s nose2. Ask the patient to turn their head to the right. Move the arm of the goniometer and align the arm

with the patient’s nose. Measure the angle of the goniometer3. Ask the patient to turn their head to the front, neutral position. Align the arms of the goniometer

with the patient’s nose4. Ask the patient to turn their head to the left. Move the arm of the goniometer to align with the

patient’s nose and measure the angle of the goniometer5. Take the average of the two readings6. A normal cervical rotation is 70° or above.

23

Sectio

n 6

Section 6

Additional tests



24

25

Sectio

n 7

Section 7

This document contains guidance on how to conduct a training session on assessing PsA in your clinic and the role of the multidisciplinary team in your unit.

This quick and easy training module is designed to give an overview and provide guidance on carrying out the assessments used to evaluate PsA. The lack of assessment of PsA in patients can have a detrimental impact on patient outcomes. This training aims to enable participants to recognise how they should be assessing for PsA and to have confidence in conducting the assessments.

This should also ensure standardised assessment across the clinic.

The training session proposed is divided into the following parts:• Part 1 – Presentation on PsA assessment. Overview of PsA and description of key assessments• Part 2 – Demonstration of assessment techniques• Part 3 – Practical session for participants• Part 4 – Discussion.

What is required for the training session:

Time:• Allow 2-2.5 hours for the whole session (if it is the first training session you may want to

allow more time)

Participants:• All members of the multidisciplinary team who see patients with PsA• It is recommended there are no more than 6-8 participants per trainer

Materials:• Assessing PsA rheumatology poster (a copy can be ordered from an AbbVie representative) • Assessing PsA training presentation • Assessment scoring sheets

- 66/68 joint count score sheet*- DLQI score sheet*- HAQ score sheet- PASI score sheet*

Organising assessment training



26

Section 7

Organising the training session

There are a number of ways to run the training session. The training session below involves performing and practising the assessments for both skin and joints.

Please find below the recommended steps to be taken in order to organise and hold the training session.

Before the training session

• Coordinate a date and time for the training session• Circulate an agenda/training plan to attendees• Reserve an appropriate room/venue for the session and organise

the correct number of chairs• Invite the relevant multidisciplinary team members from your clinic • Check attendees’ availabilities, transport and funding• Organise refreshments• Check availability of projector or print slides

If you would like support to organise the meeting, please contact your local AbbVie representative.

Key considerations

Depending on the size of the group it may be advisable to split the group into pairs or a few small groups, so one person performs the tests while the rest of the group observes. While the assessments are being performed the group can discuss whether they agree or disagree with the way the assessment is being conducted.

If you split the group into pairs or small groups, you might want to consider whether you want to split up the more experienced members of the group or to keep similar levels together so they feel less inhibited to express their opinion.

27

Section 7

On the day

Introductions and welcome

1. Gather the attendees in the reserved room and ask all attendees to introduce themselves if necessary

2. Introduce the aims and objectives of the training sessiona. To introduce techniques for conducting joint and skin assessmentsb. To familiarise the group with the different assessments and build confidence

in using themc. To ensure all members of the multidisciplinary team are conducting the assessment

appropriate to them in the same way.

(It might be helpful to emphasise that often different techniques are not wrong but if everyone is using a different technique it can distort the scores and therefore impact on the treatment decisions for an individual person with PsA).

Part 1 – Presentation on PsA assessment. Overview of PsA and description of key assessments (allow 15 mins)

Presentation• Overview of PsA • Introduction to the PsA Assessment Academy and the PsA T2T Modular Approach

for PsA assessment • MDA and PsARC as disease outcome measures• Assessments recommended to assess PsA in the PsA T2T Modular Approach

Part 2 – Demonstration of assessments (allow 45 mins)

We would recommend that prior to the day you:• Select which of the assessments below you would like to focus on (you will not have time

to go into detail for all of them)• Decide prior to the presentation if you would like to demonstrate the PASI, BSA or both.

A training presentation is provided to support your training/provide further details.



