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Rheumatology for Registrars

Rheumatology for Registrars. Pam Brown May 2007 pambrown@easynet.co.uk. Workshop content. What do you want from this workshop Common conditions Osteoporosis OA, PMR, RA, Back pain - Group work and presentations Websites and other resources Qs and As . GP 20+ years

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Rheumatology for Registrars

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  1. Rheumatology for Registrars Pam Brown May 2007 pambrown@easynet.co.uk

  2. Workshop content • What do you want from this workshop • Common conditions • Osteoporosis • OA, PMR, RA, Back pain - Group work and presentations • Websites and other resources • Qs and As

  3. GP 20+ years Previously Clinical assistant in rheumatology Currently Clinical assistant osteoporosis Trustee, National Osteoporosis Society Steering committee Primary Care Rheumatology Society Lecturer, University of Bath MSc in Primary Care Rheumatology Team doctor, Team Wales Commonwealth Games, 2002 and 2006 My credentials!

  4. E-learning and signposting • Individual musculoskeletal learning needs assessment • Prioritise information gaps and cover sequentially or agree to fill opportunistically as PUNs and DENs arise • Use web-based resources/signposted websites to fill gaps • Review musculoskeletal learning needs assessment at end of registrar year • continue to update with PUNs and DENs

  5. What do you want from this workshop

  6. Why learn about rheumatology? • PCR Society Survey 1986 – 25% of consultations were for musculoskeletal conditions • 2004 survey 100 consecutive patients • 24% musculoskeletal • 20% paediatrics • 10% psychiatry, CHD/stroke, respiratory • Musculoskeletal • 4 back pain, 1 gout, 1 RA, 3 PMR, 2 osteoporosis • 4 OA, 4 injuries, 5 aches and pains

  7. GP consultations 3rd RCGP Morbidity Study

  8. Quiz • Which joints most commonly involved in OA? • What are the underlying causes for gout? • 3 red/3 yellow flags in back pain? • Survival rate 1 year after hip fracture? • What test should we carry out on all fallers? • How can we differentiate OA and RA? • Starting doses of steroids in PMR and GCA?

  9. Rheumatology basics • We learn about ‘diseases’ • OA • Osteoporosis • Gout • Patients present with ‘symptom complexes’ • Groin pain • Stiff joints • Can’t walk upstairs We use history, examination and investigation to sort out the differential diagnosis, then formulate a management plan for the individual patient sitting in front of us

  10. Rheumatology basics • Need to identify ‘red flags’ • Malignancy • Wt loss, systemic symptoms, unremitting pain, night pain • Bone or joint sepsis • Hot, swollen joint, systemic upset, single joint involvement • Nerve or vessel problems • Nerve root distribution pain, weakness, sensory loss • Cold extremity, pulseless Remember referred pain! Remember most have multiple pathology

  11. History and examination Resources • Clinical assessment of the musculoskeletal system ARC handbook/DVD • Crash course Rheumatology and orthopaedics - Coote and Haslam • Rheumatology Guidebook - Ferrari, Cash and Maddison

  12. Examination • Multiple joints involved – screen all joints eg GALS; localise and examine specific joints • Single joint/area – examine this and joint above and below • Examination system • Inspection • Palpation • Movements – Active, passive, resisted • Special tests

  13. Common diseases/conditions • Osteoporosis • OA • Back pain • Polymyalgia rheumatica/Giant cell arthritis • Rheumatoid arthritis

  14. Group work Spend 10 minutes preparing a 5 minute summary presentation using your own knowledge and the resources provided. • Pathological process • Management options/plan • Guidelines/evidence based info available to guide decision-making eg SIGN, NICE, Prodigy • Who needs referral • Areas of uncertainty and challenges

  15. Osteoporosis • Osteoclasts resorbing more bone than osteoblasts laying down – gradual loss of bone; increased fracture risk • Fracture as acute exacerbation of osteoporosis, the chronic disease • Target high risk groups • Previous fracture patients – new, old • Oral steroids 3 months or more • Frail elderly housebound/care homes • Multiple risk factors primary prevention

