Rheumatological

RHEUMATOLOGICAL

 

Rehabilitation Guidelines for Rheumatological Diseases

 

Goals:

 

To maintain or restore the individual’s ability to function successfully in personal,family and community life by developing that person to fullest physical, psychological, social, vocational, and education potential consistent with his or her physiologic or anatomic impairment and environmental limitations.

 

Assessment of the patients with Rheumatic Diseases:

 

Physical Function Assessment

 

Manual muscle strength testing

Range of motion: using goniometer

Transfer and ambulation.

Ability to perform activities of daily living (ADLs, ambulation dressing, eating, personal hygiene, transfer and toileting.)

Occupational activities including job, housework and school work

Sexual activities

Sleep history

 Psychological /Cognitive Function Assessment

 

Affective function (depression, anxiety, mood)

Coping skills

Cognitive function

Compliance with treatment plan

Social function assessment (family, friends, community)

 

Social support systems

  • Interpersonal relationship
  • Family function
  • Social economic / financial
  • Ability to fulfill social roles

 

American Rheumatism Association (ARA)Classification of Rheumatic Diseases:

  1. Systemic Connective Tissue Diseases
  2. Vasculitides
  3. Sero Negative Spondyloarthropathies
  4. Arthritis associated with infectious agents
  5. Rheumatic Disorders associated with metabolic, endocrine, and hematologic diseases
  6. Bone and Cartilage Disorders
  7. Hereditary, Congenital and Inborn errors of metabolism associated with rheumatic syndromes
  8. Non-articular and regional musculoskeletal disorders\
  9. Neoplasms and tumor like lesions
  10. Miscellaneous Rheumatic Disorders.

 

Health Care Personnel

 

Physical therapist:

Administers and instructs patients in the use of various therapeutic and pain-relieving techniques, including heat, cold, traction, diathermy, electrically stimulation, therapeutic exercise, stretching, transfer skills, ambulation methods, and joint ROM function/strength.

 

Occupational therapist:

Responsible for optimizing function by instruction in joint protection and energy conservation. In addition, OTs provide or fabricate adaptive equipment and splinting, especially for upper extremity functional activities. Some OTs but usually podiatrists provide orthotics for lower  extremity problems.

 

Social workers and rehabilitation counselors:

Assist in the management of social, economic and psychologic problems that creates stress for the patient and family. This can include assistance in recreational activities as well as interpersonal and sexual relationships.

 

Psychotherapist:

 

Assist the patient with the psychologic problems that arise from dealing with pain and loss of function.

 

Vocational counselors:

 

Can mobilize community resources to retrain and restore the patient to the work place.

 

Arthritis rehabilitation nurses and patient educators:

 

Assist in instruction about the rheumatic disease and its therapy. Provide information, motor compliance, and give emotional support to the patient and family.

 

Early Diagnosis & Management of Rheumatoid Arthritis

 

Suspect RA if:

 

Morning stiffness> 30 mins.

3 or more tender and swollen joints areas

symmetrical joint involvement.

(metacarpophalangeal joints and / or metatarsophalangeal joints)

 

By Investigation there are:

 

positive rheumatoid factor and /or anti- CCP.

Raised ESR & / or CRP

Radiological changes in hands that indicate RA

NB: Absence of any key symptoms, signs or test results does

 

not necessarily rule out RA.

 

Initial Therapy:

 

Simple Analgesic: paracetamol (Panadol)

Patient education: ice / heat; exercises

Enhanced primary care referrals as required to physiotherapy, occupational therapy, psychology

Assessment of fatigue, sleep quality, impact of activities of daily living and others.

 

Non-steroidal Anti-inflammatory (NSAIDS):

after careful evaluation of cardiovascular, astrointestinal, and renal status.

 

If persistent swelling beyond 6 weeks:

 

Continue NSAIDS

Disease modifying anti-rheumatic drugs (Methothraxate 2.5 mg tablet  4 tables weekly)

Low dose of oral corticosteroid

 

Advanced Therapies:

 

Combination DMARDs (Methotraxate & Sulfasalazine)

Leflunonmide or Cyclosporin

Biological agents (anti- tumor necrozing factor (anti-TNF)

Ongoing Monitoring of RA

 

Assess response to management:

 

Joint count, ERS, CRP, Physical function

Monitor for potential toxicity (skin bone marrow, liver, renal, lung, gout, heart, blood test and urine test)

Review mood, sleep, ADLs, fatigue

Rheumatology review at least 3 times per year

Encourage smoking cessation

Aggressive control of cardiovascular risk factors.

if on corticosteroids, offer osteoporosis protection, monitor for hypertension, cataract and hyperlipidemia.

Encourage physical activity and participation.

 

Management of Osteoarthritis

 

  1. Non-pharmacological management of osteoarthritis

 

Exercise and manual therapy

Weight loss

Aids and devices

Assistive devices (for example, walking sticks and tap turners) should be considered as adjuncts to core treatment for people with osteoarthritis who have specific problems with activities of daily living. Healthcare professionals may need to seek expert advice in this context (for example, from occupational therapists or Disability Equipment Assessment Centres).

 

  1. Pharmacological management of osteoarthritis

 

Oral analgesics

Topical treatments NSAIDs

NSAIDs and highly selective COX-2 inhibitors

Intra-articular injections

  • Intra-articular corticosteroid injections should be considered as an adjunct to core treatment for the relief of moderate to severe pain in people with osteoarthritis.
  • Intra-articular hyaluronan injections are not recommended for the treatment of osteoarthritis.

 

III. Referral for specialist services

 

Referral criteria for surgery

 

Clinicians with responsibility for referring a person with osteoarthritis for consideration of joint surgery should ensure that the person has been offered at least the core (non-surgical) treatment options (see recommendation 1.1.5 and figure 2).

 

Referral for joint replacement surgery should be considered for people with osteoarthritis who experience joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment. Referral should be made before there is prolonged and established functional limitation and severe pain.

 

Patient-specific factors (including age, gender, smoking, obesity and comorbidities) should not be barriers to referral for joint replacement surgery.

 

Decisions on referral thresholds should be based on discussions between patient representatives, referring clinicians and surgeons, rather than using current scoring tools for prioritization.