28

Section 7

Assessments:

Standard:• Joint count

- Provide an overview on how to assess joints for swelling/tenderness

- Patient global activity VAS and patient pain VAS

- Agree standardised questions

• Dermatology Quality Life Index (DLQI) and Health Assessment Questionnaire (HAQ)

- Data collection and scoring

Intermediate:• 66/68 joint count

- Demonstrate how to perform the 66/68 joint count (using the A1 poster Assessing Psoriatic Arthritis and training videos)

- Split the group into pairs and discuss the different aspects of the 66/68 joint count focussing on the location of each joint and the technique

• Patient and physician global assessments

- Highlight the standardised question

Advanced:• Tender dactylitis count

- Demonstrate how to perform the tender dactylitis count • Leeds Enthesitis Index (LEI)

- Demonstrate how to perform the LEI• Psoriasis Area Severity Index (PASI) or BSA

- Demonstrate how to do a skin assessment using PASI/BSA

Part 3 – Practical session for participants to carry out the assessments on each other (allow 30-60 mins)

• Split the group into pairs

• Practice assessing the joints for the 66/68 joint count (depending on the level of experience of the group you may want to also include other assessments in this section)

Part 4 – Discussion (allow 30 mins)

• Depending on the experience of the group this time may be used for any questions related to the Modular Approach

• There is an accompanying training presentation if you want to go through each assessment in more detail

29

Section 7

• Informal practice sessions with colleagues are an ideal way to improve assessment skills• We would recommend aiming to perform this training every 12-18 months, depending on the

number of new starters you have in your clinic, to ensure assessment techniques remain standardised within your clinic.

Conclusion



30

31

Sectio

n 8

Section 8

A. 66/68 joint count poster*

B. 66/68 joint count score sheet*

C. A quick guide to assessing PsA*

D. DLQI and score sheet*

E. HAQ and HAQ score sheet

F. PASI score sheet*

G. Invitation for clinicians*

Appendices



32

Section 8

Appendix A – 66/68 joint count poster

Joint Assessment




1

2 3

4

5

7

6

8

9

Temporomandibular Joint (TMJ)The line of the temporomandibular joint can easily be found by placing the tips of two fingers immediately in front of the tragus of the ear. As the patient opens their jaw the mandibular condyle moves forwards anda depression can be felt.

1

Sternoclavicular Joint (SCJ)To palpate the SCJ find the manubrial notch at the top of the sternum. Move your fingers laterally to the medial end of the clavicle. To check position ask the patient to shrug their shoulders upwards.

2

Acromioclavicular Joint (ACJ)Move the fingers laterally along the clavicle until where the end of the clavicle meets the acromium. The position of the joint line can be checked by asking the patient to shrug their shoulders. This is usually the site that thebra strap sits on women.

3

Distal Interphalangeal Joints (DIPs)IP of thumb, PIPs and DIPs are all assessed using the interlocking “C” technique. With index finger and thumb on each hand make a “C” shape. Position one Canteriorly/posteriorly over the joint line and the other one laterally. Then in turn squeeze the fingers over the joint line. If there is an effusion within the joint you will feel the fluid moving below your fingers. This technique iscalled “ballotting”.

4

HipThe hip joint is too deep seated to palpate, hence 66 swollen versus 68 tender. Therefore only tenderness is assessed. Tenderness of the hip is classified as pain on movement when flexing and rotating the hip.

5

AnklePlace both index fingers on the medial and lateralmalleoli and place both thumbs on the midline of the ankle joint. Ask the patient to plantar flex and dorsiflex the ankle to ensure you are on the joint line.

6


7


8

Proximal Interphalangeal Joints (PIPs) of FeetThese are done in the same way as assessing the DIPs of hands, although it is a little more difficult to get yourfingers into the spaces between toes.

9

Joint Count 66/68

Assessing Tender JointsJoint tenderness should be assessed by pressing on the joint using the thumb and index finger. A general guide to the amount of pressure required is press until it causes ‘whitening’ of the examiner’s nail bed.


33

Section 8

Patient number: _________

Joint Count Scoring SheetTender and swollen measurements

Tender (0-68)

Tender (0-68)

This PsA Assessment initiative is led by the UK PsA Assessment Academy and funded by AbbVie. Date of preparation: July 2015 Job Code: AXHUR151220f

