OA RA Algorithm

Patient with MSK
complaints
Ver 7.8 March 2016
Patient Self Monitoring & Management
Any RED FLAGS?
Possible Infection:
-Swelling, warmth, pain
Possible Fracture:
-Significant trauma
-Constitutional symptoms
(fever, burning, weight
loss, malaise)
-Minor trauma if older or
-Osteoporotic
-Acute severe pain
Inflammatory
Other:*
-Focal or diffuse muscle
weakness
-Neurogenic pain
-Claudication pain pattern
-Rash
Non-Inflammatory
· Pain increased with rest or
immobility
· Swelling due to effusion or
synovial thickening
· Local warmth – frequently
· Morning stiffness > 30 min
· Swelling in one or more
joints
· Pain with activity and at
rest
· Boney enlargement
· Local warmth – occasional
· Morning stiffness < 30 min
· Gradual onset
Rheumatoid
Arthritis
OsteoArthritis
TOOLS
Patient Questionnaire
MSK Patient Self Management
MSK Differential Diagnosis
Opioid Management
MSK Physician Resources
RACE Referral
PHQ 9 Assessement form
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Patient
Questionnaire
History
Patient SelfManagement
Differential
Diagnoses
Physical Exam
GPAC
Guidelines
Management
Options
Medications
Physician
Resources
Referral
Monitoring &
Follow-up
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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
Car accident
Accident, including falls
(Date of injury:
(Date of injury:
(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:
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
Your general activity: ______
Your mood: ______
Your ability to walk: _______
Normal work: _____
Relationships:
Sleep:
_______
_______
Not applicable
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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RA Red Flags
Red Flags and History
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
History of significant trauma (e.g. fracture)

Acute severe pain

Neurogenic pain or claudication pain pattern

Focal or diffuse muscle weakness

Hot and swollen joints

Night pain

Significant constitutional signs and symptoms (e.g. fever, weight loss, malaise)
Characteristics of Arthritis and Factors Suggestive of OA
Characteristics of Inflammatory versus Non-Inflammatory Arthritis:
Feature
Inflammatory arthritis
Non-inflammatory Arthritis
Joint pain
With activity and at rest
With activity
Joint swelling
Soft tissue
Bony
Joint deformity
Common
Common
Local erythema
Sometimes
Absent
Local warmth
Frequent
Absent
Morning stiffness
> 30 minutes
< 30 minutes
Systemic symptoms
Common, especially fatigue
Absent
Factors Suggestive of OA:

Gradual onset (usually after age 40)

Absence of inflammation (morning stiffness < 30 minutes, minimal heat, minimal swelling, no redness)

Findings on physical exam include: crepitus, bony enlargement, decreased range of motion, malalignment,
tenderness to palpitation

Synovial fluid analysis indicates clear yellow fluid, WBC <2000/mm, normal viscosity

Radiographic features indicate joint space narrowing, subchondral sclerosis, marginal osteophytes, subchondral cysts

Absence of systemic symptoms or signs suggesting alternate diagnoses

Joint pain with activity

Joints most likely afflicted include hip, knee, cervical and lumbar spine, thumb CMC (carpo-metacarpal), finger PIP
(proximal interphalangeal), DIP (distal interphalangeal) and first MTP (metatarsophalangeal) joint
Risk Factors to consider:







Older age
Obesity
Inactivity
Family History
Muscle Weakness
Previous trauma or deformity
Mechanical factors





Onset of pain (acute or gradual)
Trauma (yes or no)
Type of arthritis (red flags for
inflammation or no)
Heavy physical activity
Pain progression


Location (non-articular or
monoarticular)
Features (transient morning stiffness;
painful crepitus; sensation of
instability; aware of deformity;
impaired use of joint (limp, falling);
loss of range of motion
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History and Physical Exam
Red Flag Indicators







History of significant trauma (e.g. fracture)
Acute severe pain
Neurogenic pain or claudication pain pattern
Focal or diffuse muscle weakness
Hot and swollen joints
Night pain
Significant constitutional signs and symptoms
(e.g. fever, weight loss, malaise)
Pain






Localized
Aggravated by motion / weight bearing
Night pain
Present at rest
Influenced by weather
Radiating widely around affected joint(s)
History – Risk factors for disease









Older age
Obesity
Inactivity
Family History
Muscle Weakness
Previous trauma or deformity
Mechanical factors
Heavy physical activity
Pain progression
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Physical Exam










Height and weight
Gait (limp)
Muscle wasting
Inflammation (heat, redness, swelling)
Range of motion tests
Pain on movement or at end of range
Leg length discrepancy while standing
Pelvis level
Balance assessment
Joint alignment (genu varum / valgus)
Function
Walking capability without significant pain:
 Distance walked ( < 1 block, 1-5 blocks, > 5 blocks )
 Household ambulation
 Unable to walk without pain
Ascending / descending stairs
Participation:
 Employment / volunteer work
 Child or elder care
 Running errands
 Using public transit
 Attending social events
History - Factors to consider





Onset of pain (acute or gradual)
Trauma (yes or no)
Type of arthritis (red flags for inflammation or no)
Location (non-articular or monoarticular)
Features (transient morning stiffness; painful crepitus;
sensation of instability; aware of deformity; impaired use of
joint (limp, falling); loss of range of motion
Abnormal Joint Findings
Abnormal Joint Findings
Hand examination:
 Joint swelling
 Bouchard’s PIP and Heberden’s DIP
 CMC squaring of the thumb
 Range of motion vs. contralateral side
 Bony prominences in joint
 Diagnostic x-ray
Foot examination:
 Range of motion vs. contralateral side
 Bony prominences in joint
 Diagnostic x-ray
Hip examination:
 Flexion into external rotation
 Limited internal rotation (in flexion)
 Limited abduction
 Fixed flexion deformity
 Leg length discrepancy
 Trendelenburg position
Knee examination:
 Quadriceps wasting
 Valgus or varus deformity
 Flexion deformity
 Patellar pain
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Appendix A
OSTEOARTHRITIS – HISTORY
This Optional Decision Support Tool pertains to the Guideline:
Osteoarthritis in Peripheral Joints – Diagnosis and Treatment
www.BCGuidelines.ca
HISTORY – FEATURES TO CONSIDER
INDICATE LOCATION(S):
Onset
Trauma
Type
Location
Features
❑
❑
❑
❑
❑
❑
Acute
Yes
Red flags for inflammation*
Non-articular
Transient morning stiffness
Aware of deformity
❑
❑
❑
❑
❑
❑
Gradual
No
Osteoarthritis
Monoarticular
Painful crepitus
Impaired use of joint (limp, falling)
❑ Polyarticular*
❑ Sensation of instability
❑ Loss of range of motion
*Refer to Guideline: Rheumatoid Arthritis – Diagnosis and Management at www.BCGuidelines.ca
INFLAMMATORY/NON-INFLAMMATORY ARTHRITIS – DIFFERENTIATION** (Note: a patient with RA may develop OA)
FEATURE
NON-INFLAMMATORY
INFLAMMATORY
Joint pain
Joint swelling
Joint deformity
Local erythema
Local warmth
Morning stiffness
Systemic symptoms
Joint distribution
With activity
Bony
Common
Absent
Absent/Minimal
<30 minutes
Absent
PIP (Proximal Interphalangeal)/
DIP (Distal Interphalangeal), first
CMC (Carpo-Metacarpal), hip,
knee, first MTP (Metatarsophalangeal)
With activity at rest
Soft tissue
Common
Sometimes
Frequent
>30 minutes
Common
Elbow, wrist, PIP/MCP, MTP
**Modified from: Getting a grip on arthritis best practice guidelines The Arthritis Society (2004) available at http://acreu.ca/pdf/Best-Practice-Guidelines.pdf
Accessed October 25, 2007.
PAIN AND FUNCTION
Mobility can be assessed using the Timed Up & Go test.† The patient is timed to rise from an arm chair (using usual footwear and walking aids), walk three metres,
turn, walk back and sit. Normal time is between 7-10 seconds. Further assessment is suggested for those who take longer time or are unsteady.
†
American Geriatric Society. The Timed Up & Go Test for Fall Risk Assessment 2001,49(5):666
Pain Features
❑
Localized
❑
❑
Aggravated by motion/weight bearing
❑
❑
Night pain
❑
❑
None/mild pain on motion
•
•
❑
Moderate pain on motion
•
•
❑
Severe pain on motion
•
•
Walking capability without significant pain
❑
❑
❑
❑
❑
PAIN SUMMARY
Scale between 1 and 10 ➟
Present at rest
Influenced by weather
Radiating widely around affected joint(s)
Patient can move about including walking or bending. They may experience some pain but it does not prevent any activity.
They usually do not require pain medication.
Patient can move about including walking or bending. They experience pain most of the time that limits their activities to some degree. For example, patient experiences trouble walking up and down stairs or may be uncomfortable standing for long periods of time.
They occasionally need pain medication.
Patient cannot walk or bend without experiencing pain. The pain restricts their activities in a major way. For example, patient experiences pain walking up and down stairs and may not be able to stand for long periods of time.
They need pain medication most of the time.
> 5 blocks
1-5 blocks
Less than 1 block
Household ambulation
Unable to walk without pain
/10
PAIN CONTROL
❑ Satisfied
❑ Unsatisfied
Indicated by:
❑ Patient
❑ Physician
OVER ➟
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REVIEW SYSTEMS
Overall risk factors for disease:
❑ Obesity
❑ Inactivity
❑ Family history
❑ Muscle weakness
❑ Previous trauma
❑ Mechanical factors
❑ Heavy physical activity
❑ Reduced proprioception
Review of risk factors for treatment with NSAIDs:
GI
❑ History of peptic ulcer
❑ Tobacco use ❑ Alcohol abuse ❑ History of GERD symptoms
❑ Liver disease
❑ Age > 65
❑ Glucocorticoids
❑ Anticoagulant
Renal
❑ Calculated eGFR < 60
❑ Anti-hypertensive medication
❑ Diuretic
Cardiovascular
❑ Hypertension
❑ Ischemic heart disease
❑ Heart failure
❑ Comorbidities (Describe):
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Patient with MSK
complaints
Patient Self Monitoring & Management
Any RED FLAGS?
Possible Fracture:
Significant trauma
Minor trauma if older or
osteoporotic
Acute severe pain
Possible Infection:
Swelling, warmth, pain
Constitutional symptoms
(fever, burning, weight
loss, malaise)
Other:*
focal or diffuse muscle weakness
Neurogenic pain
Claudication pain pattern
Rash
NO
YES
Immediate diagnosis and treatment
Does condition involve joints?
YES
Refer to non-articular algorithm
NO
Is there inflammation?
Suspect:
YES
Osteoarthritis
Osteonecrosis
NO
Are there more than 3 joints involved?
NO
YES
Complaints less than 6 weeks duration?
NO
Chronic Polyarthritis
Suspect:
·
·
·
Rheumatoid Arthritis
Connective tissue disorder
Other inflammatory
arthritis
Recommend early
consultation with arthritis
specialist for diagnosis and
initiation of DMARDS
Complaints less than 6 weeks duration?
YES
YES
Suspect:
· Early inflammatory
arthritis
· Viral / post viral arthritis
· Reactive arthritis
· Gout
· Pseudo-gout
Careful follow-up and consider
Referral to arthritis specialist
NO
Chronic Mono / Pauci-arthritis
Suspect:
· Psoriatic arthritis
· Reiter’s syndrome
· Reactive arthritis
· Gout / Pseudo-gout
Consider synovial fluid analysis
or
Referral to arthritis specialist
Adapted from: Ontario Treatment Guidelines for Osteoarthritis and Rheumatoid Arthritis and Acute Musculoskeletal Injury. Toronto, Publications Ontario, 2000, p 8.
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Non-Articular Conditions
Are Symptoms Localized to a Specific Structure?
Suspect:
· Bursitis
· Entrapment syndrome
· Soft Tissue Injury
· Tendonitis
NO
YES
Is there Inflammation?
Suspect:
· Polymyalgia
Rheumatica
· Connective Tissue
Disorder
Consider Referral to
Rheumatologist
YES
NO
Is there Generalized Tenderness to Touch?
Suspect:
· Fibromyalgia
· Hypothyroidism
· Somatization
NO
YES
Reassess as Necessary
Source: Ontario Treatment Guidelines for Osteoarthritis and Rheumatoid Arthritis and Acute Musculoskeletal Injury. Toronto, Publications Ontario, 2000, p 8.
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Differential Diagnoses
Early diagnosis of OA is important for modifiable factors such as weight loss, exercise programs
and patient self-management.
Characteristics of Inflammatory versus Non-Inflammatory Arthritis:
Feature
Inflammatory arthritis
Non-inflammatory Arthritis
Joint pain
With activity and at rest
With activity
Joint swelling
Soft tissue
Bony
Joint deformity
Common
Common
Local erythema
Sometimes
Absent
Local warmth
Frequent
Absent
Morning stiffness
> 30 minutes
< 30 minutes
Systemic symptoms
Common, especially fatigue
Absent
Factors Suggestive of OA:

