S-58 1 Vanderbilt University Medical Center, Nashville, Tennessee, USA; 2 Jyväskylä Central Hospital, Jyväskylä, Finland. Tuulikki Sokka, MD, PhD; Theodore Pincus, MD. Please address correspondence to: Tuulikki Sokka, MD, PhD, Vanderbilt University School of Medicine, 203 Oxford House, Box 5, Nashville, TN 37232-4500, USA. E-mail: t.sokka@vanderbilt.edu Clin Exp Rheumatol 2005; 23 (Suppl. 39): S58-S62. © Copyright CLINICAL AND EXPERIMENTAL RHEUMATOLOGY 2005. Key words: Joint assessment, rheumatoid arthritis. ABSTRACT A count of swollen and tender joints is the most specific quantitative clinical measure to assess and monitor the sta - tus of patients with rheumatoid arthri - tis. Many methods have been described to quantitate joint abnormalities, inclu - ding scoring various numbers of joints (with or without grading of abnormali - ty) for different types of abnormalities, including swelling, tenderness, pain on motion, limited motion, and deformity. This article reviews selected methods for the performance of joint counts, with discussion of their advantages and limitations in the assessment of pa - tients with rheumatoid arthritis. Introduction A joint count is the most specific clini- cal method to quantify abnormalities in patients with rheumatoid arthritis (RA). The swollen joint count reflects the amount of inflamed synovial tissue and the tender joint count is associated more with the level of pain. Formal joint counts have been described with the evaluation of 28 to 80 joints, with or without grading of severity of abnormal- ity, and sometimes weighting larger joints. Joint counts are included in his- torical indices of disease activity, such as “a therapeutic scorecard in rheuma- toid arthritis” (1) and the Lansbury In- dex (2). Joint counts are a major com- ponent of the disease activity score (DAS) (3,4) and similar indices (5), the American College of Rheumatology (ACR) Core Data Set for clinical trials in RA(6), and the ACR remission crite- ria (7). Improvement in joint scores is required to meet ACR improvement criteria (8). Clinically detectable inflam- mation antedates structural damage of joints (9), and rheumatologists are urged to include a joint count at each visit of each patient (10). This essay presents a brief description and discussion of the development of the joint count over the last half centu- ry. Description of abnormalities in a quantitative joint evaluation Abnormalities assessed in formal joint counts include swelling, tenderness, pain on motion, limited motion, and de- formity. Joint swelling is defined as soft tissue swelling of the joint which is detectable along the joint margins. A synovial effusion invariably means that the joint is swollen. Fluctuance is a characteristic feature of swollen joints; neither bony enlargement nor deformi- ty of the joint constitutes “swelling”. Joint swelling may influence the range of joint motion, which can be useful to recognize the presence of swelling. Ex- amples include decreased dorsiflexion of the wrist and decreased elbow exten- sion when joint swelling is present. Joint tenderness is defined as pain at rest that is induced by pressure at ex- amination of some joints such as the metacarpophalangeal (MCP) and wrist joints. The examiner uses his/her thumb and index finger to exert pressure that is sufficient to cause whitening in the examiner’s nailbed, which is called the “rule of thumb”. Joint tenderness is correlated significantly with pain on motion (11). Pain on motion may be substituted for pressure at examination for the shoulder, tarsal and hip joints. Limited motion is of value to be asses- sed in each joint, rather than a formal assessment of range of motion, which may be useful in orthopedic evalua- tions, but is not necessary in rheumato- logic care. Generally, the assessor may serve as the normal "control" for range of motion. A joint deformity may be reducible or non-reducible; joint defor- mity is correlated significantly with joint limited motion. In view of the fact that joint swelling and tenderness may improve over five years while joint lim- ited motion deformity may progress (see below) (12,13), it may be of value to include assessment of limited motion or deformity in any database which is projected to be analyzed over periods longer than a year. Quantitative joint assessment in rheumatoid arthritis T. Sokka 1,2 , T. Pincus 1