Tender Joints: Number /68 Swollen Joints: Number /66

Erythema

1 = light red


3 = dark red




1 – Mild Light red Predominantly fine scaling Slight, butcovering part of the lesion definite

elevation;typically edgesindistinctor sloped

2 – Moderate Red, but not Fine to rough scaling Moderatedark red covering a large part of elevation with

the lesion rough orsloped edges

3 – Severe Dark red Rough, thick scaling Markedcovering a large part of elevation;the lesion typically

with hard orsharp edges

4 – Very severe Very dark red Very rough, very thick Very marked(changing to purple) scaling totally covering elevation;

the lesion typically with hard,sharp edges

Scaling

Scaling






Extent score Grade

0 None

1 1% to 9%

2 10% to 29%

3 30% to 49%

4 50% to 69%

5 70% to 89%

6 90% to 100%

Erythema

Erythema

Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

Erythema

Scaling





Scaling

Scaling





Scaling

Scaling





Scaling

Extent TotalArea score extent

Head x 0.1& Neck

Arms x 0.2

Trunk x 0.3

Legs x 0.4

SeverityExtent


Total extent xErythema Scaling Induration Total severity total severity

Head + + =& Neck

Arms + + =

Trunk + + =

Legs + + =


(0-4)(0-6) (0-4) (0-4)


With AbbVie

Definition of the criteria:

Response = improvement in ≥ 2 of the 4 tests:

• One of which must be thejoint tenderness or swellingscore

• No worsening in any of thefour measures

• Improvement is definedas a decrease ≥ 30% inthe swollen or tender jointscore and a decrease ≥1in either of the globalassessments

“Considering all the ways your arthritis affects you, how are you feeling today?”

Recommended questions for the patient and physician using a 0–5-point Likert scale.

“Considering all the ways the arthritis affects your patient, how is your patient feeling today?”

5Very good, no symptoms,


Very poor, very severe symptoms which are intolerable, inability to carry out normal activities

2 43

Swollen (0-66)

Swollen (0-66)

PtGA PtGAPGA PGA

Global PsARC Assessment

0

Global VAS Pain /10

Patient and physician global assessment

Patient (PtGA)

Physician (PGA)

PsARC criteria (pre-treatment)

PsARC criteria (post-treatment)

1

Appendix B – 66/68 joint count score sheet



34

Section 8

Joint Assessment




1

2 3

4

5

7

6

8

9

Temporomandibular Joint (TMJ)The line of the temporomandibular joint can easily be found by placing the tips of two fingers immediately in front of the tragus of the ear. As the patient opens their jaw the mandibular condyle moves forwards anda depression can be felt.

1

Sternoclavicular Joint (SCJ)To palpate the SCJ find the manubrial notch at the top of the sternum. Move your fingers laterally to the medial end of the clavicle. To check position ask the patient to shrug their shoulders upwards.

2

Acromioclavicular Joint (ACJ)Move the fingers laterally along the clavicle until where the end of the clavicle meets the acromium. The position of the joint line can be checked by asking the patient to shrug their shoulders. This is usually the site that thebra strap sits on women.

3

Distal Interphalangeal Joints (DIPs)IP of thumb, PIPs and DIPs are all assessed using the interlocking “C” technique. With index finger and thumb on each hand make a “C” shape. Position one Canteriorly/posteriorly over the joint line and the other one laterally. Then in turn squeeze the fingers over the joint line. If there is an effusion within the joint you will feel the fluid moving below your fingers. This technique iscalled “ballotting”.

4

HipThe hip joint is too deep seated to palpate, hence 66 swollen versus 68 tender. Therefore only tenderness is assessed. Tenderness of the hip is classified as pain on movement when flexing and rotating the hip.

5

AnklePlace both index fingers on the medial and lateralmalleoli and place both thumbs on the midline of the ankle joint. Ask the patient to plantar flex and dorsiflex the ankle to ensure you are on the joint line.

6


7


8

Proximal Interphalangeal Joints (PIPs) of FeetThese are done in the same way as assessing the DIPs of hands, although it is a little more difficult to get yourfingers into the spaces between toes.

9

Joint Count 66/68

Assessing Tender JointsJoint tenderness should be assessed by pressing on the joint using the thumb and index finger. A general guide to the amount of pressure required is press until it causes ‘whitening’ of the examiner’s nail bed.