Gradual onset (usually after age 40)

Absence of inflammation (morning stiffness < 30 minutes, minimal heat, minimal swelling, no
redness)

Findings on physical exam include: crepitus, bony enlargement, decreased range of motion,
malalignment, tenderness to palpitation

Synovial fluid analysis indicates clear yellow fluid, WBC <2000/mm, normal viscosity

Radiographic features indicate joint space narrowing, subchondral sclerosis, marginal
osteophytes, subchondral cysts

Absence of systemic symptoms or signs suggesting alternate diagnoses

Joint pain with activity

Joints most likely afflicted include hip, knee, cervical and lumbar spine, thumb CMC (carpometacarpal), finger PIP (proximal interphalangeal), DIP (distal interphalangeal) and first MTP
(metatarsophalangeal) joint
Diagnoses that may mimic OA:

Inflammatory arthropathies

Crystal arthropathies (gout or pseudo gout)

Bursitis (e.g. Trochanteric, Pes Anserine)

Soft tissue pain syndromes

Referred pain

Medical conditions presenting with arthropathy (e.g. neurologic, metabolic, etc.)
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Investigations
Factors to consider prior to treatment and management include the following:
 Rule out alternate diagnosis. If the diagnosis is unclear, a Rheumatology assessment
can assist with ruling out non-OA conditions or arthritic mimics.
 Severity of condition (pain and function)
 Impact on independence in society
 Patient goals, expectations, preferences, past treatments
 Self-management needs and modifiable factors (e.g. weight management strategies,
exercise, education about pain management)
 Psychosocial issues such as pain amplification, depression, cognition, adherence to
treatment, social support.
Order tests when history and physical findings indicate and consider inflammatory versus noninflammatory presentations (non-OA or OA respectively).
For the most part lab tests are ordered for monitoring liver and renal function and other possible
side effects of medications (haemoglobin, blood pressure, AST or ALT, and creatinine tests.)
X-rays may indicate OA, but may not relate to symptoms. X-rays are generally not useful
except for alternate diagnosis or orthopedic referral.
Key questions to consider:
 What do you want this test to answer?
 How will it change your management of this patient?
The table below highlights investigations to consider for osteoarthritis:
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Treatment and Management Options
Since there are no known cures for OA, the treatment and management goals are to reduce
pain, maintain or improve joint mobility, limit functional disability and improve self-management.
The four pillars of treatment / management are:
 Medications,
 Referrals (surgical and non-surgical),
 Rehabilitation,
 Patient education and self-management.
Factors to Consider in Treatment







Cognitive status (ability to learn and to adhere to treatment)
Substance abuse and/or prior dependency
Drug interactions (alcohol, over the counter medications, supplements and herbals)
Language issues (ability to understand treatment recommendations)
Attitude towards patient self management e.g. adaptive exercise, healthy eating and
rehabilitation
Social / financial support
Impact of condition on the following:
o Sleep (night pain)
o Pain features and level of pain
o Activities of Daily Living
o Recreation activities
o Work (household, paid employment, volunteer activities)
o Mobility (walking distance, falls etc.)
o Social isolation / depression
o Risk of falls
The following are medication options endorsed by BC’s GPAC Guidelines.
Medications for Mild OA


Occasional prn use of acetaminophen up to 1 gram 4 times per day and add prn NSAIDs
if necessary
If the person is on self-directed care and is doing well, then do routine follow-up unless
there is a significant change in pain or function
Note: Gastrointestinal Issues with NSAIDs
 There is no evidence that NSAIDs alter the natural course of arthritis. The patient
should be made aware that NSAIDs represent symptomatic therapy, and that the
therapy is associated with some risk of gastrointestinal issues such as ulcers or GI
bleeds. Patients should be informed to stop taking the medications and be reassessed if
they have the following symptoms: stomach pain, heartburn, blood in vomit or stools.
 If the patient is experiencing GI problems, refer to guideline: Dyspepsia – Clinical
Approach to Adult Patients available at www.BCGuidelines.ca
Physician Resources
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Medications for Moderate OA






For symptomatic OA, prescribe full dose acetaminophen (1 g 4 x day)
Within 30 days, do a baseline haemoglobin, blood pressure, AST or ALT, and creatinine
if further therapy is contemplated
If regular dosing of acetaminophen at 4 g/day or with NSAIDs, follow-up every 3-12
months depending on co-morbidities and severity
Consider lowering dose where there is liver disease, alcohol abuse, and for the elderly
If the patient is using diclofenac, consider rare development of hepatitis
Consider risks and benefits of gastroprotection
Medications for Severe OA


Same as for moderate OA but review more frequently (every 1-6 months) with a view to
surgical referral
If there is an increase in severity, i.e. treatment is no longer efficacious or new
symptoms, then revisit more often
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Guidelines &
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Osteoarthritis (OA) Medications Table
Protocols
Advisory
Committee
BRITISH
COLUMBIA
MEDICAL
ASSOCIATION
Effective Date: September 15, 2008
Ministry of
Health Services
This Medication Table pertains to the Guideline Osteoarthritis in
Peripheral Joints – Diagnosis and Management
www.BCGuidelines.ca
Regularly review current listings of Health Canada advisories, warnings and recalls at: http://www.hc-sc.gc.ca/ahc-asc/media/advisories-avis/index_e.html
APPROX.
DosePharmaCare
Coverage
cost/month
MAR 06
Drug
Serious Side Effects
NON-NARCOTIC ANALGESICS Acetaminophen is as effective as oral NSAIDs for pain relief according to evidence1.
acetaminophen
generics available
650-1000 mg q4-6h OR SR caps
1300 mg q8h; max 4000 mg/day
mefenamic acid
generics available
250 mg PO q 6h prn
(generally 7 day max)
$5-$13
full coverage for OA only via special
authority
$0.34/tab full coverage for lowest cost brand
rare elevations of INR when
using warfarin
anticoagulants, liver toxicity
Similar to NSAID risks
below
NSAIDs Acetaminophen is the first choice. Trials have not demonstrated any consistent superiority of one NSAID over another2
acetylsalicylic acid
(enteric-coated)
generics available
2600-5400 mg PO daily,
divided q4-6h
$3-$6
full coverage
ibuprofen
generics available
200-500 mg bid-tid up to 1500
mg 24hr
$3-$10
full coverage
naproxen
generics available
250-500 mg bid-tid
max 1500 mg/day
$10-$14
diclofenac
generics available
Not recommended due to
side effects
diflunisal
generics available
250-500 mg PO q12h
$27-$32
flurbiprofen
generics available
50-100 mg PO bid-tid;
max 300 mg/day
$16-$32
indomethacin
generics available
25-50 mg bid-tid;
max 200 mg/day
$5-$15
ketoprofen
generics available
75 mg PO tid or 50 mg PO qid;
max 300 mg/day
meloxicam
generics available
7.5-15 mg PO od
$17-$20
nabumetone
generics available
500 mg
$30-$60
piroxicam
generics available
20 mg PO qd
sulindac generics available
150-200 mg PO bid;
max 400 mg/day
Either 300 mg bid or SR 600 mg
tiaprofenic acid
generics only for 300 mg
od
tolmetin
200-600 mg PO tid; max 1800
generic available
mg/day
$21
$22
$24-$30
$25-$40
$40-$80
The side-effects listed
below apply to NSAID class of drugs:
• GI ulceration, perforation
with or without bleeding
full coverage
• severe diarrhea
• hepatotoxicity
• renal impairment
Not recommended due to
• cardiovascular events
side effects
• CHF; angina;
partial coverage or full coverage with
hypertension; arrhythmia;
special authority
bronchospasm;
pulmonary edema
partial coverage or full coverage with
• blood dyscrasias
special authority
• thrombocytopenia
partial coverage or full coverage with
• erythema multiforme
special authority
• symptoms of aseptic
partial coverage or full coverage with
meningitis
special authority
• blurred or diminished
vision
no coverage (full coverage with special
• fluid retention
authority)
no coverage (full coverage with special
authority)
no coverage (full coverage with special
authority)
no coverage (full coverage with special
authority)
no coverage (full coverage with special
authority)
no coverage (full coverage with special
authority)
etodolac
generics available
300 mg PO bid
$51
no coverage
ketorolac
generics available
10 mg PO q4-6h; max 40 mg/day;
short-term use only
$59
no coverage
GI bleed, erythema
multiforme, bronchospasm,
hepatotoxicity
peptic ulcer, with/without
bleeding; fatalities in the
elderly
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APPROX.
DosePharmaCare
Coverage
cost/month
MAR 06
Drug
Serious Side Effects
COX 2 inhibitors
celecoxib
(no generics)
200mg PO od or 100 mg bid
$42
no coverage; full coverage with
special authority
as above in NSAIDs
40 drops, applied qid
$50
no coverage
colitis, arrhythmia, 1%
may develop hepatitis
$7.40/50g
tube
no coverage
allergic skin reaction
$20-$40
no coverage
skin irritation; sun
sensitivity
NSAIDs (Topicals)
diclofenac sodium
Other Topicals
menthol
apply tid-qid
capsaicin
apply tid-qid to unopened skin
INTRA-ARTICULAR MEDS (injection): steroids
triamcinolone
2.5-40 mg intra-articularly
$2.60-$5.50 full coverage
/injection
anaphylaxis, masking of
infections
NARCOTICS (oral)
full coverage *Requires a controlled
prescription form when prescribed
as a single entity or when included in
preparations with > 60mg codeine
common: CNS depression;
constipation; sweating;
nausea and vomiting
$0.06$0.13/tab
full coverage
major: respiratory
depression; circulatory
depression; cardiac
arrest; hypersensitivity
individualized
ASA with codeine
15 mg or 30 mg
oxycodone with acetindividualized
aminophen 5mg/325mg
2.5mg/325mg
$0.07$0.18/tab
full coverage
$0.13
$0.61/tab
full coverage
hydromorphone*
PO: 2-4 mg q4-6h
$30-$90
full coverage for immediate
release–controlled release
(long-acting) is special authority
morphine*
PO initial dose: 10 mg q4h OR 30 $33-$52
mg SR q12h; titrate dose
appropriately
PO initial dose: 5-10 mg q6h OR $51-$506
10-20 mg SR q12h; titrate dose
appropriately
codeine*
generics available
15-60 mg PO
$13-$18
acetaminophen with
codeine 15 mg and 30
mg (Emtec® acetaminophen 300 + codeine
30 mg, no caffeine)
1-2 tabs PO q4h PRN; max 12
tabs/day
oxycodone*
tramadol with
acetaminophen
(Tramacet®) 37.5mg/
325mg OR single
entity controlled release
(Zytram XL®) 150 mg,
200 mg, 300 mg,
400 mg
full coverage
full coverage for immediate
release–controlled release
(long-acting) is special authority
Tramacet®: 1-2 tabs q4-6h PRN; Tramacet®: no coverage
$77-$153
max 8 tabs/day; max 5 days of
treatment
Zytram
XL®:
Zytram XL®, PO initial dose:
$48-$120
150 mg q24h; titrate dose
appropriately
other: arrythmias;
syncope; headache;
dysphoria; agitation;
seizure; urinary retention;
blood dyscrasias;
potential for dependency;
serious outcomes
when combined with
CNS depressants (e.g.,
alcohol),
acetaminophen: liver
toxicity
seizures (esp. with
antidepressants);
convulsions; allergic
reactions; respiratory
depression; addiction;
cancer; pregnancy issues;
dizziness; nausea
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APPROX.
DosePharmaCare
Coverage
cost/month
MAR 06
Drug
Serious Side Effects
Viscosupplementation (Devices as per Health Canada)
hyaluronic acid
Durolane®,
Hyalgan®,
Orthovisc®,
Ostenil®,
Neovisc®,
Synvisc®
1-3 injections
$200-$400
per vial
no coverage
allergic reaction
Herbals and supplements: not recommended
Products with a DIN (Drug Identification Number) have been supported by good-quality studies for safety and effectiveness. Products with a
NPN (Natural Health Product Number), USP number (US Pharmacopeia), Consumers Lab logo, or NSF™ international certification may ensure
quality but do not ensure effectiveness.
chondroitin
sulphate
200-400 mg bid–tid
$10
no coverage
glucosamine
sulphate
500 mg tid
$50
no coverage
methylsulfonylmethane
(MSM)
1-3 grams bid
$10-$48
no coverage
s-adenosylmethionine
(SAMe)
400 mg tid-qid 200 mg tid
$120
no coverage
unknown and may have
serious interactions with
other drugs
*Requires the use of a Controlled Prescription Program Form (formerly triplicate prescription program) Special Authority criteria and forms are
available on the PharmaCare Web site at http://www.health.gov.bc.ca/pharme/sa/criteria/formsindex.html
Note: Cardiovascular risk and NSAIDS
“Health Canada acknowledges the panel’s view that, as a group, selective COX-2 inhibitors are associated with an increased risk of cardiovascular
events, a risk that is similar to those associated with most NSAIDs [The cardiovascular safety concerns associated with the traditional NSAIDs are
not extended to aspirin3]. The panel noted that this risk is present for all patients taking anti-inflammatory agents and that it increases with longerterm use and when other risk factors, such as cardiovascular disease, are present.”4
References
1. Tanna, S. Osteoarthritis opportunities to address pharmaceutical gaps. 2004. Available at URL: http://mednet3.who.int/prioritymeds/report/
background/osteoarthritis.doc. Accessed October 30, 2007.
2. The University of British Columbia Therapeutics Initiative. Should we be using NSAIDS for the treatment of Osteoarthritis and “Rheumatism”. Therapeutics Letter 1995;4:1-4. Available at URL: http://www.ti.ubc.ca/PDF/4.PDF. Accessed October 30, 2007.
3. Health Canada Health Products and Food Branch Marketed Health Products Directorate and Therapeutic Products Directorate. Report on the
cardiovascular risks associated with COX-2-selective non-steroidal anti-inflammatory drugs. 2006 June. Available at URL: http://www.hcsc.gc.ca/dhp-mps/prodpharma/activit/sci-consult/cox2/cox2_cardio_report_rapport_e.html. Accessed October 25, 2007.
4. Health Canada Health Products and Food Branch Marketed Health Products Directorate and Therapeutic Products Directorate. Panel on the
safety of COX-2 NSAIDs. 2005 June 9-10; Ottawa. Available at URL: http://www.hc-sc.gc.ca/dhp-mps/prodpharma/activit/sci-consult/cox2/
index_e.html. Accessed October 29, 2007.
Resource Documents
Canadian Pharmacists Association. Compendium of Pharmaceuticals and Specialties. Ottawa: Canadian Pharmacists Association; 2008 Canadian
Pharmacists Association, Therapeutic Choices. 2008. Drug Prices: obtained from PharmaNet, for prescription medications, and at various Victoria,
BC retail outlets for non-prescription medications.
Notes:
A.
B.
C.
D.
If a medication has a generic equivalent, the drug cost is for the generic product.
For prescription medications, the price does not include professional fees.
For non-prescription medications, the price does not include applicable sales taxes.
Where a price range is indicated, this reflects the cost based on minimum and maximum dose ranges.
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Indications for Surgical and Non-surgical Referral
Indication for Surgical Referral
Indication
Criteria
Failure of a non-operative Program
Inadequate pain control
Increasing need for narcotic medications
Significant pain on motion, resting pain,
presence of night pain
Increasing Functional Restrictions
Inability to walk without significant pain
Significantly modified daily activities (e.g.
putting on shoes, climbing stairs, squatting
and bending)
Increasing threat to patient’s ability to work or
live independently
Significant Abnormal findings on
Examination