  16. Mx options • Lifestyle – exercise, ca/vitamin D, stop smoking, moderate alcohol intake – throughout life • Ca 1-1.2g/vitamin D 800iu/day in frail elderly/those at risk to prevent hip #/adjuvant Rx • Bisphosphonates, raloxifene, strontium ranelate • Teriparatide for severe osteoporosis • # patients – pain relief, prompt surgery, good quality rehab

  17. NICE Technology Appraisal 87January 2005 • Secondary prevention in post-menopausal women with clinically diagnosed fracture only • All patients should have adjuvant Ca/vit D • Over 75 treat; others by DXA and age • Bisphosphonates, raloxifene, teriparatide • NICE primary prevention, secondary prevention update (strontium), guideline 2007?

  18. Osteoporosis • Steroid-induced osteoporosis • >65, previous fracture or other risk factors – Rx bisphosphonate + Ca/vit D • <65 DXA – Rx if T score –1.5 • Guidelines • RCP/BATS/NOS Osteoporosis guidelines and Rx update • RCP/BATS/NOS Glucocorticoid-induced OP guidance 2002 • SIGN guidelines • Blue book for orthopaedic surgeons • NICE guidance for secondary prevention • NICE Falls guideline

  19. Osteoporosis • Referral • Diagnostic uncertainty • Specialist investigations – men, pre-menopausal, DXA if no open access • Rx failures/specialist Rx – intolerance, IV bisphosphonate, teriparatide (PTH) • Uncertainties • NICE primary prevention TA 2007 • nGMS contract 2007/8? • 10 year fracture risk assessment tool 2007 • Challenges • Only 10% high-risk patients treated at present • Motivating primary care to take action

  20. Group work Spend 10 minutes preparing a 5 minute summary presentation using your own knowledge and the resources provided. • Pathological process • Management options/plan • Guidelines/evidence based info available to guide decision-making eg SIGN, NICE, Prodigy • Who needs referral • Areas of uncertainty and challenges

  21. OA

  22. OA key facts • Common • >1.5 million people in E and W • 10-20% of these symptomatic • Only small percentage present for help • Failure hyaline cartilage – no DMARDs yet • Joints affected • Hands – DIP, PIP, CMC thumb • Hips, knees, ankles, great toes • Cervical and lumbar spine • Xray appearances correlate poorly with symptoms

  23. Management plan • Identify those with inflammatory arthropathy or other disease • Patient education and self-management • Achieve symptom relief and improve quality of life • Maintain mobility and function • Refer appropriate patients for surgery or other management Remember hip fracture in patients with hip pain

  24. OA management • Pain relief • Simple/compound analgesics, exercises • Glucosamine sulphate, patellar taping, TENS • Topical capsaicin/NSAID; acupuncture • Oral NSAIDs – COX2s, gastro-protection • Injections – peri-articular, intra-articular • Joint replacement • Unload the joint • Lose weight • Walking stick • Shock-absorbing shoes

  25. Joint replacement • NICE referral guidance hip/knee OA • ? Infection – same day • Rapid deterioration/severe disability (2/52 hip, soon – ‘locally agreed’ knee) • Symptoms impair QOL – routine • Giving way despite Rx– soon (knee only) • Acute inflammation (gout, haemarthrosis, pseudogout) – 2/52 (knee only)

  26. PMR/GCA

  27. Polymyalgia rheumatica and Giant cell arteritis • 50% of those with GCA have PMR symptoms • 15-50% PMR patients have symptoms GCA • Muscle pain/stiffness hip and shoulder girdle • Flu-like symptoms, fever, weakness, wt loss • GCA – headaches, blurred or double vision, jaw/tongue pain, pain on chewing • ESR/CRP +/- temporal a biopsy; use Ix to exclude other diagnoses eg myeloma

  28. PMR/GCA Management Plan • PMR steroid regime • 10-20mg/day 2-4/52 • 2-4 weekly reduce by 2.5mg to 10mg • 4-6 weekly reduce by 1mg to 5mg • Continue 5mg for 12/12 • Final reduction - reduce by 1mg/day every 6-8/52 to 3mg then every 12/52 until stopped • GCA steroid regime • Visual disturbance admit urgently • Otherwise 40mg/day 2-4/52 • 2-4 weekly reduce by 5mg to 10mg then as for PMR • Remember prophylaxis with bisphosphonates

  29. RA

  30. RA key facts • Incidence 5/10,000 per year; peak 50-60yrs • 0.5-1% of population, 3 females:1male • 50% disabled/unable to work by 10 years • Different presentations • Symmetrical inflamed small joints • Fatigue and EMS but little to see initially • Episodic polyarthritis/palindromic symptoms • Systemic disease - extra-articular conditions • Nodules, vasculitis, scleritis, pericarditis Remember increased CHD risk!