Appendix C – A quick guide to assessing PsA

A Quick Guide to Assessing PsAErythema

1 = light red


3 = dark red




1 – Mild Light red Predominantly fi ne scaling Slight, but covering part of the lesion defi nite elevation; typically edges indistinct or sloped 2 – Moderate Red, but not Fine to rough scaling Moderate dark red covering a large part of elevation with the lesion rough or sloped edges



Scaling

Scaling






Extent score Grade

0 None

1 1% to 9%

2 10% to 29%

3 30% to 49%

4 50% to 69%

5 70% to 89%

6 90% to 100%

Erythema

Erythema

Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

Erythema

Scaling





Scaling

Scaling





Scaling

Scaling





Scaling


Head x 0.1 & Neck

Arms x 0.2

Trunk x 0.3

Legs x 0.4

Severity Extent



Head + + = & Neck

Arms + + =

Trunk + + =

Legs + + =


(0-4) (0-6)(0-4)(0-4)


With AbbVie


PASI and BSA The skin should be assessed using either the PASI (Psoriasis Area Severity Index) or the BSA (Body Surface Area). PASI is an assessment of the body in four regions: head and neck, arms, trunk (including groin and axillae) and legs (including buttocks). The assessment includes the severity of specific symptoms, and the extent the regions are affected by psoriasis. BSA is assessment of the percentage of area of the body covered by psoriasis.

Skin Assessment

“Considering all the ways your arthritis affects you, how are you feeling today?”




Definition of the criteria: Response = improvement in ≥ 2 of the 4 tests:


• No worsening in any of the four measures• Improvement is defined as a decrease ≥



“Considering all the ways the arthritis affects your patient, how is your patient feeling today?”






50 2 43Erythema

1 = light red


3 = dark red




1 – Mild Light red Predominantly fi ne scaling Slight, but covering part of the lesion defi nite elevation; typically edges indistinct or sloped 2 – Moderate Red, but not Fine to rough scaling Moderate dark red covering a large part of elevation with the lesion rough or sloped edges



Scaling

Scaling






Extent score Grade

0 None

1 1% to 9%

2 10% to 29%

3 30% to 49%

4 50% to 69%

5 70% to 89%

6 90% to 100%

Erythema

Erythema

Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

Erythema

Scaling





Scaling

Scaling





Scaling

Scaling





Scaling


Head x 0.1 & Neck

Arms x 0.2

Trunk x 0.3

Legs x 0.4

SeverityExtent



Head + + = & Neck

Arms + + =

Trunk + + =

Legs + + =


(0-4)(0-6) (0-4) (0-4)


With AbbVie


Patient (PtGA)

Physician (PGA)

1


Basic (minimum) assessmentIntermediate assessmentAdvanced assessment


(MDA) Assessment

• Dactylitis





A patient with PsA is in MDA when they meet 5/7 of the following criteria: Moving Towards a T2T Approach



• PASI (≤ 1) or BSA (≤ 3)

• HAQ (≤ 0.5)







T2T PsA

• Joint Count



• DLQI*

• HAQ*



Revealing more


A Quick Guide to Assessing PsA


PASI and BSA The skin should be assessed using either the PASI (Psoriasis Area Severity Index) or the BSA (Body Surface Area). PASI is an assessment of the body in four regions: head and neck, arms, trunk (including groin and axillae) and legs (including buttocks). The assessment includes the severity of specifi c symptoms, and the extent the regions are affected by psoriasis. BSA is assessment of the percentage of area of the body covered by psoriasis.

Skin Assessment


”




Defi nition of the criteria: Response = improvement in ≥ 2 of the 4 tests:


• No worsening in any of the four measures• Improvement is defi ned as a decrease ≥




”






5 024 3Erythema

1 = light red


3 = dark red




1 – Mild Light red Predominantly fine scaling Slight, but covering part of the lesion definite elevation; typically edges indistinct or sloped 2 – Moderate Red, but not Fine to rough scaling Moderate dark red covering a large part of elevation with the lesion rough or sloped edges



Scaling

Scaling





About PASIPASI is derived from skin assessment of the body in four regions: head and neck, arms, trunk (including groin and axillae) and legs (including buttocks). The assessment of the severity of the symptoms erythema, scaling and induration is performed separately for each region. The extent

Extent score Grade

0 None

1 1% to 9%

2 10% to 29%

3 30% to 49%

4 50% to 69%

5 70% to 89%

6 90% to 100%

Erythema

Erythema

Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

Erythema

Scaling





Scaling

Scaling





Scaling

Scaling





Scaling


Head x 0.1 & Neck

Arms x 0.2

Trunk x 0.3

Legs x 0.4

Severity Extent



Head + + = & Neck

Arms + + =

Trunk + + =

Legs + + =


(0-4) (0-6)(0-4)(0-4)

1 2 3 4

This PsA Assessment initiative is led by the UK PsA Assessment Academy and funded by AbbVie. Date of preparation: July 2014. Job code: AXHUR141094(1)


Patient (PtGA)

Physician (PGA)

1




(MDA) Assessment

• Dactylitis






Moving ToToT wards a T2T Approach



• PASI (≤ 1) or BSA (≤ 3)

• HAQ (≤ 0.5)







T2T PsA

• Joint Count



• DLQI*

• HAQ*



Revealing more



Standard (minimum) assessment

35

Section 8

Appendix D – DLQI and score sheet



36

Section 8

Appendix E – HAQ and HAQ score sheet

37

Section 8

Plaque location

Reference:1. NICE Technology Appraisal Guidance TA103. Etanercept and efalizumab for the treatment of adults with psoriasis.