Progressing deformity
Loss of extension
Loss of flexion
Decreasing range of motion.
Notable leg length discrepancy
Progression of Disease on X-ray


Evidence of progressive bone loss
Advanced loss of joint space in
association with moderate to severe pain
Evidence of increasing acetabular
protrusion or femoral head collapse in the
hip

Intensity and duration of Pain
Referral Forms

Considering use of or tolerance level
reached to manage patients with opiates
and intra-articular injections.
Non-Surgical Referral
RACE Line
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Indications for Rehabilitation and Non-Surgical Referral
Health Service Provider
Criteria
Rheumatology
Red flag conditions, alternative diagnosis, unexpected, unusual disease
progression or complications
Emergency:
 Suspected septic arthritis
 Aggressive connective tissue disease or systemic vasculitis
 Temporal arteritis
Urgent:
 Early inflammatory arthritis
 Acute monoarthritis (non-septic)
 Polyarthritis with functional impairment
 Connective tissue disease which is active but not life threatening
 Polymyalgia rheumatica
Semi-urgent:
 Joint effusions
 Gout
Routine:
 Painful degenerative arthritis
Sports Medicine Specialist



Sports related injury
MVA
WCB claim
Pain Specialist

Patient has ongoing pain and pain related disability despite adequate trials
of medication and referral and participation in Self Management Program
Neuropathic pain syndromes, such as: complex regional pain syndrome,
sciatica, and new onset herpetic neuralgia, need to be seen on an
expedited basis

Physiotherapist
Patients who require:
 Exercise prescription to improve pain, function and participation in daily
activities / leisure activities
 Recommendation on physical activities and healthy lifestyle, including
weight management
 Gait and balance training
 Education and support
Occupational Therapist
Patients who require:
 Assistance with managing pain, fatigue and daily activities
 Prescription of splints, mobility devices or equipment to improve function
 Work site / home adaption
Dietitian
Education on healthy eating and managing weight fluctuations
Home Care
Support required for managing activities of daily living in the home
Referral Form
Specialist
Acknowledgement
Specialist
Consult Report
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Print
MSK Referral Form – GP to Specialist
Reason for referral: ________________ ____________________________________ Consult 2nd Opinion Diagnosis Level of Urgency: Emergency Referred by: _________________________________ GP Walk‐in Clinic Emergency Dept. Urgent Elective
Preferred Specialist: ______________________ First Available: ____________________________ Funding Source / Payer Coverage : WCB ICBC PRIVATE OTHER Patient Name: PHN: Date of birth: Referring Physician: Phone: Fax: Most Responsible Physician: Phone Fax: Abnormal Findings on Physical Exam: Pain Levels / Symptoms & Duration of Symptoms: Functional Limitations: Relevant Family History: Relevant Lab and X‐ray Results: (Please attach) Co‐morbidities: Recent relevant consultations: FOLLOW‐UP RESPONSIBILITY: Advice Only from Specialist Ongoing Specialist Care Shared Care Current Medications / Drug name: Start Dose Frequency Taking as Prescribed Comments GP SIGNATURE: ____________________________________________ DATE: ________________ RACE Line
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Acknowledgment of Referral – Specialist to GP
Thank you for your referral to ____________________. Patient Name: PHN: Date of birth: Place Patient Information sticker here TO BE COMPLETED BY SPECIALIST: Acknowledgement of Referral within 48 hours Our office will make the appointment with your patient within the next ___________ week(s) Your patient is booked to see a specialist on ____________________________ Please notify your patient of the above appointment We will notify your patient of the above appointment Attached is additional information for you to give to your patient We require additional information before we can book the patient prior to the patient’s appointment Next
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MSK Specialist Consult Report – Response to Referring GP
Patient Name: PHN: Date of birth: Date Seen by Specialist: FOLLOW UP ACTION RESPONSIBILITIES TREATMENT DIAGNOSIS BACKGROUND Symptoms and functional limitations: Rationale for diagnosis / level of severity: Alternatives for treatment (costs / benefits/ drawbacks): Responsibility for treatment and follow‐up care: Advice Only from Specialist Ongoing Specialist Care Most Responsible Physician: Specialist: Investigations / tests required: Follow‐up visit with Specialist: Shared Care Copy to: Referring Physician: Fax : Date: Most Responsible Physician: Fax: Date: SPECIALIST SIGNATURE: _______________________________________ DATE: ________________________ Return to page 1
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Print
Follow-up Assessment Checklist – History
1. Joint pain:

Improvement: Overall, compared to last visit, the joint pain is:



Better
OR: Level of
pain has been:


1
2
3
4

None
5
6
7

Mild
8
9
10

Moderate
Severe
Frequency: The joint pain is present:
Continuously

Worse
Severity: On a scale of 0 to 10, where 0 = no pain at all, and 10 = very severe pain, how
much pain have you had in the last month, on average, from your arthritis?
0


The same

Intermittently – If so:
Does the pain interfere with sleep?



Daily

Yes

Weekly
Other _______
No
Comments about joint pain: ________________________________________________
2. Duration of morning stiffness: _______________________________________________
3. Fatigue severity: On a scale of 0 to 10, where 0 = no fatigue at all, and 10 = very severe
fatigue, how much fatigue have you had, on average, in the last month?
0
1
2
3
4
5
6
7
8
9
10
OR: Level of
 None
 Mild
 Moderate
fatigue has been
4. Global disease activity rating by patient: (mark on line below)

Severe
Considering all of the ways your arthritis has affected you, how do you feel your arthritis is
today?
0
1
2
3
4
5
6
7
Very Well
8
9
10
Very Poor
5. Functional limitations: Do you have difficulties with (answer Yes or No):

Self-care activities (e.g. washing, dressing, eating) __________

Mobility: Walking __________ Standing__________ Stairs __________
6. Difficulties with work, leisure or other usual activities:

Yes

No
_________________________________________________________________________
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Appendix E
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Print
OSTEOARTHRITIS –
PATIENT ASSESSMENT FOLLOW-UP
This Optional Decision Support Tool pertains to the Guideline:
Osteoarthritis in Peripheral Joints – Diagnosis and Treatment
www.BCGuidelines.ca
Pain
Satisfactory pain control
Night pain affecting sleep
Overall pain rating (0= none; 10= most)
❑ yes
❑ yes
Satisfaction with Function
Walking
Interference with activities of daily living (ADLs or IADLs)
Work
Recreation
❑
❑
❑
❑
Patient Education
Self-management completed
Weight loss/diet plan needed
Joint protection
❑ yes
❑ yes
❑ yes
Rehabilitation and Exercise
Home exercise program
❑
Community exercise program
❑
Physical therapy for ROM and strengthening
❑
Medical devices
❑
Orthotics
Cane/walker
Raised seats/devices
yes
yes
yes
yes
❑ no
❑ no
❑
❑
❑
❑
no
no
no
no
❑ no
❑ no
❑ no
Tolerated
yes ❑
yes ❑
yes ❑
yes ❑
no
no
no
no
Tried
❑ yes ❑ no
❑ yes ❑ no
❑ yes ❑ no
Medications for OA (names, doses and side effects)
Acetaminophen
❑
NSAIDs
❑
Gastro protection
❑
Cox-2 inhibitor
❑
Opiates
❑
Injectibles
❑
❑
❑
❑
❑
❑
Suitable
❑ yes ❑ no
❑ yes ❑ no
❑ yes ❑ no
Tolerated
yes ❑ no ❑
yes ❑ no ❑ yes ❑ no ❑
yes ❑ no ❑
yes ❑ no ❑
yes ❑ no ❑
yes ❑ no ❑
Referrals
Surgical
❑ yes
Other (indicate):
❑ no
Effective Change plan
yes ❑ no
❑ yes
❑ no
yes ❑ no
❑ yes
❑ no
yes ❑ no
❑ yes
❑ no
yes ❑ no
❑ yes
❑ no
❑ N/A
Goal Setting
Effective Change plan
yes ❑ no
❑ yes
❑ no
yes ❑ no
❑ yes
❑ no
yes ❑ no
❑ yes
❑ no
yes ❑ no
❑ yes
❑ no
yes ❑ no
❑ yes
❑ no
yes ❑ no
❑ yes
❑ no
yes ❑ no
❑ yes
❑ no
Urgent?
❑ yes
❑ no
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Patient
Questionnaire
History
Patient SelfManagement
Differential
Diagnoses
Physical Exam
GPAC
Guidelines
Management
Options
Investigations
Physician
Resources
Referral
Monitoring &
Follow-up
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History
RA is primarily a clinical diagnosis, based on signs and symptoms suggesting inflammation and
joint distribution. In assessing disease activity consider:
o Amount / severity of pain:
o Frequency of pain:
o Pain interferes with sleep: yes / no
o List or diagram of joints affected with pain on history
o Duration or early morning stiffness
o Fatigue
o Functional limitations
o Difficulties with usual activities, work, leisure
o Joint count: number of tender and swollen joints
Key Features of Inflammation suggesting RA






