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Arthritis
care 101
What you need to
know
Osteoarthritis is the
most common type of arthritis. It is caused by
cartilage wearing down over time; the loss of
cartilage means bones may rub together, causing
pain and swelling. Osteoarthritis can be identified
by its gradual onset and lasting discomfort. The
most useful diagnostic methods are physical examination,
getting a patient history about the type and severity
of the pain, and examining x-rays to confirm the
loss of cartilage.
Rheumatoid arthritis
is less common but generally more severe. It is
an autoimmune disorder, and can cause swelling
of the internal organs as well as of the joints
(most commonly the hands and feet). Warning signs
include stiffness after waking that lasts for
at least 30 minutes, and symmetrical pain (inflammation
in the same joints, on both sides of the body).
Symptoms can include flu-like presentation, hard
nodules near the joints, and general fatigue.
A number of blood tests — including rheumatoid
factor, white blood cell count, and C-reactive
protein — are available to help diagnose
rheumatoid arthritis. Treatment is available,
but it's important to start early in the course
of the disease for best results. If you suspect
a patient has RA, refer them to a rheumatologist
immediately.
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Arthritis is, paradoxically, one
of the most common diseases afflicting Canadians but
one of the most frequently overlooked in primary care.
"It may a bit strong to say [family physicians] don't
have enough knowledge," says Dr Jane Aubin, scientific
director of the Canadian Institutes of Health Research
(CIHR) Institute of Musculoskeletal Health and Arthritis,
"but the fact that many people are not being quickly
diagnosed says there's a deficiency in physician awareness
in diagnosing arthritis."
A lack of time to see patients
— the traditional culprit at the heart of many
of our healthcare system's troubles — plays a role,
she explains, but the underlying problem is FPs' lack
of familiarity with evidence-based guidelines for diagnosing
and managing the various forms of the common disease.
In response to the shortcomings
in arthritis care, two very different approaches for
improving the situation have emerged in Canada over
the past several years. The first, best practices initiatives,
stress the deficiencies in FPs' diagnoses, rates of
referral and pain management as established by researchers.
On the other hand, patient education initiatives focus
instead on providing patients with easy to understand
information and guidance on how to determine what treatment
and pain management might be most appropriate for them.
Despite their differences, the
two approaches may provide a roadmap of sorts to an
improved future for arthritis care.
WEAR
AND TEAR
"Part of the issue," according to Dr Aubin, "is that
many people in the general population and many family
physicians still unfortunately think arthritis —
or aches and pains in the joints — is a natural
consequence of getting older."
It's a common fallacy, says the
former scientific research chair and CEO of the Canadian
Arthritis Network, and one that FPs must be wary of.
"Obviously, wear and tear on the joints occurs, but
I wouldn't say arthritis is a natural part of aging,"
she says. "The issue is whether it's even recognized
as something that needs to be treated."
CLINICAL
REFORM
The revelation that arthritis has been largely left
by the wayside in Canadian primary care was made public
thanks in part to the Summit on Standards in Arthritis
Prevention and Care, organized by the Alliance for the
Canadian Arthritis Program in November 2005.
The most pressing issues for FPs,
explained Dr Aubin, are the very basic ones: diagnosis
and pain management. Of course, patients often need
complex treatments including physical therapy and joint
replacement surgery that are beyond the realm of family
practice — but none of the care specialists can
offer is available to patients who aren't first diagnosed
in a timely fashion by their FPs.
And patients rarely see specialists:
a 2005 study in Arthritis & Rheumatism by
researchers from UBC's Arthritis Research Centre of
Canada found use of drug treatment by FPs was "inappropriately
low" and proper prescriptions increased 31-fold when
patients were under the care of a rheumatologist. Unfortunately,
only 34% of patients saw a rheumatologist over a two
year period, and just 48% over five years.
PATIENT
EDUCATION
Some researchers have focused instead on getting the
information directly into patients' hands. Dr Lucie
Brosseau, a University of Ottawa rehabilitation epidemiologist,
presented her new knowledge-transfer model at the Cochrane
Symposium in Ottawa in February.
For her experiment, Dr Brosseau
and her colleagues first met with a small group of influential,
interested arthritis patients, trained them to teach
others about arthritis self-management methods and then
sent them out to give workshops in their communities.
The results were promising: participants' in the expert-patients'
workshops improved their knowledge of a variety of self-management
techniques by between 20% and 55% from baseline. "If
patients are well trained by health professionals, they
can teach other patients self-management in a practical
way and get results," says Dr Brosseau.
While some may argue her work conflicts
with what clinical reformers like Dr Aubin are trying
to accomplish, Dr Brosseau sees patient initiatives
as complementary. The majority of evidence-based guidelines
for arthritis treatment have not been adopted by FPs,
she says. "We know they are widely disseminated, but
we don't know if they are using them."
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