Patient-Reported Rheumatoid Arthritis Flares in Agreement With Clinical Exams

Closeup side view of a mid 50’s man having his wrist examined by a doctor. The patient has suffered a dislocation by physical injury.
Patient-reported flares in rheumatoid arthritis indicated increased disease activity concordant with clinical examinations.

With respect to rheumatoid arthritis (RA), patient-reported flares indicated increased disease activity concordant with clinical examinations, according to a study published in Rheumatology.

Researchers in this prospective, observational study evaluated the association between patient-reported flares of swollen and tender joints, increases in disease activity after a clinical examination, and swelling detected by ultrasonography, in patients with RA. To be included, patients had to meet the criteria for RA from the American College of Rheumatology 1987 or the American College of Rheumatology/European League Against Rheumatism 2010. They also had to have the rheumatoid factor and/or anti-cyclic citrullinated peptide (CCP) positive status, have stable disease-modifying antirheumatic drug treatment, and not have swollen joints at baseline.

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At baseline, demographic and clinical evaluation data were collected, and patients completed the Flare Instrument and the Outcome Measures in Rheumatology flare questionnaires. Ultrasonography examinations were completed using a General Electric Logiq E9 US machine with a multifrequency linear array transducer 6-15. When a patient-reported flare occurred, the patient was to contact the hospital and a physical visit for the flare was scheduled within 3 days.

Of the 80 RA patients included in this study, the mean age was 64.8 years; 69% were women, and the mean disease duration was 10.3 years. Over the 1-year follow-up, 36% of the patients reported a hand flare, and all measures of disease activity were increased at the flare visit, with a rise in disease activity score DAS28-C-reactive protein (P <.001) and 65.5% of the patients meeting the criteria for the DAS flare definition.

Ultrasonography at baseline indicated that synovitis and tenosynovitis were present in 63.8% and 19.0% of patients’ wrists, respectively. At flares, synovitis and tenosynovitis were present in 84.5% and 41.0% of their wrists, respectively.

For the clinical examination, the highest concordances between patient-reported joint flare and the assessment for swelling and tenderness were in the proximal interphalangeal joint (93% and 83%), the metacarpophalangeal joint (88% and 82%), and the wrist (79% for both). The agreement between clinical evaluation and ultrasonography was also highest for the proximal interphalangeal joint (74-81%), the metacarpophalangeal joint (60-65%), and the wrist (41%). 

Specificities were high for swollen joints and tender joints for both patient-reported flares and clinical examinations (86-100% and 88-100%, respectively), and sensitivities were lower for swollen joints and tender joints for both patient-reported flares and clinical examinations (12-34% and 4-32%, respectively).

Limitations of this study included the small sample size, only including rheumatoid factor and or anti-CCP positive patients, and not including effusion, which is a common abnormality.

The researchers concluded that “[p]atient self-assessment of joints, which was highly concordant with clinical examination, may be a potential amendment to traditional monitoring of patients [with RA] to capture flares between routine clinical visits.”


Kuettel D, Terslev L, Weber U, et al. Flares in rheumatoid arthritis: do patient-reported swollen and tender joints match clinical and ultrasonography findings? [published online June 25, 2019]. Rheumatology. doi: 10.1093/rheumatology/kez231