Early morning stiffness (EMS) ≥ 30 minutes and stiffness post immobility
Pain worse in AM and post immobility, better with mild activity
Joint swelling (in ≥ 1 joint) for ≥ 6 weeks
Swelling or tenderness in small joints of the hands, especially metacarpophalangeal
(MCP), proximal interphalangeal (PIP), or wrists, and in feet especially
metatarsophalangeal (MTP)
Symmetrical involvement
Fatigue symptoms
Typical Joint Distribution in RA:
Black= Joints most commonly
affected
Gray= Joints often affected
White= Joints usually not
affected
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Red Flags
Red flags help identify potentially serious conditions and require
immediate or emergency / expedited referral to a specialist or
emergency department.
Areas for Observation:
 Acute monoarthritis requires urgent joint aspiration to rule-
out septic or crystal arthritis
 Giant cell arteritis – if suspicion of giant cell arteritis based
on typical headache, visual disturbance, jaw claudication,
and/or constitutional symptoms
 Acute Systemic Vasculitis – significant concern for acute
development of a systematic vasculitis with major organ
involvement e.g. acute pulmonary, cardiac, renal,
gastrointestinal or neurological features; cutaneous vasculitis
or digital infarcts
 Acute connective tissue disease – significant concern for
acute development of major organ involvement from
connective tissue disease, e.g. acute pulmonary, cardiac,
renal, hematological, neurological features; cutaneous
vasculitis or digital infarcts
 Significant unexplained constitutional symptoms of either
fever >38 degrees or weight loss 5% in preceding 6 weeks,
where there is a strong suspicion that it may relate to a
connective tissue disease or vasculitis
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Rheumatoid Arthritis Classification Criteria
Below are 2 sets of classification criteria from the American College of Rheumatology (2010 and
1987). The 2010 criteria were developed to better classify patients with early disease. These
are not diagnostic criteria, but classification criteria designed for research. Not all RA patients
will meet the classification criteria.
1987 ACR Criteria for the Classification of Rheumatoid Arthritis
Criterion
Definition
1. Morning stiffness
Morning stiffness in and around the joints, lasting at
least 1 hour before maximal improvement
2. Arthritis of 3 or more joint areas
At least 3 joint areas simultaneously have had soft
tissue swelling or fluid (not bony overgrowth alone)
observed by a physician. The 14 possible areas are
right or left PIP, MCP, wrist, elbow, knee, ankle, and
MTP joints
3. Arthritis of hand joints
At least 1 area swollen (as defined above) in a wrist,
MCP, or PIP joint
4. Symmetric arthritis
Simultaneous involvement of the same joint areas
(as defined in 2) on both sides of the body (bilateral
involvement of PIPs, MCPs, or MTPs is acceptable
without absolute symmetry)
5. Rheumatoid nodules
Subcutaneous nodules, over bony prominence, or
extensor surfaces, or in juxta articular regions,
observed by a physician
6. Serum rheumatoid factor
Demonstration of abnormal amounts of serum
rheumatoid factor by any method for which the
result has been positive in < 5% of normal control
subjects
7. Radiographic changes
Radiographic changes typical of rheumatoid arthritis
on posteroanterior hand and wrist radiographs,
which must include erosions or unequivocal bony
decalcification localized in or most marked adjacent
to the involved joints (osteoarthritis changes alone
do not qualify)
* For classification purposes, a patient shall be said to have rheumatoid arthritis if he / she has
satisfied at least 4 of these 7 criteria. Criteria 1 through 4 must have been present for at least 6
weeks. Patients with 2 clinical diagnoses are not excluded. Designation as classic, definite, or
probable rheumatoid arthritis is not to be made.
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The 2010 ACR-EULAR Classification Criteria for Rheumatoid Arthritis
Target population (Who should be tested?): Patients who
1. Have at least 1 joint with definite clinical synovitis (swelling)
2. With synovitis not better explained by another disease
Add score of each category, a score of > 6/10 classifies a patient as having definite RA
Joint Involvement Score





1 large joint
2-10 large joints
1-3 small joints (with or without large)
4-10 small joints (with or without large)
> 10 joints (at least 1 small joint)
0
1
2
3
5
Serology



Negative RF and anti-CCP
Low-positive RF or anti-CCP
High-positive RF or anti-CCP
0
2
3
Acute Phase Reactants


Normal CRP and ESR
Abnormal CRP or ESR
0
1
Duration of Symptoms











< 6 weeks
> 6 weeks
0
1
The criteria are aimed at classifying newly presenting patients. Patients with erosive disease
typical of RA with a history compatible with prior fulfillment of the 2010 criteria should be
classified as having RA. Patients with longstanding disease, who based on retrospectively
available data, have previously fulfilled the 2010 criteria should be classified as having RA.
Although a score of < 6/10 is not classifiable as having RA, status can be reassessed over time.
Joint involvement refers to any swollen or tender joint on examination, excluding distal
interphalangeal joints, first carpometacarpal joints, and first metatarsophalangeal joints.
Patients are placed in the highest category possible based on the pattern of involvement
Large joints= shoulders, elbows, hips, knees, and ankles.
nd th
Small joints= MCP joints, PIP joints, 2 -5 MTP joints, thumb interphalangeal joints, and wrists.
Negative refers to values less than or equal to the upper limit of normal (ULN); low-positive refers
to values that are higher than ULN but < 3 times the ULN; high positive values are > 3 times the
ULN.
Normal / abnormal for erythrocyte sedimentation rate (ESR) and C-reactive protein(CRP) is
determined by local laboratory standards.
Duration of symptoms refers to patient self-report of the duration.
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Physical Exam and Assessment
This physical exam and assessment may be used for either the initial or follow-up visits.
BP _______
ESR _______ CRP _______
Relevant findings from investigations or history:
___________________________________________________________________________
Mark the tender and swollen joints on the homunculus and write the total number of tender and
swollen joints below
N
N
N
N
N
N N
T
Swollen
=
S
Tender & Swollen = B
N
N
N
N
N
=
N
N
N
Tender
N
N
N N
N N
N N
N
N
N
N
N
N
N
The physical exam and assessment is continued on the next several pages.
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Physician assessment of global disease activity (0-10 scale): _______
What is your assessment of the patient’s current disease activity?
0
1
2
3
4
5
6
7
8
9
10
None
Extremely
Active
Patient assessment of global disease activity (0-10 scale): _________
Considering all of the ways your arthritis has affected you, how do you feel your arthritis is
today?
0
1
2
3
4
5
6
7
8
9
Very
Well
10
Very
Poor
Assessment of Disease Activity
Composite disease activity score: (choose one):
Simplified Disease Activity Index (SDAI)




Calculation: Number of swollen joints + number
of tender joints + patient global + physician
global + CRP
0.00
Total score (sum of items) = _______
Preferable if CRP is available


1. Number of swollen joints: _______
(do not count the feet)
2. Number of tender joints _______
(do not count the feet)
3. Patient global assessment of
disease activity (0-10 scale): _______
Clinical Disease Activity Index (CDAI)

Items from history and physical
exam
Calculation: Number of swollen joints + number
of tender joints + patient global + physician
global
0
Total score (sum of items) = _______
Use if CRP is not available
4. Physician global assessment of
disease activity (0-10 scale): _______
5. CRP: _______
Specific cut-offs values have been identified that represent remission or low, moderate and high
disease activity states. They are as follows:
SDAI
CDAI
Remission
< 3.3
< 2.8
Low Disease Activity
3.4 - 11
2.9 - 10
Moderate Disease Activity
12 - 26
11 - 22
High Disease Activity
> 26
> 22
Click on Disease Activity to go to clinical treatment targets
RESET
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Clinical Treatment Targets:

Eradication of inflammation in order to prevent joint damage, physical disability and premature mortality. Aiming only at
controlling symptoms is not sufficient. Persistent swelling, even without pain, leads to joint erosions and deformities. Frequent
follow-up is needed (every 1 to 3 months) to assess disease activity and adjust DMARD therapy until the target is reached.

Clinical Remission, i.e., the absence of signs and symptoms of active inflammation:
o No swollen joints
o EMS < 15 minutes
o No or minimal systemic symptoms such as fatigue
o No or minimal pain from inflammation
o Normal ESR or CRP
o Little to no radiographic progression
If remission is achieved:
o This is the main target, no change in DMARD is needed.
o If remission has been sustained for > 6 months, very gradual reduction in DMARD dose might be attempted. For
example reductions by 2.5 mg of methotrexate every 3-6 months. Dose should be increased back to previous level as
soon as symptoms worsen or remission state is lost.
o IF DMARDs are tapered and remission is lost, there is a risk that it might not be achieved again. Therefore decision
to taper must be made carefully with patient.

Low Disease Activity (LDA) is an acceptable alternative target, particularly if remission is not possible in long standing
disease or when co-morbidities or other patient factors limit DMARD options. Use of composite measures (e.g. CDAI and
SDAI) is recommended to assess low disease activity, but the following can be useful as a guide:
o < 3 swollen joints
o If swelling is present only mild swelling
o No swelling of large joints
o Little to no radiographic progression
Yearly X-Rays are recommended to assess radiographic progression and step-up treatment if joint space narrowing or
erosions progress.
If Low Disease Activity state is achieved:
o If DMARDs have not been optimized, modify DMARD therapy in an attempt to achieve remission (i.e., increase
DMARD dose to maximum recommended or tolerated dose, or consider adding DMARD in combination )
o This is an alternative target which may be acceptable, especially in long standing disease, if medications have been
maximized and remission does not seem possible.

If Moderate or High Disease Activity state:
o Treatment target has not been reached and DMARD therapy MUST be modified
o This may include increasing dose of current DMARD to maximum recommended or maximum tolerated dose;
changing to parenteral administration of MTX; adding a DMARD in combination therapy; or switching to a new
DMARD, or a biologic if DMARD failure.
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Differential Diagnosis
The following diagram illustrates various criteria and features for differentiating between
rheumatoid arthritis and other arthritic conditions.
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The following are conditions to rule out before starting DMARDs.
Condition
Features

Osteoarthritis





Crystal arthropathy: gout or pseudogout


Septic arthritis


Viral arthritis



Hepatitis B & C associated arthritis
Metabolic disorders



Typically affects the distal interphalangeal
(DIP) joints of the hands and the
carpometacarpal joint at the base of the
thumb.
Swelling of the joints is hard and bony
Stiffness and pain are worse after activity
Stiffness in the morning or after immobility
does not last long (gelling)
Monoarticular, especially the first MTP
joint, or oligoarticular.
Joint aspiration is needed to look for urate
crystals or calcium pyrophosphate crystals
(CPPD).
Radiologists can perform joint aspirations if
GP is not confident of technique
Usually monoarticular but rarely can be
polyarticular
Joint aspiration must be performed for
synovial fluid culture and cell count.
Transient polyarthritis usually lasting < 6
weeks
Common causes: Rubella and parvovirus
Less commonly: mumps, alphaviruses,
enterovirus and herpes virus
Autoimmune arthritis associated with
Hepatitis B & C infection
Abnormal liver function tests (AST & ALT)
Perform Hepatitis B & C serology if
appropriate ie: abnormal liver function test
or high risk
Rule out hyper or hypothyroidism (TSH),
hyperparathyroidism
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Other Inflammatory Arthritis Conditions
Other Inflammatory Arthritis
Features
Connective Tissue Diseases




Psoriatic Arthritis – requires same urgency
of treatment as RA






Spondylarthropathies








Such as Systemic Lupus Erythmatosus (SLE) and
Sjogren’s syndrome
Joint distribution is similar to RA
Other symptoms include malar rash,
photosensitivity, skin rashes, mucosal ulcers, dry
eyes and mouth, alopecia, pleuritic chest pain,
and Raynaud’s phenomenon
May still require a DMARD for symptom control
but inflammation does not cause joint erosion and
damage
Can involve DIP, hands, feet and large joints,
often asymmetrical
Can involve back and neck like AS
Dactylitis (sausage digits) and enthesitis
(inflammation where tendons insert into bone)
may also be present
Skin psoriasis and nail changes
Family history of psoriasis
Requires DMARDs to prevent joint damage like
RA
Includes ankylosing spondylitis (AS), reactive
arthritis, and arthritis with inflammatory bowel
disease (IBD)Inflammatory back or neck pain:
Prolonged stiffness and pain in the morning and
post-immobility
Night pain waking patient up from sleep
Onset age <40 years old
May have associated peripheral arthritis,
enthesitis and plantar fasciitis
History of uveitis, infectious diarrhea, urethritis,
STDs, and IBD are highly suggestive of
spondylarthropathies
Joint involvement requires DMARD to prevent
joint damage
Spine involvement may require NSAIDs and/or
biologics.
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Typical Joint Involvement in Various Types of Arthritis
Black= joints most commonly affected
Grey= joints often affected
White= joints usually not affected
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Investigations
The following investigations may be utilized for suspected or confirmed rheumatoid arthritis.
Baseline only:
Rheumatoid factor (RF) or anti-cyclic citrullinated peptide antibody (anti-CCP) are useful when
positive;
o Negative serology does not rule out RA
o High positive indicates poorer prognosis
o No need to repeat over time
o Consider LFTs, TSH, Cr and urine analysis as baseline tests
Baseline and Follow-up:
CBC and ESR or CRP; elevation suggests inflammation but does not prove this; neither does
normal value exclude inflammation

