CLINICAL PRACTICE – POINT OF CARE TOOLS Rheumatoid Arthritis Juvenile Idiopathic Arthritis ...

81 Pages·2013·3.71 MB·English

by  Parry, Sharon

PSP Musculoskeletal (MSK)

CLINICAL PRACTICE – POINT OF CARE TOOLS

Rheumatoid Arthritis
Juvenile Idiopathic Arthritis
Osteoarthritis
Low Back Pain

Train the Trainer Session 1
April 4 – 5, 2013

It is the intention of the PSP that health educators and health providers only use this publication and its content for
non-commercial educational purposes only.
Contents
Introduction to Compendium of Tools ....................................................................................... 3
Electronic Toolkits ..................................................................................................................... 4
Tools Common to All Packages.................................................................................................. 8
Patient Questionnaire .......................................................................................................................................... 9
Brief Pain Inventory............................................................................................................................................ 12
PHQ-2 and PHQ-9 – Screens for Depression ...................................................................................................... 14
RACE Line – Rapid Access to Consultant Expertise ............................................................................................ 17
Referral and Consult Report Tools ..................................................................................................................... 18
Brief Action Planning Flow Chart ....................................................................................................................... 23
The Brief Action Planning Guide (8 Nov 2012) ................................................................................................... 25
Follow-up for Brief Action Planning ................................................................................................................... 26
Brief Action Planning for Health......................................................................................................................... 27
Resources for Health Professionals ......................................................................................... 28
Arthritis Resources and Supports ....................................................................................................................... 29
LBP Resources .................................................................................................................................................... 32
Summary of Resources by Organization ............................................................................................................ 34
Core Tools for Rheumatoid Arthritis ....................................................................................... 37
History ................................................................................................................................................................ 38
Red Flags ............................................................................................................................................................ 41
Investigations ..................................................................................................................................................... 42
Physical Exam and Assessment .......................................................................................................................... 43
Other Management Considerations .................................................................................................................. 47
Decision to start Patients on DMARDs ............................................................................................................... 48
Management of Co-Morbidities ......................................................................................................................... 50
Follow-up Assessment Checklist ........................................................................................................................ 51
Referrals to Rheumatology ................................................................................................................................ 53
Tools for Juvenile Idiopathic Arthritis...................................................................................... 54
Algorithm for Youth and Children ...................................................................................................................... 55
Classification of Juvenile Idiopathic Arthritis (2011) .......................................................................................... 55
JIA Referrals........................................................................................................................................................ 57
Core Tools for Osteoarthritis ................................................................................................... 58
History ................................................................................................................................................................ 59
Algorithms .......................................................................................................................................................... 59
Patient Assessment Follow-up ........................................................................................................................... 62
Indications for Surgical Referral ......................................................................................................................... 63
Indications for Rehabilitation and Non-Surgical Referral ................................................................................... 64
Core Tools for Acute and Chronic Low Back Pain .................................................................... 65
Red Flags ............................................................................................................................................................ 66
Yellow Flags ........................................................................................................................................................ 68
Neuropathic Pain (DN4 – Questionnaire) .......................................................................................................... 71
Opioid Risk Assessment Tools ............................................................................................................................ 72
Opioid Management Reference Guide .............................................................................................................. 75
Urine Drug Screens ............................................................................................................................................ 77
Giving Patients the Green Light ......................................................................................................................... 80
Return to Work Letter ........................................................................................................................................ 81

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Introduction to Compendium of Tools

This compilation of tools is a condensed version of the more detailed toolkits commissioned by the Joint Ministry
of Health & BCMA Shared Care Committee. This MSK (Musculoskeletal) Practice Support Program covers FOUR
conditions –Rheumatoid Arthritis (RA), Juvenile Idiopathic Arthritis (JIA) Osteoarthritis (OA) and Low Back Pain
(LBP).

The purpose of these toolkits is to provide:
 Point of care tools and reference materials to guide evidence-based screening and investigations for
appropriate diagnosis, triage, referral and treatment decisions.
 Resources and supports for patients to support them as partners in goal-setting and in managing pain and
function relating to these diseases / complaints.

