What is REMS
Regional examination of the musculoskeletal system refers to the more detailed examination that should be carried out once an abnormality has been detected either through the history or through the screening examination (GALS). REMS involves the examination of a group of joints which are linked by function, and may require a detailed neurological and vascular examination.
REMS was born out of a desire to standardize examination of the musculoskeletal system, allowing for more systematic teaching and learning. It was developed through a national consensus process involving UK consultants in rheumatology, orthopaedics and care of the elderly and selected general practitioners. It led to an agreed set of ‘core’ skills (see Appendix 2). It is important to note, however, that a number of other specific tests may be used by musculoskeletal practitioners as an adjunct to the REMS examination.
A paediatric REMS (pREMS) has also been developed and educational resources are in preparation. (Foster HE, Kay LJ, May CR, Rapley TR. Pediatric regional examination of the musculoskeletal system: a practice- and consensus-based approach. Arthritis Care & Research 2011;63(11):1503-1510)
There are five key stages which need to be completed during an examination of the joints in any part of the body:
- Introduce yourself.
- Look at the joint(s).
- Feel the joint(s).
- Move the joint(s).
- Assess the function of the joint(s).
It is important to introduce yourself, explain to the patient what you are going to do, gain verbal consent to examine, and ask the patient to let you know if you cause them any pain or discomfort at any time. In all cases it is important to make the patient feel comfortable about being examined. A good musculoskeletal examination relies on patient cooperation, in order for them to relax their muscles, if important clinical signs are not to be missed.
The examination should always start with a visual inspection of the exposed area at rest. Compare one side with the other, checking for symmetry. You should look specifically for skin changes, muscle bulk, and swelling in and around the joint. Look also for deformity in terms of alignment and posture of the joint.
Using the back of your hand, feel for skin temperature across the joint line and at relevant neighbouring sites. Any swellings should be assessed for fluctuance and mobility. The hard bony swellings of osteoarthritis should be distinguished from the soft, rubbery swellings of inflammatory joint disease. Tenderness is an important clinical sign to elicit – both in and around the joint. Identifying inflammation of a joint (synovitis) relies on detecting the triad of warmth, swelling and tenderness.
The full range of movement of the joint should be assessed. Compare one side with the other. As a general rule both active movements (where the patient moves the joint themselves) and passive movements (where the examiner moves the joint) should be performed. If there is a loss of active movement, but passive movement is unaffected, this may suggest a problem with the muscles, tendons or nerves rather than in the joints, or it may be an effect of pain in the joints. In certain instances joints may move further than expected – this is called hypermobility.
It is important to elicit a loss of full flexion or a loss of full extension as either may affect function. A loss of movement should be recorded as mild, moderate or severe. The quality of movement should be recorded, with reference to abnormalities such as increased muscle tone or the presence of crepitus.
It is important to make a functional assessment of the joint – for example, in the case of limited elbow flexion, does this make it difficult for the patient to bring their hands to their mouth? In the case of the lower limbs, function mainly involves gait and the patient’s ability to get out of a chair.
For the purposes of this handbook (and the accompanying DVD) the REMS examination has been divided into seven areas, each of which is described in detail below. However, it should be remembered that this is an artificial division and that one group of joints may need to be examined in conjunction with another group (e.g. the shoulder and cervical spine).
Recording the findings from the regional examination
The positive and significant negative findings of the REMS examination are usually documented longhand in the notes. If no abnormality is found then ‘REMS normal’ is sufficient. You may find it helpful to document joint involvement on a homunculus such as the one shown below. The total number of tender and swollen joints can be used for calculating disease activity scores – these are useful in monitoring disease severity and response to treatment over time.
REMS general principles: checklist
- Introduce yourself
- Gain verbal consent to examine
- muscle wasting
- full range of movement – active and passive
- restriction – mild, moderate or severe?
- functional assessment of joint(s)
CMC(J) carpometacarpal (joint); CT computerized tomography; DEXA dual-energy x-ray absorptiometry; DIP(J) distal interphalangeal (joint); ESR erythrocyte sedimentation rate; GALS gait, arms, legs and spine; MCP(J) metacarpophalangeal (joint); MRI magnetic resonance imaging; MTP(J) metatarsophalangeal (joint); NSAID non-steroidal anti-inflammatory drug; OA osteoarthritis; PIP(J) proximal interphalangeal (joint); RA rheumatoid arthritis; REMS regional examination of the musculoskeletal system.