Joint aspiration for culture, crystal and cell count, particularly if monoarthritis, to rule out
septic arthritis or crystal arthritis

Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)
o High ESR or CRP at baseline is associated with poorer prognosis
o Useful for monitoring disease activity and response to treatment

CBC with differentials
o Anemia or increased platelets can indicate active inflammation
o Monitoring for bone marrow suppression from DMARDs (e.g. MTX, sulfasalazine,
leflunomide, gold, biologics)

Renal function and Liver enzymes
o As baseline prior to starting medications
o Monitoring for liver toxicity from DMARDs (e.g. methotrexate, sulfasalazine,
leflunomide)
o Urine analysis and creatinine to monitor for gold toxicity
o Follow blood pressure and renal function to monitor for NSAID toxicity

Eye exam every 12 months to monitor for hydroxychloroquine toxicity

Refer to Table X from BC guidelines for specific tests and frequency to monitor for
DMARD toxicity.
X-rays:

Yearly X-Rays of hands and feet as well as any symptomatic joint, early in disease and
when disease is active, are recommended to assess radiographic progression (i.e.
erosions and joint space narrowing)

Erosions rarely seen on X-Rays in disease of < 6 months duration and can occur even
with minimal symptoms

Radiographic progression indicates need for medication change.
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Other Management Considerations
Management and treatment of RA falls into two broad categories – management of early RA
and management of established RA.
Management of Early RA includes:

Patient education including:
o Self management strategies for pain and fatigue
o Connecting with community resources
o Address other relevant concerns such as nutrition, exercise, and mental health

Referral to Physiotherapy and Occupational Therapy with expertise in RA management

Start NSAIDS for pain management (Start NSAIDs for pain management (see Treatment
Options for Pain – Beyond Medications, Surgery and Injections for other pain
management information)

If confident of diagnosis, consider starting hydroxychloroquine (daily dose of 6.5mg/kg
lean body weight) or sulfasalazine (starting at 500 mg daily and increasing to 1 gm twice
a day; after performing baseline CBC and LFTs) while the patient is waiting to be seen
by a rheumatologist.

If symptoms are severe and patient is having difficulties functioning in daily life, consider
intra-muscular injection of 40 mg of DepoMedrol.

Specialist referral and be sure to indicate “urgent – new onset of RA.”

Follow-up every 1-3 months to adjust therapy until a state of remission or low disease
activity (LDA) is achieved.
Management of Established RA includes:

Suppression of all inflammation to prevent joint damage

Follow-up by GP every 3-6 months. At each visit:
o Review current drug therapy including dose, compliance and side effects
o Assess patient for active joint inflammation and disease activity, to determine if
target is reached and whether therapy needs to be modified
o Differentiate inflammation versus damage
o Review laboratory results for monitoring DMARD toxicity

Assess co-morbidities (Risk factors for cardiovascular diseases, osteoporosis, infections,
malignancies) and extra-articular manifestations

Consider referral to allied health professionals (Physiotherapy, Occupational Therapy,
social worker, vocational counselor)

Consider implications of chronic disease (pain management, psychosocial issues,
depression, areas of self-management, patient education)

Follow-up with specialist every 6-12 months if disease is well controlled
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DECISION TO START PATIENT ON DMARDs
The standard of care has changed for Treatment of RA – E.A.R.L.Y Treatment of RA with
DMARDs means:
E
A
R
L
Y
Early diagnosis and treatment of RA
Aggressive use of DMARDS alters the course of RA
Remission is the new target of RA treatment
Long Term use of DMARDs
Yes, DMARDs are safe when monitored closely
PAST
PRESENT
NSAIDS first
Watchful waiting
DMARDs last resort
Early and aggressive use of DMARDs
NSAIDs were the first line of treatment
NSAIDs are not enough
DMARDs were used as a last resort ; if
NSAIDS did not control symptoms, or once
damage occurred
All active RA warrants DMARDs
DMARDs are used early, continuously and
aggressively
Goal was to manage symptoms
The goal is to eradicate inflammation in order
to prevent irreversible damage
Deformity and disability were a normal
consequence of the disease process
Deformity, disability and premature death are
preventable with DMARDs
DMARDs were considered toxic
DMARDs are safe if monitored closely
Note: Gastrointestinal Issues with NSAIDs
 There is no evidence that NSAIDs alter the natural course of arthritis. The patient
should be made aware that NSAIDs represent symptomatic therapy, and that the
therapy is associated with some risk of gastrointestinal issues such as ulcers or GI
bleeds. Patients should be informed to stop taking the medications and be reassessed if
they have the following symptoms: stomach pain, heartburn, blood in vomit or black
stools.
 If the patient is experiencing GI problems, refer to guideline: Dyspepsia – Clinical
Approach to Adult Patients available at www.BCGuidelines.ca
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Clinical Treatment Targets:

Eradication of inflammation in order to prevent joint damage, physical disability and premature
mortality. Aiming only at controlling symptoms is not sufficient. Persistent swelling, even without pain,
leads to joint erosions and deformities. Frequent follow-up is needed (every 1 to 3 months) to assess
disease activity and adjust DMARD therapy until the target is reached.

Clinical Remission, i.e., the absence of signs and symptoms of active inflammation:
o No swollen joints
o EMS < 15 minutes
o No or minimal systemic symptoms such as fatigue
o No or minimal pain from inflammation
o Normal ESR or CRP
o Little to no radiographic progression
If remission is achieved:
o This is the main target, no change in DMARD is needed.
o If remission has been sustained for > 6 months, very gradual reduction in DMARD dose might
be attempted. For example reductions by 2.5 mg of methotrexate every 3-6 months. Dose
should be increased back to previous level as soon as symptoms worsen or remission state is
lost.
o IF DMARDs are tapered and remission is lost, there is a risk that it might not be achieved again.
Therefore decision to taper must be made carefully with patient.

Low Disease Activity (LDA) is an acceptable alternative target, particularly if remission is not possible
in long standing disease or when co-morbidities or other patient factors limit DMARD options. Use of
composite measures (e.g. CDAI and SDAI) is recommended to assess low disease activity, but the
following can be useful as a guide:
o < 3 swollen joints
o If swelling is present only mild swelling
o No swelling of large joints
o Little to no radiographic progression
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Yearly X-Rays are recommended to assess radiographic progression and step-up treatment if joint
space narrowing or erosions progress.
If Low Disease Activity state is achieved:
o If DMARDs have not been optimized, modify DMARD therapy in an attempt to achieve
remission (i.e., increase DMARD dose to maximum recommended or tolerated dose, or
consider adding DMARD in combination )
o This is an alternative target which may be acceptable, especially in long standing disease, if
medications have been maximized and remission does not seem possible.

If Moderate or High Disease Activity state:
o Treatment target has not been reached and DMARD therapy MUST be modified
o This may include increasing dose of current DMARD to maximum recommended or maximum
tolerated dose; changing to parenteral administration of MTX; adding a DMARD in combination
therapy; or switching to a new DMARD, or a biologic if DMARD failure.
Access to RACE
Management of RA should always be done conjointly with a rheumatologist, either through office visits or
telephone discussion.
Access to Rheumatologists can be facilitated through the RACE Line (Rapid Access to Consultant Expertise).
RACE means timely telephone advice from specialists for family practitioners, Community Specialists
or House staff, all in one phone call.
Monday to Friday 0800-1700 Local Calls: 604-696-2131 Toll Free: 1-877-696-2131
RACE provides:
 Timely guidance and advice regarding assessment, management and treatment of patients
 Assistance with plan of care
 Learning opportunity – educational and practical advice
 Enhanced ability to manage the patient in your office
 Calls returned within 2 hours and commonly within an hour
 CME credit through “Linking Learning to Practice”
http://www.cfpc.ca/Linking_Learning_to_Practice/
RACE





does not provide:
Appointment booking
Arranging transfer
Arranging for laboratory or diagnostic investigations
Informing the referring physician of results of diagnostic investigations
Arranging a hospital bed.
Unanswered Calls?
If you call the RACE line and do not receive a call back within 2 hours – call the number below. All
unanswered calls will be followed up. For questions or feedback related to RACE, call: 604-682-2344,
extension 66522 or email [email protected]
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The following are conditions to rule out before starting DMARDs.
Condition
Features

Osteoarthritis





Crystal arthropathy: gout or pseudogout


Septic arthritis


Viral arthritis




Hepatitis B & C associated arthritis

Metabolic disorders

Typically affects the distal
interphalangeal (DIP) joints of the
hands and the carpometacarpal joint at
the base of the thumb.
Swelling of the joints is hard and bony
Stiffness and pain are worse after
activity
Stiffness in the morning or after
immobility does not last long (gelling ; <
30 minutes)
Monoarticular, especially the first MTP
joint, or oligoarticular.
Joint aspiration is needed to look for
urate crystals or calcium
pyrophosphate crystals (CPPD).
Radiologists can perform joint
aspirations if GP is not confident of
technique
Usually monoarticular but rarely can be
polyarticular
Joint aspiration must be performed for
synovial fluid culture and cell count.
Transient polyarthritis usually lasting <
6 weeks
Common causes: Rubella and
parvovirus
Less commonly: mumps, alphaviruses,
enterovirus and herpes virus
Autoimmune arthritis associated with
Hepatitis B & C infection
Abnormal liver function tests (AST &
ALT)
Perform Hepatitis B & C serology if
appropriate ie: abnormal liver function
test or high risk
Rule out hyper or hypothyroidism
(TSH), hyperparathyroidism
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Medication Options
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Management of Co-Morbidities
The following table may be used for the management of co‐morbidities in patients with rheumatoid arthritis. Condition Comments Cardiovascular Disease (CVD) 


o CVD risk should be assessed in all patients o Count RA as one additional risk factor for CVD in the All patients with RA are at increased scoring of cardiovascular risk risk of CVD o Monitor blood pressure regularly Risk increases with increased disease o Measure lipids yearly activity and severity Risk increased in patients with positive o Discuss weight management if needed RF, anti‐CCP and high ESR or CRP o Encourage physical activity o Address smoking cessation if applicable Infections 
People with RA are at increased risk of infections 
Risk increases with increased disease activity and severity 
Some DMARDs also increase risk of infections (e.g. biologics, leflunomide, cyclosporine, methotrexate) however reduced inflammation seems to attenuate this risk. 
Prednisone increases risk of infection more than DMARDs Osteoporosis 
RA patients are at increased risk of osteoporosis due to inflammation, reduced physical activity and prednisone use Depression 
RA patients are at increased risk of depression o Advise patients to seek medical attention if symptoms of infections o Manage RA patients on DMARDs as immunocompromised hosts (especially if on biologics) o Minimizing dose and duration of prednisone is important. o Immunizations  Yearly influenza vaccine for all RA patients  Pneumococcal Vaccine in all patients prior to starting immunosuppressants and one booster after 5 yrs  Hepatitis A and B in high risk o Assess risk factors for osteoporosis o Measure bone density if risk factors, prednisone use or fragility fracture o Provide counseling for Calcium and Vitamin D supplementation o Encourage exercise o Bisphosphonate for osteoporosis prevention if prednisone >7.5 mg per day for expected duration of more than 3 months o Screen for depression using PHQ2 and PHQ9 tools if appropriate, especially early in disease Next
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Referrals to other members of the Interdisciplinary Care Team:
Physiotherapist:
 For advice on an exercise program to improve function, support participation in
daily activities / leisure and maintain or improve body movement, strength, and
flexibility
 For use of non-pharmacological treatments to improve pain and deal with
inflamed joints, such as heat, ice, etc.
 For advice regarding mobility aids and gait training
 Education and support for physical activities and healthy lifestyle
 www.bcphysio.org
Occupational Therapist:
 For assessment of activities of daily living
 For an ergonomic assessment of work
 To provide splints, orthotics, mobility and other assistive devices or tools to
reduce fatigue and improve function
 Work site and home adaptation
 www.bcsot.org
Dietitian:
 To provide information about food and dietary concerns
 For weight management if increased risk of CVD
 Health Link BC: Dial 811 (Hearing impaired 711)
Social Worker:
 To help connect patients and their families with supportive community resources
 To provide support and advice to patients experiencing difficulties coping with RA
or with emotional or social difficulties
 To provide advice regarding work if a vocational counselor is not available
 www.bccollegeofsocialworkers.ca
Vocational Counselor:
 To assess work situation and recommend job accommodations if necessary
 To provide career counseling
 To advise regarding available resources for employment issues
RACE Line
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Monitoring and Follow-up
For rheumatoid arthritis patients, the following monitoring and follow-up information should be
taken into consideration.

