The Difficulty of Diagnosing

A question frequently asked by arthritis patients, especially those in the early stages of the disease, is why it’s so hard to nail down a diagnosis of a specific type of arthritis or other connective tissue disease. Why, patients wonder — with all the diagnostic tools available — can’t my physician just tell me what’s wrong?

Unfortunately, arthritis is a disease that usually begins in a very nonspecific way, and it’s often not until several symptoms have appeared and many tests have been run — sometimes months into the course of the disease — that the rheumatologist can diagnose with certainty the type and severity of arthritis at hand.

With rheumatoid arthritis, for example, the type of onset varies and the appearance of the joints can be nonspecific. A patient can have an acute onset, in which the inflammatory process blossoms rapidly, or an insidious onset, which is much slower. Inflammation may start in a single joint or in several at once. Depending on the onset and the joints affected, physicians may be looking at a number of different disease forms. They must then turn to laboratory testing, X-rays and clinical examination to gather the clues needed to diagnose the disease more specifically.

There is no specific test for rheumatoid arthritis. Rather, there are several tests which, taken together, can give the rheumatologist some confirmation of the clinical findings. One of the most common tests is a cheap, crude, nonspecific test called the sedimentation rate, which literally dates back to the ancient Greeks. This test looks at the rate of red blood cell sedimentation over one hour’s time. The faster the red blood cells fall, the more inflammation is present.

Of course, any inflammatory disease can produce a high “sed rate” (as the test is commonly abbreviated). It is only useful as part of the analysis.

The rheumatoid factor test, which was discovered by chance 50 or 60 years ago, is similarly flawed. The test has a high incidence of false negatives; only about 60 percent to 70 percent of people with rheumatoid arthritis respond to the test. And the results can change over the course of a particular patient’s disease (going from negative to positive, for example). As with the sed rate test, a positive rheumatoid factor is just one corroborating test that helps the physician reach a diagnosis.

Because of the inexact nature of the tools at his or her disposal, the physician’s experience and knowledge is key to making a diagnosis. Pattern recognition is very important. A good rheumatologist, on meeting a new patient, will listen to the individual’s story, and many times a pattern will emerge. Listening to the patient is very important.

Patients can help themselves by being good observers. Try to follow the “five W’s” of journalism, so to speak. What joint did the swelling start in? How fast did it come on? What are the characteristics of the pain?

What affects the pain? Does the pain and swelling move from one joint to another? Was anything else going on at the time? These clues put together, plus lab tests, X-rays and the doctor’s examination of the patient, may well end up forming a diagnostic picture.

The lesson to be learned is twofold: If you are suffering from arthritis symptoms, find an experienced rheumatologist and be sure to bring him or her as much information as possible. Working together, you have a better chance of reaching a diagnosis quickly, so that the treatment process can begin.

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