July 2006. Available at http://guidance.nice.org.uk/TA103. Accessed August 2015.

Even mild psoriasis can be distressing to a patient if it’s in a visible area such as the face.1

This chart enables you to record the location of a patient’s plaques at each visit to accurately

track their progress.

Name Date

This PsA Assessment initiative is led by the UK PsA Assessment Academy and funded by AbbVie. Date of preparation: August 2015 Job Code: AXHUR151220j

Don’t forget signs of PsA on nails

Remember to check around the hairline

Appendix F – PASI score sheet


Erythema

1 = light red


3 = dark red


Severity Score Erythema Scaling Induration0 – None No redness No scaling No elevation

1 – Mild Light red Predominantly fine scaling Slight, butcovering part of the lesion definite elevation;

typically edges indistinct

or sloped

2 – Moderate Red, but not Fine to rough scaling Moderate dark red covering a large part of elevation with

the lesion rough or sloped edges

3 – Severe Dark red Rough, thick scaling Marked covering a large part of elevation; the lesion typically with hard or

sharp edges

4 – Very severe Very dark red Very rough, very thick Very marked (changing to purple) scaling totally covering elevation;

the lesion typically with hard,

sharp edges

Scaling

Scaling






Extent score Grade

0 None

1 1% to 9%

2 10% to 29%

3 30% to 49%

4 50% to 69%

5 70% to 89%

6 90% to 100%

Erythema

Erythema

Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

1 = light red


3 = dark red


Erythema

Erythema

Scaling





Scaling

Scaling





Scaling

Scaling





Scaling


Head x 0.1 & Neck

Arms x 0.2

Trunk x 0.3

Legs x 0.4

SeverityExtent



Head + + = & Neck

Arms + + =

Trunk + + =

Legs + + =


(0-4)(0-6) (0-4) (0-4)

1 2 3 4

This PsA Assessment initiative is led by the UK PsA Assessment Academy and funded by AbbVie. Date of preparation: August 2015 Job Code: AXHUR151220j


38

Section 8

Appendix G – Invitation for clinicians

This PsA Assessment initiative is led by the UK PsA Assessment Academy and funded by AbbVie Ltd.

1. Gladman DD, Antoni C, Mease P, Clegg DO, Nash O. Psoriatic arthritis: Epidemiology, clinical features, course, and outcome. Ann Rheum Dis 2005; 64 (suppl 2): ii14–ii17.2. Lee S, Mendelsohn A, Sarnes E. The Burden of Psoriatic Arthritis. P&T 2010 December; 35(12):680–689.

Date of preparation: August 2014 AXHUR130256h(1)

[Insert hospital name][Insert hospital address][Insert hospital address][Insert hospital address]

[Insert date]

Dear [Insert name],

PsA Assessment Training

I would like to invite you to join the Psoriatic Arthritis (PsA) assessment training takingplace on [Insert date] at [Insert time] in [Insert room].

PsA is a complex condition involving the joints and the skin, and many patients remainundiagnosed.1 PsA can progress notably within the first 2 years of disease onset.1

To optimise best practice and patient outcome, all appropriate patients should bescreened for PsA to help prevent irreversible joint damage.

It is, therefore, essential that all members of the team are familiar and are confident inconducting all components of the PsA assessment.

For this training to be a success it relies on all members of the clinic who conductPsA assessments to participate, so I would be grateful if you could make the PsAassessment training a priority in your diary.

I look forward to seeing you at the training.

Kind regards

[Insert name]

With AbbVie

Symptoms of PsA can place a considerable burden on patients and negativelyaffect a patient’s quality of life.2

39

1. Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis. NICE Technology appraisals TA199, August 2010.

2. Reich K, Krüger K, Mössner R, Augustin M. Epidemiology and clinical pattern of psoriatic arthritis in Germany: a prospective interdisciplinary epidemiological study of 1511 patients with plaque-type psoriasis. Br J Dermatol. 2009 May;10(5):1040-1047.