Frequency:
o Every 1-3 months when disease is active to adjust therapy and achieve a state of
remission or low disease activity (LDA).
o Every 3-6 months once target is reached to ensure remission or LDA is
maintained and to monitor for drug toxicity.

Follow-up assessment should:
o Assess disease activity to determine if target is reached and whether therapy
needs to be modified
o Review medications, including compliance and side-effects
o Monitor for drug toxicity
o Assess co-morbidities (Risk factors for cardiovascular diseases, osteoporosis,
infections, malignancies)
o Discuss need for allied health professionals (PT, OT, social worker, vocational
counselor)
o Provide patient education and enhance self-management
Goal Setting
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Follow-up Assessment Checklist
1. Joint pain:

Improvement: Overall, compared to last visit, the joint pain is:



Better

The same
Worse
Severity: On a scale of 0 to 10, where 0 = no pain at all, and 10 = very severe pain, how
much pain have you had in the last month, on average, from your arthritis?
Numerical rating scale (0-10) _______

OR: Level of pain has been:


Mild

Moderate

Severe
Frequency: The joint pain is present:
Continuously


None


Intermittently – If so:
Does the pain interfere with sleep?


Daily

Yes
Weekly

Other _______
No
Comments about joint pain: ________________________________________________
2. Duration of morning stiffness:
_________________________________________________________________________
3. Fatigue severity: On a scale of 0 to 10, where 0 = no fatigue at all, and 10 = very severe
fatigue, how much fatigue have you had, on average, in the last month?
Numerical rating scale (0-10) _______________
OR: Fatigue has been:


None
Mild

Moderate

4. Global disease activity rating by patient: _______
Severe
Disease Activity Rating
Considering all of the ways your arthritis has affected you, how do you feel your arthritis is
today?
0
Very Well
1
2
3
4
5
6
7
8
9
10
Very Poor
5. Functional limitations: Do you have difficulties with (answer Yes or No):


Self-care activities (e.g. washing, dressing, eating) _________________________
Mobility: Walking __________ Standing__________ Stairs __________________
6. Difficulties with work, leisure or other usual activities:
________________________________________________________________________
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7. List of current medications:
Drug
Dose
Compliance
Side-effects
8. Non-pharmacological therapy:
a. _________________________________________________________________________
b. _________________________________________________________________________
c. _________________________________________________________________________
d. _________________________________________________________________________
9. Change in therapy recommended:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Goal Setting
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Follow-up Assessment Checklist – Assessment of Disease Activity
Composite disease activity score: (choose one):
Items from history and physical
exam checklists
Simplified Disease Activity Index (SDAI)




1. Number of swollen joints: _______
Number of swollen joints + number of
Tender joints + patient global + physician
Global + CRP
Total score: _______
2. Number of tender joints _______
3. Patient global disease activity
(0-10 scale): _______
Clinical Disease Activity Index (CDAI)




4. Physician global disease activity
(0-10 scale): _______
Number of swollen joints + number of
Tender joints + patient global +
Physician global
Total score: _______
5. CRP: _______
Disease Activity State Achieved:

Remission

Low disease activity


Moderate
SDAI
CDAI
Remission
< 3.3
< 2.8
Low Disease Activity
3.4 - 11
2.9 - 10
Moderate Disease Activity
12 - 26
11 - 22
High Disease Activity
> 26
> 22
High disease activity
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Referrals to Rheumatology
Early RA


For new onset inflammatory arthritis or suspected RA, early referral to a rheumatologist, or
discussion with a rheumatologist, is mandatory; shared care is always indicated:
o Indicate “URGENT: new-onset RA”.
o Referral should be seen rapidly, within 4 weeks.
See below for interim management
Established RA



RA should always be followed conjointly with a rheumatologist, unless not possible
Generally, every patient with RA should be on a DMARD
Reasonable to ask for earlier follow up appointment:
o If complications from medications or management uncertainty.
o If symptoms are not well controlled with treatment, such as persistent joint swelling, or
moderate or high disease activity state on CDAI or SDAI.
o If development of new extra-articular features of RA (e.g., eyes, lungs, pericarditis,
cutaneous vasculitis, peripheral neuropathy)
Useful Information to include on Referral
This information will help rheumatologists prioritize referrals.

Whether this is a new-onset inflammatory arthritis

Symptom duration

Number of tender and swollen joints

Length of early morning stiffness

If systemic symptoms are present (e.g. fatigue)

Any important functional limitations, activity restriction or recent inability to work

Include relevant labs(e.g., ESR or CRP, RF) and x-rays
RACE Line
CART Referral Form
General Referral Form
Acknowledgement Form
Specialist Consult Form
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ARTHRITIS REFERRAL TOOL
PATIENT NAME:
PHYSICIAN NAME:
DATE OF BIRTH:
PHONE:
ADDRESS:
FAX:
ADDRESS:
PHONE:
PHN:
PHYSICIAN #:
HISTORY (PATIENT OR PHYSICIAN TO COMPLETE)
□Male □ Female
4. HOW LONG have you had THIS PROBLEM? □< 6m □<12m □>1yr □>5yr
5. Are you ABORIGINAL? □YES □NO
1. AGE:
2. GENDER:
3. SHADE areas of PAIN or STIFFNESS
6. What does your joint pain or stiffness GET BETTER with?
□Activity (Keep moving)
□Rest (Sit or Lie down)
□Other
7. Have you noticed OBVIOUS SWELLING in your JOINTS? □YES □NO
If YES, WHICH JOINTS are SWOLLEN?
□Fingers □Wrists □Elbows □Knees □Ankles □Feet
8. Have you STOPPED WORKING because of THIS PROBLEM? □YES □NO □N/A
9. Do you or any of your family members have PSORIASIS? □YES □NO
10. Check if YOU HAVE any of the following conditions: □Rheumatoid Arthritis
□Psoriatic Arthritis □Lupus □Ankylosing Spondylitis □Gout □Fibromyalgia
If so, do you think you may be “flaring”? □YES □NO
11. HOW LONG does your MORNING STIFFNESS
|______________l______________l_____________l_____________|
last from the time you wake up? (place mark on line)
0
½ hr
1 hr
1½ hr
2 hr
PHYSICAL (PHYSICIAN TO COMPLETE)
12. WHICH JOINTS are SWOLLEN on EXAMINATION?
□None □Not Sure □Fingers □Wrists □Elbows □Knees □Ankles □Feet
13. Other RELEVANT Physical Exam Findings:
LABORATORY & IMAGING (PLEASE ATTACH ALL LAB & IMAGING REPORTS)
Hgb:
WBC:
PLT:
ESR:
CRP:
RF:
ANA:
DIAGNOSIS ( PHYSICIAN TO COMPLETE )
14. What do YOU THINK is the DIAGNOSIS: ________________________________________________________________________
□Inflammatory
□Rheumatoid-Psoriatic-Reactive Arthritis □Ankylosing Spondylitis □PMR
15. CLASSIFY the PROBLEM: Condition
□Lupus-Connective Tissue Disease □Vasculitis □Crystalline (Gout or CPPD)
□Mechanical-Degenerative Condition (□Osteoarthritis □Mechanical Back Pain, etc.)
□Chronic Pain Condition (□Fibromyalgia)
□Other:
16. Has this Patient EVER seen a Rheumatologist Before? □NO
□Not Sure □YES (please attach all consult notes)
17. Is this Problem related to a PRIOR INJURY? □YES □NO
18. Is Self-Reliance / Independence affected? □YES, requires assistance □YES, no assistance required □NO
19. How SOON does this patient NEED to be ASSESSED?
□24-48 hrs (call) □2-8 Weeks □2-4 Months □4-6 Months
Please ATTACH and OTHER INFORMATION you think is important (i.e. PMH, Current Meds, labs, investigations)
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Classification Criteria for Rheumatoid Arthritis
Below are 2 sets of classification criteria from the American College of Rheumatology
(2010 and 1987). The 2010 criteria were developed to better classify patients with early
disease. These are not diagnostic criteria, but classification criteria designed for
research. Not all RA patients will meet the classification criteria.
1987 ACR Criteria for the Classification of Rheumatoid Arthritis
Criterion
Definition
1. Morning stiffness
Morning stiffness in and around the joints
2. Arthritis of 3 or more joint areas
At least 3 joint areas simultaneously have had
soft tissue swelling or fluid (not bony
overgrowth alone) observed by a physician.
The 14 possible areas are right or left PIP,
MCP, wrist, elbow, knee, ankle, and MTP joints
3. Arthritis of hand joints
At least 1 area swollen (as defined above) in a
wrist, MCP, or PIP joint
4. Symmetric arthritis
Simultaneous involvement of the same joint
areas (as defined in 2) on both sides of the
body (bilateral involvement of PIPs, MCPs, or
MTPs is acceptable without absolute symmetry)
5. Rheumatoid nodules
Subcutaneous nodules, over bony prominence,
or extensor surfaces, or in juxta articular
regions, observed by a physician
6. Serum rheumatoid factor
Demonstration of abnormal amounts of serum
rheumatoid factor by any method for which the
result has been positive in < 5% of normal
control subjects
7. Radiographic changes
Radiographic changes typical of rheumatoid
arthritis on posteroanterior hand and wrist
radiographs, which must include erosions or
unequivocal bony decalcification localized in or
most marked adjacent to the involved joints
(osteoarthritis changes alone do not qualify)
* For classification purposes, a patient shall be said to have rheumatoid arthritis if he /
she has satisfied at least 4 of these 7 criteria. Criteria 1 through 4 must have been
present for at least 6 weeks. Patients with 2 clinical diagnoses are not excluded.
Designation as classic, definite, or probable rheumatoid arthritis is not to be made.
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The 2010 ACR-EULAR Classification Criteria for Rheumatoid Arthritis
Target population (Who should be tested?): Patients who
1. Have at least 1 joint with definite clinical synovitis (swelling)
2. With synovitis not better explained by another disease
Add score of each category, a score of > 6/10 classifies a patient as having definite RA
 The criteria are aimed at classifying newly presenting patients. Patients with
erosive disease typical of RA with a history compatible with prior fulfillment of the
2010 criteria should be classified as having RA. Patients with longstanding
disease, who based on retrospectively available data, have previously fulfilled the
2010 criteria should be classified as having RA.
 Although a score of < 6/10 is not classifiable as having RA, status can be
reassessed over time.
 Joint involvement refers to any swollen or tender joint on examination, excluding
distal interphalangeal joints, first carpometacarpal joints, and first
metatarsophalangeal joints.
 Patients are placed in the highest category possible based on the pattern of
involvement
 Large joints= shoulders, elbows, hips, knees, and ankles.
 Small joints= MCP joints, PIP joints, 2nd-5th MTP joints, thumb interphalangeal
joints, and wrists.
 Negative refers to values less than or equal to the upper limit of normal (ULN);
low-positive refers to values that are higher than ULN but < 3 times the ULN; high
positive values are > 3 times the ULN.
 Normal / abnormal for erythrocyte sedimentation rate (ESR) and C-reactive
protein (CRP) is determined by local laboratory standards.
 Duration of symptoms refers to patient self-report of the duration
Joint Involvement Score





1 large joint
2-10 large joints
1-3 small joints (with or without large)
4-10 small joints (with or without large)
> 10 joints (at least 1 small joint)
0
1
2
3
5
Serology



Negative RF and anti-CCP
Low-positive RF or anti-CCP
High-positive RF or anti-CCP
0
2
3
Acute Phase Reactants


