We are back, another week, another blog. I have been thinking this week about Rheumatology and its place in the hearts and minds of MSK Therapists. While I was thinking about this I found the start of a blog I planned on writing about 2 years ago and it triggered me to write this. I am going for a shameless request this week to increase visibility. Why not suggest it to a colleague, tag them on social media or bring it up in a training session? Its much more fun when we learn together!
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This weeks Legend of the Blog is Andrew Cuff, who apart from his boat shoe wearing nature, changed so much of my thinking around Red Flag recognition, understanding, framing and teaching. His incessant cricket references should not deter you from checking out the courses he has on offer, I have done a lot of courses on red flags for MSK and his is by FAR the best available for clinical application. Follow him on twitter and check his website
Rheumatology is a branch of medicine dealing with the investigation, diagnosis and management of arthritis and other inflammatory or autoimmune conditions. According to the British Society of Rheumatology this incorporates over 200 disorders. It is important to not at this stage that a significant number of musculoskeletal conditions also affect other organ systems. I personally find it fascinating how contemporary discussions around even Osteoarthritis, arguably the archetypal mechanical condition a few years ago now focusses around metabolic features and systemic inflammation.
Rheumatology for MSK Therapists varies wildly depending upon the setting the individual places themselves in and the point within the care pathway that they meet a patient. Let me provide some examples. I am working in a Private Practice Physiotherapy Clinic and in walks John, he has bilateral metacarpal-phalangeal joint swelling with significant early morning joint stiffness, I correctly recognise this might be Rheumatoid Arthritis. At this time, my absolute priority is to get John in front of a Rheumatologist as quickly as possible, this process again will vary depending on local pathways. I might provide John with some advice from a physiotherapy perspective which we will cover later in this audiobook but in reality, John has what I would argue are Red Flags or signs that point to a systemic inflammatory condition that needs onwards referral for further investigation. He at this time is not a Physiotherapy candidate.
Now, let’s say John walks in to my clinic 6 weeks later, he might have exactly the same symptoms but he has now been seen by Rheumatology, received a diagnosis and started medication, he is now a physiotherapy candidate. A caveat to that rather binary distinction is that there are of course things that can be done during that period of 6 weeks which was an arbitrary period of time as well, that could help John to manage his symptoms. Rather my point here is that we absolutely should not delay his getting to Rheumatology in any way.
There is another clear example of this time difference. Lets take Sue, she has plantarfasciitis in her right foot which has lasted the best part of a week. I discuss her past medical history and she has cutaneous Psoriasis (and no other relevant issues). We discuss her load profile and a graded loading program as a management strategy. Now, lets say Sue walks in with EXACTLY the same symptoms but has had them for 6 months and already tried a graded loading program. This now chronic plantarfasciitis and none response to therapy makes me consider if a Spondyloarthritis might be the underlying cause.
Rheumatology recognition sits as a slightly odd priority for therapists, it is not a true medical emergency like cauda equina syndrome that requires the patient to attend A+E, nor is it like an acute undiagnosed Osteoporotic fracture where we need to know its stability before proceeding with any Physio at all. Almost all outcomes in Rheumatology are linked to delay to diagnosis, pain, disability, medication requirements, ability to work and a lot more are deleteriously affected by longer waits for diagnosis and therefore effective treatment. This is the reason I consider these to be Red Flag conditions when undiagnosed. Shortening this delay is by far the most effective thing you can do for your patient.
I have commented many times about attempting to understand these conditions to enable effective screening, its not easy. Humans it turns out are unique and so don’t often fit into lovely diagnositic medical boxes. It is not sufficient to have a knowledge of the musculoskeletal system, these conditions affect other systems (integamentry system for example…) and overlap with other multi system disorders such as metabolic conditions.
Of course I am biased but I want to try and pull more attention towards these conditions, particularly because of the MSK nature they are going to present to Physios, Chiros, Osteos, Sports Therapists and others. I see so much attention given to tendons, low back pain, anterior knee pain… Shove some of that towards Rheumatology, we might not be the ones making a big difference with treatment but arguably the biggest difference here is appropriate RECOGNITION.
Thank you so much for reading, please do check out my other blogs and resources and I hope to see at least some people in person at some point in the near future!
Music Choice: Hoobastank – “Born To Lead”
“With eyes closed tightly
I march so blindly
Pretending every thing’s fine
‘Cause you’re there to keep me in line”