3. Gladman DD, Antoni C, Mease P, Clegg DO, Nash O. Psoriatic arthritis: Epidemiology, clinical features, course, and outcome. Ann Rheum Dis. 2005; 64 (suppl 2):ii14–ii17.

4. Haroon M, Gallagher P, FitzGeraldet O. Diagnostic delay at more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis. Ann Rheum Dis. 2014;0:1–6. doi:10.1136/annrheumdis-2013-204858.

5. Kyle S, Chandler D, Griffiths CEM, Helliwell P, Lewis J, McInnes I, Oliver S, Symmons D, McHugh N, on behalf of the British Society for Rheumatology Standards Guidelines Audit Working Group (SGAWG). Guideline for anti-TNF-a therapy in psoriatic arthritis. Rheumatology 2005;44:390–397.

6. Coates LC, Fransen J, Helliwell PS. Defining minimal disease activity in psoriatic arthritis: a proposed objective target for treatment. Ann Rheum Dis. 2010;69:48–53.

7. Coates LC, Cook R, Lee KA, Chandran V, GladmanDD. Frequency, predictors, and prognosis of sustained minimal disease activity in an observational psoriatic arthritis cohort. Arthritis Care and Research. 2010;62(7):970–976.

8. Coates LC, Helliwell PS. Validation of minimal disease activity criteria for psoriatic arthritis using interventional trial data. Arthritis Care and Research. 2010;62(7):965–969.

9. Golimumab for the treatment of psoriatic arthritis. NICE Technology appraisals TA220, August 2010.

10. SIGN Guideline 121: Diagnosis and management of psoriasis and psoriatic arthritis in adults October 2010.

11. Gottlieb A, Korman NJ, Gordon KB. et al. Guidelines of care for the management of psoriasis and psoriatic arthritis. J Am Acad Dermatol. 2008;58:851-64.

12. Coates LC, Tillett W, Chandler D, Helliwell P, Korendowych E, Kyle S, McInnes IB, Oliver S, Ormerod A, Smith C, Symmons D, Waldron N, McHugh J on behalf of BSR Clinical Affairs Committee & Standards, Audit and Guidelines Working Group and the BHPR. The 2012 British Society for Rheumatology guidelines for the treatment of psoriatic arthritis with biologics. Rheumatology 2012.

13. Anderson K, Zimmerman L, Caplan L, Michaud K. Measures of rheumatoid arthritis disease activity. Arthritis Care & Research. November 2011;63(S11):S14 –S36.

14. Hawker GA, Mian S, Kendzerska T, French M. Measures of Adult Pain. Arthritis Care & Research. November 2011; 63(S11):S240–S252.

15. Bruce B, Fries JF. The Stanford Health Assessment Questionnaire: Dimensions and Practical Applications. Health and Quality of Life Outcomes 2003;1:20.

16. HAQ instructions: http://aramis.stanford.edu/downloads/HAQ%20Instructions%20(ARAMIS)%206-30-09.pdf. Last accessed September 2015.

17. Day SH, Butt S, Deighton C, Gadsby K. The Consequence of Using Different Methods of Joint Assessment on the Eligibility for Access to Anti-TNF in Psoriatic Arthritis (PsA). British Society of Rheumatology Annual Meeting 2010. OP39.

18. Healy PJ, Groves C, Chandramohan M, Helliwell PS. MRI changes in psoriatic dactylitis—extent of pathology, relationship to tenderness and correlation with clinical indices. Rheumatology 2008;47:91–95.

19. Finlay AY. Current severe psoriasis and the Rule of Tens. British Journal of Dermatology. 2005;152:861–867.

20. Long CC, Finlay AY, Averill RW. The Rule of Hand: 4 hand areas = 2 FTU = 1 g. Arch Dermatol. 1992;128(8):1129-1130.

21. National Psoriasis Foundation https://www.psoriasis.org/about-psoriasis. Last accessed September 2015.

References



This PsA Assessment initiative is led by the UK PsA Assessment Academy and funded by AbbVie Ltd. Date of preparation: October 2015; Job Code: AXHUR151220I

Date post:	04-Feb-2018
Category:	Documents
Upload:	vanlien
View:	213 times
Download:	0 times

Assessing Psoriatic Arthritis in your clinic · PDF fileAssessing Psoriatic Arthritis in your...

Documents