Normal CRP and ESR
Abnormal CRP or ESR
0
1
Duration of Symptoms


< 6 weeks
> 6 weeks
0
1
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Self Management Links
Patient Education and Self Management
Increasingly clinicians are recognizing the importance of working with patients as partners in
areas where they can assume responsibility and ownership of their choices. This requires
building the patient’s confidence in their ability to change and to adopt healthier behaviors. It
also assumes patient involvement in setting out a realistic treatment and management plan.
Patient Self Management:
The tasks that an individual must undertake to live well with one or
more chronic conditions. These tasks include gaining confidence
to deal with medical management, role management, and
emotional management. (Adams, Greiner, and Corrigan, 2004)
Self Management Support
The systematic provision of education and supportive
interventions by health care staff to increase patients’ skills and
confidence in managing their health problems, including regular
assessment or progress and problems, goal setting, and problemsolving support. (Adams, Greiner, and Corrigan, 2004)
For health care providers these materials are intended to:
 Facilitate awareness of education programs and information resources available to
patients and their families
 Integrate patient self-management goals into the care planning / treatment process
 Provide tools that can assist health care providers in assessing patient readiness to set
goals and assume responsibility for self care
 Identify guiding principles and tools to assist in communicating with individuals with low
levels of health literacy so that they can make informed decisions and take appropriate
actions to protect and promote their health.
 Identify key points of discussion relating to lifestyle choices that need to occur with
patients either in a one on one or group setting
For patients and their caregivers these materials are intended to:
 Build patient confidence in coping with the disease / condition by providing information
on the resources and supports available
 Give patients tools to document questions and diarize experiences through various
stages of the disease / condition
 Facilitate a network of support for families and care givers at the local, community level
 Identify the cross-over and linkage of these arthritic conditions with other chronic
diseases
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Return to RA Page
Discussion Topics for Health Care Providers and Patients
The purpose of this resource is to identify key topics for conversations between health care providers and
patients regarding self-care responsibilities relating to management of MSK conditions. These topics may be
discussed in a group setting or a one-on-one basis. This resource is intended to be used as:
1.
A checklist guide for physicians and other health care professionals regarding topics to be discussed
with their arthritis patients.
2. A guide for patients on topics they may wish to raise with their care provider(s) and as key areas to
track in a patient passport / health journal.
3. An outline of topics to be covered in structured group medical visits or in education programs.
A critical component of delivering a key health message is health literacy and ensuring effective
communication with patients, some of whom may have diverse cultural, ethnic and linguistic backgrounds. In
addition, two listings of additional resources and organizations available to support patients and health care
providers in managing MSK conditions are provided.
Quick Links
Click on the following links to go to a Discussion Topic section:

Health Provider Commitment to
Individuals and their Health
Specific Disease
Information for Patients
A Comparison of Inflammatory
Arthritis & Osteoarthritis
Managing
Daily Activities
Exercise
Healthy Eating &
Weight Management
Managing
Pain
Medications
Management
Dealing with
Psycho-Social Issues
Access to
Services & Resources
Pain
Toolbox
Goal
Setting
Access to Services / Resources
Summary of Patient Resources by Organization
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Self Management Links
Health Provider Commitment to Individuals and their Health
Underlying Values
Healthcare Team

Commitment to care

Acknowledgement that diagnosis is a life changing event;
association with fatigue, depression, isolation, anxiety

Message of hope; treatments are available

Knowledge is power

Many resources available to support patient with disease
management

Patient is the leader or “quarterback” of their health care
team

Helpful to have one primary healthcare provider for
guidance/referrals—often GP or rheumatologist

Examples of Team members:
 Family Physician
 Specialist (rheumatologist, orthopedic surgeon,
sports medicine physician, physiatrist)
 Physiotherapist, occupational therapist, dietitian
 Nurse practitioner, nurse, or home support
 Psychologist, social worker
SMART Goals
 Important for managing a chronic condition
 Specific – What do I want to achieve?
 Measurable & Meaningful – What will indicate my success?
Is my goal important to me?
 Attainable – Is this goal within reach for me?
 Realistic – Am I being realistic about my goal?
 Time-framed – When do I want to reach my goal?
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Specific Disease Information for Patients
Rheumatoid Arthritis
What is Rheumatoid Arthritis?
 Most common type of inflammatory arthritis
 affects ~1% of the adult population and affects women more
than men
 can start at any age but most commonly occurs in the 30-50
age group
 Inflamed joints are painful, swollen, hot and stiff
 Inflammation is in the lining of the joints, and if it is not
controlled, it will cause permanent damage to the bone and
cartilage
Cause
 Unknown
 Caused by the body’s immune system attacking the joints—is
an autoimmune disease
 Smoking increases the risk of developing RA
Diagnosis
 Symptoms:
o may be sudden or gradual
o pain or stiffness with swelling in joints, usually worse
in the morning
o commonly starts in the fingers, wrists and feet
although other joints may be involved
o most often tends to be symmetrical, involving joints
on both sides of the body
 Blood test is not completely diagnostic; may take months to
confirm diagnosis
Treatment
 Important to treat RA early and aggressively
 DMARDs can slow or stop inflammation that causes joint
damage, but cannot reverse damage
 Referral to rheumatologist
 Learn about RA, set goals
 Most well-balanced RA treatment plans include medications,
weight control, exercise, pain management, relaxation,
healthy eating, smoking cessation
 Access community services/programs
 Access other healthcare providers as needed, e.g.
physiotherapist, occupational therapist, dietitian, etc
Osteoarthritis Information
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Specific Disease Information for Patients
Osteoarthritis
What is Osteoarthritis?
 Most common type of arthritis
 Most common in the hands, hips, knees and spine
 Breakdown of the cartilage on the ends of bones
 Symptoms can include pain, stiffness and mild swelling
Cause
 Unknown
 Factors that increase your chance of getting OA include

Examples of Team members:
 Age (getting older)
 Excess weight
 Heredity
 Injury and overuse
 Other types of arthritis
Treatment
 Learn about OA, set goals
 Weight control, exercise, pain management, relaxation,
healthy eating
 Access community services/programs
 Access other healthcare providers as needed, e.g.
physiotherapist, occupational therapist, dietitian, etc
RA Information
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A Comparison of Inflammatory Arthritis and Osteoarthritis
Features
Inflammatory Arthritis
Osteoarthritis
What are examples of
diseases?

Rheumatoid arthritis


Psoriatic arthritis

Ankylosing spondylitis

Systemic lupus
erythematosus
Osteoarthritis
Who gets it?
Usually starts in middle age
(30 – 60) and tends to get
worse over time. However, it
can start at any age.
More common as we age, tending to
occur in joints that have been subject
to “wear and tear” by excessive use
What is the cause?
The body’s immune system
attacking the joints
Deterioration of cartilage
How quickly does it start?
Fairly quickly, affecting joints
over a period of weeks to
months
Usually slowly, with joints getting
worse over a period of months to
years
How many joints does it
affect?
Usually lots of joints and tends
to be symmetrical, involving
joints on both sides of the
body (i.e. both hands, both
elbows etc.)
Usually a few joints and tends to be
asymmetrical (not matching), with
swelling and pain in single joints (i.e.
on knee, one finger etc.)
What joints can be affected?

Small joints of the hands
and feet


Wrists, elbows, shoulders,
knees, hips
Most commonly joints of the
fingers, neck, lower back, knees
and hips

Can occur in any joint

Stiff, painful and enlarged joints

Gradual onset and worsening
What are the usual
symptoms?

Any joint can be affected

Joint pain, swelling,
tenderness and redness of
the joints

Prolonged morning
stiffness and less range of
movement

Sometimes fever, weight
loss, fatigue and/or
anemia
What amount of morning
stiffness is experienced?
Morning stiffness lasting more
than 60 minutes
Morning stiffness lasting about 15-30
minutes
What medications are
available?


Analgesics

NSAIDS

Injections, steroids and
viscosupplementation
Non-steroidal antiinflammatory Drugs
(NSAIDS)

Disease-modifying AntiRheumatic Drugs
(DMARDS)

Steroids

Biologics

Steroid Injections
(Source: the Arthritis Society - Arthritis Medications – A Consumer’s guide, January 2011)
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Managing Daily Activities
Keywords
Discussion
Pacing and Energy Conservation
 Pace activities and take frequent breaks. Balance
work with rest.
 Plan ahead and do the most difficult tasks when
feeling best. Prioritize.
 Avoid repetitive tasks and sustained postures
 Find the easiest way to work. Modify or avoid
activities that cause pain.
 Be realistic of abilities. Ask for help with more
difficult tasks
Modifying Activities/ Equipment
 Use large muscles whenever possible, i.e.
push/pull rather than carry items
 Stairs – avoid and use the elevator/escalator. If
necessary, lead with the good leg going up and the
painful leg going down
 Unload joints with a cane, walker, Nordic walking
poles
 Make sitting/standing easier by using higher
chairs, armrest, raised cushion, raised toilet seat
 Hands – use large-handled pens, garden tools,
kitchen aids (or enlarge standard items with foam
tubing)
 Bathroom safety / reducing risk of falls – grab
bars, shower seats, etc
 Consider referral to an occupational therapist for
hand splints, knee/ankle braces, supportive
footwear/orthotics
Sleep
 Consider body positioning
 Lack of sleep can lead to low energy, fatigue,
increased pain and depression
 Good sleep hygiene
Work
 Consider the rate, duration and nature of work.
 Work (paid and unpaid) is important to both
physical and mental health and is a very
important part of life for many people
 Consider workplace ergonomics
 May need to provide plan for progressive return to
work, changing jobs or re-entering the workforce
 Consider the type and duration of commute, and
consider telecommuting where feasible
Resources
www.arthritis.ca
The Arthritis Society – Lifestyle Series: Arthritis in
the Workplace
www.coag.uvic.ca/cdsmp
Chronic Disease Self-Management Program –
CDSMP is an evidence-based peer-led patient
education program offered throughout BC.
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Self Management Links
http://oasis.vch.ca/
OASIS Program – Primary Education Sessions
www.cbtforinsomnia.com
A 5 week, 5 session online cognitive-behavioural
therapy (CBT) program for insomnia
http://yoursleep.aasmnet.org/
American Academy of Sleep Medicine
http://www.sleepfoundation.org
National Sleep Foundation – information on how to
sleep well
http://www.sleepeducation.org/home
A Sleep Diary for documenting sleep so that health
care providers can help determine the problem
http://www.css.to/centers.html
Canadian Sleep Society. Find a sleep lab near you
Footeducation.com
Created by orthopaedic surgeons to provide patients
and medical providers with current and accurate
information on foot and ankle conditions and their
treatments.
Foothealth.ca
British Columbia Podiatric Medical Association
http://podiatrycanada.org
Canadian Podiatric Medical Association
http://apma.org
American Podiatric Medical Association
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Self Management Links
Exercise
Benefits
 Maintain/restore joint movement and relieve stiffness
 Cartilage nutrition
 Stabilize joints with strong muscles
 Improve energy and endurance
 Reduce risk of falling by improving posture and balance
 Maintain a healthy body weight (every extra lb puts 4-6lbs or stress
through weight-bearing joints)
Components
 Cardiovascular exercise
 Strength training
 Balance and Core body strengthening
 Flexibility training (range of motion and stretching exercises
General Principles
 Start slowly and gradually progress intensity and duration.
 Break activities up throughout the day
 Warm up before exercising by doing range of motion exercises or by
applying heat to the joint (warm shower, hot pack, etc)
 Taking medication before exercise may help to minimize symptoms and
improve exercise tolerance
 Reduce load on joints by exercising in water or cycling
 Use walking aids such as a cane, walker or Nordic walking poles
 Refer to a physiotherapist for a specific exercise program and advice on
proper joint positioning, exercise equipment and technique
Pain

Avoid exercises that increase joint pain

If exercise causes joint pain that lasts more than 2 hours or in to the next
day, re-evaluate the exercise program.

During a flare-up, use ice, medications and rest to relieve symptoms.
Move the joint in a non-weight bearing position and avoid resistance
exercise

Non-pharmacological options are available for pain management,
Please see the Pain Toolbox Treatment Options for Pain – Beyond
Medications, Surgery and Injections for more information:
Resources
www.arthritis.ca
The Arthritis Society – Lifestyle Series: Physical Activity and Arthritis
http://oasis.vch.ca/
OASIS Program – Primary Education Sessions
www.physicalactivityline.c
om
Phone: 604-241-2266
Phone: 1-877-725-1149
A free resource for physical activity and healthy living information.
www.phac-aspc.gc.ca/hpps/hl-mvs/pa-ap/indexeng.php
Canada’s Guide to Physical Activity
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Healthy Eating & Weight Management

Eat according to Canada’s Food Guide. Serving
recommendations by age and sex are designed to meet
minimal daily nutrient requirements

Anyone over 50 should supplement a minimum of 400 IU of
Vit D

Include Omega-3 Fatty Acids in your diet, found in. Increased
intake has been linked to a reduction in RA symptoms and
inflammation

If you’re low in any food group on a regular basis, a multivitamin/mineral supplement is recommended, as is improving
your diet

Patients who are unsure of how to change their diet should be
referred to a dietitian or telephone resource
Tips for Weight Management

Eat breakfast to boost metabolism


Take at least 20 minutes to eat a meal and chew slowly to
give your body time to know when you are full

Eat smaller meals more often so you can burn calories
between meals. If you eat too much at one time your body will
store extra calories as fat.