  31. RA management • Aim for early diagnosis – refer if suspicious • Reduce symptoms – NSAIDs, analgesics, DMARDs • Minimise disease progression, maintain function/QOL • Education • DMARDs • Multidisciplinary support – physio, OT • Surgery • Minimise adverse drug effects • Shared care for DMARD monitoring, clear guidelines on testing/responsibility • TNF antagonists (etanercept, infliximab) • Steroids – I/A or low dose oral - specialist use only • Manage co-morbidities eg lung disease, CHD

  32. Back pain

  33. Back pain key facts • 16.5M people have back pain each year • 3-7 M consult; 1.6M attend OPD; 100,000 admitted; 24,000 have surgery per year • 7% adults present to GP each year • 90% recover within 6/52; 2-7% chronic pain • Once off for 6/12, only 50% return to work • 100M days lost from work

  34. Back pain key facts • Types • Simple mechanical back pain – 90% recover 6/52 • Nerve root pain – sciatica – 50% recover 6/52 • Inflammatory back pain – AS, Psoriasis, Colitis • Others – trauma, OP, tumours • Xray LS only if • Red flag or • Fracture risk (trauma, steroids, osteoporosis, >70) • Xray and FBC, ESR • Cancer, recent infection, fever >38, IV Drug abuse, pain worse at rest, wt loss, prolonged steroids Royal College of Radiologists 1998 Making the best use of a department of clinical radiology

  35. CERTIFICATE Areas to explore with the back pain patient • What do you think is the Cause of your pain • Ever had prolonged back pain previously? Ever had other long term pain problems? • Other people’s Response to the back pain • Time off for the problem • If off work – do you think you will return? • Financial – benefits or compensation? • What Investigations already? • What are you doing to Cope? • Affect – have you felt down, depressed or hopeless? • What have you been Told by physios, doctors etc? • Expectations – what do you hope we can do to help?

  36. Red flags • Significant injury • PMH cancer • First presentation <20 or >55 • Systemic upset – fever, wt loss • Steroid Rx or abusing drugs • Thoracic pain • Multilevel neurological signs or symptoms • Structural deformity • Pain constant, progressive and unrelenting • Difficulty urinating

  37. Psychosocial Yellow flagsin back pain • Belief that back pain is harmful/disabling • Avoiding movement because of fear of triggering pain • Reduced activity levels • Low mood • Withdrawal from social interaction • Opting for passive Rx rather than actively participating • Litigation or benefit from back pain

  38. Back pain management plan • Symptomatic Rx • Analgesics, NSAIDs, muscle relaxants • Mobilise, exercise, ice, heat, electrical therapies (U/S, diathermy, interferential, TENS) • Complementary therapies • Acupuncture, manipulation – chronic only • Rehabilitation to improve mobility and flexibility • Education and exercise to prevent recurrence • Surgery where appropriate • Avoid diazepam, bed rest, plaster jackets, time off work Waddell G et al Low back pain evidence review 1999 RCGP London

  39. Back pain referral • Immediately for cauda equina syndrome – incontinence, urinary retention, loss of sensation and muscle tone around anus • Urgently for possible serious spinal pathology/red flags • Consider routine referral for nerve root pain not resolving within 4-6 weeks – orthopaedic or neurosurgical

  40. Secondary care referral – why? • Diagnostic difficulties • OA/RA; unusual conditions • Investigative help • Special imaging – MRI, CT, bone scan • Nerve conduction studies • Specialist conditions • RA, AS, SLE, Pagets • Specialist treatments • DMARDs, surgery, joint/soft tissue injections, multidisciplinary team access

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