The resource material has been compiled from a number of sources including:
 guidelines published in 2006 (RA) and 2008 (OA) by the Guidelines and Protocols Advisory Committee –
British Columbia, Canada;
 recommendations from the 2011 Canadian Rheumatology Association guide for pharmacological
management of RA;
 the Ontario Treatment Guidelines for Osteoarthritis and Rheumatoid Arthritis and Acute Musculoskeletal
Injury published in 2000;
 guidelines published in 2009 by TOP (Toward Optimized Practice) , Alberta Canada – for acute and chronic
low back pain ;
 New Zealand Guidelines published in October 2004; and
 Advice from BC based Clinical Experts meeting between 2011-2013 Vancouver, British Columbia.

Goals and Objectives

Rheumatoid Arthritis Juvenile Arthritis Osteoarthritis Low Back Pain
For early RA (symptoms of Identify children and Obtain an accurate Increase the use of
< 6 months duration) – adolescents with JIA as early diagnosis with functional evidence-informed
initiate rapid access, as possible in the course of assessments approaches for
intervention and disease to: assessment, diagnosis and
treatment in order to - Decrease pain Identify conditions / treatment of non-specific
change the course of the - Limit or eliminate criteria for surgical low back pain
disease by aggressive disability referral
suppression of - Allow early treatment Promote appropriate
inflammation. and improved outcomes Maintain or improve joint diagnostic tests,
- Assist GPs with mobility treatment and specialist
For established RA – assessment of children referrals
ensure suppression of and adolescents with MSK Limit functional disability
inflammation and prevent complaints. Facilitate dialogue and
joint damage through: Manage pain and function improved working
- Initiation and Avoid multiple referrals through patient relationships between
maintenance of strategy and physician visits education, rehabilitation, family physicians and
for maximum control of without diagnosis medications and referrals other health care
inflammation providers involved in the
- Management of chronic Support the relationship Improve self-care care of patients receiving
disease of GPs and pediatricians in treatment for LBP
referral and shared care
networks Encourage patients to
engage in appropriate
self-care activities

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Electronic
Toolkits
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The following diagram identifies the components of the RA and OA electronic toolkits.

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Tools Common to
All Packages

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Patient Questionnaire

Patient Name: ___________________________________ Date: _______________________

1. What is the #1 problem you are seeing your doctor for today: _______________________
________________________________________________________________________
Is this problem the result of a:
Work-place injury (Date of injury: )
Car accident (Date of injury: )
Accident, including falls (Date of injury: )

2. Please describe the symptoms you are having: ____________________________________
__________________________________________________________________________
3. How did your symptoms start: __________________________________________________
__________________________________________________________________________
4. How long have you had these symptoms? Please write the number of days, weeks, months or years:
Days: ______ Weeks: _______ Months: _______ Years: _______

5. Are your symptoms always there or do they come and go? Always there: ____
Come and go: ____
6. On the following picture, mark the area where you are having these symptoms:

7. What currently gives you relief? _________________________________________________
___________________________________________________________________________
8. What have you tried for relief? __________________________________________________
__________________________________________________________________________

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Additional Questions if Joint Pain: (RA & OA TOOLKITS)

9. Are any of your joints swollen? Yes No
10. Do you have any joint pain? Yes No
11. Does your pain get worse with use or activity Yes No
12. Does your pain get worse with rest or inactivity? Yes No
13. Do your joints feel stiff or more sore when you get out of bed in the morning? Yes No

If yes, how long does this pain or stiffness last? ___________________________________
_________________________________________________________________________

14. What do you understand is the cause of your pain? ________________________________
_________________________________________________________________________

15. Have you experienced any of the following in the last 1 to 4 weeks?

Fever Fatigue
Weight loss Bowel or bladder problems
Night sweats Tingling / numbness
Night pain that wakes you up Other : _________________

16. Using the following scale, please rate to what extent your symptoms interfere with your general activity,
mood, relationships, etc.:

0 = Does not interfere 1 2 3 4 5 6 7 8 9 10 = Completely interferes Not applicable

Your general activity: ______ Your mood: ______
Your ability to walk: _______ Normal work: _____
Relationships: _______ Sleep: _______ Enjoyment of life: ______

17. Are you currently getting treatment for any other health problems? If so, please describe:

_____________________________________________________________________________

_____________________________________________________________________________

Thank you for answering these questions.

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