Do not eat for 2 to 3 hours before going to sleep. If you eat a
large meal or snack non-stop before going to bed, your body
may not have a chance to burn calories.

Drink low calorie fluids like water, herbal teas, flavoured water
and vegetable juices. Aim for 8 glasses or 2 liters a day.

Eat your vegetables. Vegetables are low in calories and full of
nutrients.

Limit foods and beverages high in calories, fat, sugar and
sodium.

Eat moderate portions. Use smaller plates, bowls, forks,
spoons, etc.

Tell your friends and family that you are trying to lose weight
and you need their support.
Nutrition
Being overweight puts extra
stress on weight bearing joints
Resources
www.arthritis.ca
The Arthritis Society – Lifestyle Series: Nutrition and Arthritis
http://oasis.vch.ca/
OASIS Program – Primary Education Sessions
www.healthlinkbc.ca
8-1-1 on your telephone
HealthLink BC – speak with a Dietitian
www.healthcanada.gc.ca/foodguide
Canada’s Food Guide
www.dietitians.ca
Dietitians of Canada. Current food and nutrition information.
www.eatracker.ca
Track and analyze your day’s food and activity choices and
compare them to the guidelines laid out by Health Canada.
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Managing Pain
General
Heat & Cold Therapies
Complementary Therapies

Pain may come and go as arthritis flares or subsides, but for
many people with arthritis, pain will never entirely disappear

Pain does not always mean damage to the joint(s)

Pain is different from muscle discomfort associated with
exercising.

Chronic pain management aided by:
o Knowledge of pain, treatment options
o Support from friends, family, others with chronic pain
o Behavioral change

Heat therapies may help to decrease pain and stiffness of the
muscles and joints and should be applied for 15-20 minutes at
a time

Cold therapies may relieve pain and reduce swelling

Risks and benefits often not clear. Examples may include:
o Vitamins, minerals, herbal supplements
o Acupuncture, massage, chiropractor, relaxation,
visualization, TENS
o Dietary changes

Consider
o What you are trying to achieve
o Costs
o Risks and side-effects
o Interactions with other medications
o Trying only one therapy at a time to determine the
effect
Resources
www.arthritis.ca
The Arthritis Society - Chronic Pain Management Workshop
http://oasis.vch.ca/
OASIS Program – Primary Education Sessions
http://www.selfmanagementbc.ca/
University of Victoria Centre on Aging - Chronic Pain Self
Management Program
www.painbc.ca
Pain BC. Non-profit organization aiming to furthering support and
education for patients and promoting engagement of patients in
health care decision making
Non-pharmacological options are available for pain management,
Please see the Pain Toolbox Treatment Options for Pain – Beyond
Medications, Surgery and Injections for more information:
http://www.painbc.ca/chronic-pain/pain-toolbox
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Self Management Links
http://www.canadianpaincoalition.ca
/index.php/en/helpcentre/conquering-pain
Canadian Pain Coalition. “Conquering Pain for Canadians”
booklet and “Conquering your Pain” video
Lifeisnow.ca
Public education sessions provided by Neil Pearson to help
people understand pain and provide optimistic guidance about
pain self-management technique
http://www.medschoolforyou.com/
Med School for You. A free online pain education module
supported by the Canadian Pain Society (CPS) & the Canadian
Pain Coalition (CPC).
http://psychologyofpain.blogspot.ca
Psychology of Pain is a blog created by Gary B. Rollman,
Professor of Psychology at the University of Western Ontario and
the former President of the Canadian Pain Society. Contains links
to many useful pain resources and discussions on a number of
pain issues.
http://www.cci.health.wa.gov.au/res
ources/doctors.cfm
> click on the [resources] button in
the upper left column, and then
> click on the button for
[consumers].
Centre for Clinical Interventions. A resource centre with
handouts aiming to help people change the way they think. It also
has psychotherapy course material for family physicians and might
be helpful for physicians who are interested in running group
sessions on coping with pain.
http://www.chronicpaincanada.com/
Phone: 1 (780) 482-6727
Email:
[email protected]
The Chronic Pain Association of Canada (CPAC) is committed
to advancing the treatment and management of chronic intractable
pain, developing research projects to promote the discovery of a
cure for this disease, and educating both the health care
community and the public to accomplish this mission.
http://www.painexplained.ca/
The Canadian Pain Society has a website for pain information for
patients and healthcare providers:
http://www.iasp-pain.org
The International Association for the Study of Pain (IASP).
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Self Management Links
Medication Management
Goals
Types
Patient’s Role

Control the symptoms of pain, stiffness and swelling

Patient needs to know:
o Reason for taking medication
o Expected benefits and timeframe
o How long they’ll be taking medication

Different types of arthritis have are treated with very
different medication classes. OA medications focus on
pain and inflammation, treating symptoms. RA
medications work to treat both symptoms and the
underlying disease process.

Analgesic - pain management (all)

Anti-inflammatory – inflammation (all)

DMARDs—including biologic response modifiers (RA)

Patient needs to know:
o How medication works
o How to take it
o Possible interactions

Communication. All medications have potential side
effects. Patients need to share any nutritional / herbal
supplements and other complementary therapies being
used.

Use a Pharmacist as a resource

Reminder system (pill box or diary)

Record of medications tried, side effects, benefits, loss of
effect
Resources
www.arthritis.ca
The Arthritis Society – Consumer’s Guide to Medications;
“An Introduction to Complementary and Alternative
Therapies”
www.healthcanada.gc.ca/medeffect
MedEffect Canada provides consumers, patients, and health
professionals with easy access to: report an adverse reaction
or side effect; obtain new safety information on drugs and
other health products; and learn and better understand the
importance of reporting side effects
www.nccam.nih.gov
National Centre for Complementary & Alternative Medicine
(American)
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Dealing with Psycho-Social Issues
Feelings about diagnosis
 Support for sense of grief or loss associated with diagnosis
 Discuss common emotional reactions, signs and symptoms

Stress


Depression


Relaxation techniques




Cognitive behavioral therapy


Social Engagement



Sexual intimacy





of stress, depression, social isolation
Discuss coping strategies
Can impact the management of arthritis and compound
illness
Discuss the signs and symptoms of stress, techniques for
becoming self-aware and strategies for coping with stress
Is treatable
Strategies for mild depression:
o Interests, hobbies, distraction
o Support network – family, friends, group
o Positive thinking, sense of humor
o Exercise
o Healthy eating
o Exercise
o Pain management
Deep breathing
Progressive muscle relaxation
Guiding imagery
Visualization
Model developed by Psychologists to help us understand
how our thoughts, feelings and behaviors/actions are
connected
Useful in the treatment of anxiety, stress, depression and
chronic pain
Important for a sense of purpose and wellbeing
Important to avoid becoming isolated
Benefits of peer support group: sharing experiences and
lessons learned, providing hope support and
encouragement when dealing with emotional and physical
pain
Can be maintained
Most couples living with arthritis find it necessary to
experiment with new positions for intercourse that put less
strain on painful joints
Sexual concerns arising from arthritis are completely valid.
Open communication between partners, and between
people with arthritis and health professionals, is vital to
maintaining an active sex life.
Important to note that arthritis disease does not cause a loss
of sex drive. However, the physical and emotional hardships
that result from arthritis can create barriers that undermine
sexual needs, ability, and satisfaction.
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Sexual intimacy
Self Management Links

Can be maintained

Most couples living with arthritis find it necessary to
experiment with new positions for intercourse that put
less strain on painful joints

Sexual concerns arising from arthritis are completely
valid.

Open communication between partners, and between
people with arthritis and health professionals, is vital to
maintaining an active sex life.

Important to note that arthritis disease does not cause a
loss of sex drive. However, the physical and emotional
hardships that result from arthritis can create barriers that
undermine sexual needs, ability, and satisfaction.
Resources
www.arthritis.ca
The Arthritis Society – Lifestyle Series: Intimacy and
Arthritis; Self Management Program
http://web.uvic.ca/~pmcgowan/research/
cdsmp/index.htm
University of Victoria Centre on Aging - Chronic Disease
Self Management Program
Bounceback
Bounce Back, Canadian Mental Health Association.
Community based mental health support to patients to help
improve their mood and quality of life through free psychoeducation and guided self-help.
o “Living Life to the Full” DVD
o Overcoming Depression, low Mood and Anxiety via
telephone coaching
Call 1-(604)-688-3234 or 1-(800)-5558222 extension 235.
http://www.getselfhelp.co.uk/chronicfp.ht
m
This is a self-help website for people that feel stuck that
offers people strategies for change. Focus on cognitive
behavioural therapy.
http://www.gpscbc.ca/psplearning/module-overview/mental-health
Practice Support Program – Adult Mental Health Module
http://www.comh.ca/antidepressantskills/adult/
Anti-depressant Skills Workbook – helping you deal with
depression
www.heretohelp.bc.ca
A project of the BC Partners for Mental Health and
Addictions Information, intended to help people better
prevent and manage mental health and substance abuse
problems
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Access to Services / Resources
Internet

Social media sites that offer tools for education, informationsharing and advocacy, i.e. websites, blogs, forums,
YouTube, Facebook, twitter, MySpace, etc

Look for:
o Established arthritis organizations that are patient
focused
o Full acknowledgement of funding sources to promote
transparency
o The URL extension on the website address. E.g. Nonprofit organizations usually end in .org; educational
institutions in .edu; and government websites in .gov
o Be wary of pharmaceutical product advertising
Resources – In addition to these resources, please refer to the Patient Self Management Toolkit
For additional information on education programs and other useful sources of information.
http://www.familycaregiversbc.ca
1-(877)-520-FCNS (3267)
Family Caregiver Network Society. Support for families of
patients with disabilities.
http://www.sparc.bc.ca
The Social Planning and Research Council of BC (SPARC
BC) – who you contact to get a Disability Parking pass.
1-(604)-718-7744 Parking Permit
http://www.labour.gov.bc.ca/wab
1-(800)-663-4261
Workers Advisor Group, for issues related to WorkSafeBC.
http://www.seedsbdc.com
1-(604)-590-4144
SEEDS. An Employment Insurance (EI)-based funding program
for starting up a business.
http://www.disabilityalliancebc.org/
1-(604)-872-1278
1-(800)-663-1278 toll free
BC Coalition of People with Disabilities’ Advocacy Access
Program. Provide individual and group advocacy for people with
disabilities and develop educational publications for people with
disabilities, governments and the public.
http://www.bchousing.org
1-(800)-257-7756
BC Housing. Information on rental subsidies and light
housekeeping.
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Self Management Links
SUMMARY BY ORGANIZATION - Education Programs and Resources for Patients
Education Program / Resource
Description
1. The Arthritis Society
Website

Downloadable PDF handouts, information about programs
www.arthritis.ca
The Arthritis Answers Line

Lower Mainland: 604.875.5051

Other: 1.800.321.1433
A telephone service available in English, French, Cantonese,
Mandarin and Punjabi.
Arthritis Self-Management Program
(ASMP)
Improve understanding of arthritis, pain management and selfmanagement strategies. Program is taught by1-2 trained
volunteers who either have arthritis or are health care
professionals. 6 sessions (2 hours, once/week), $25.00 per
person.
Chronic Pain Management
Workshop
Improve understanding of treatment and management of pain in
arthritis. Workshop is led by ASMP leaders. Classes range from
10 - 14 people
Lifestyle Makeover Challenge
4 week programs that encourage exercise and healthy eating to
delay the onset and reduce pain of osteoarthritis
Take Charge! Early Intervention for
Osteoarthritis
4 week program to help patients with arthritis deal with the
physical and emotional aspects of the disease
Joint Works and Water Works group
exercise programs
45 min – 1 hr group exercise programs for people with arthritis,
offered in various BC communities
2. HealthLink BC


www.healthlinkbc.ca
8-1-1 on your telephone to speak
to a nurse, pharmacist or
dietician


Large online database offering general information on
Osteoarthritis, Rheumatoid Arthritis and Low Back Pain
among hundreds of other health issues.
Translation services available in over 130 languages by
request.
3. Hospital Programs / Services

Some hospitals offer independent programs and services for
patients with arthritis or MSK issues. Contact your local
hospital to enquire about available programs.
4. Mary Pack Arthritis Program
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Education Program / Resource
Description

Locations:
www.arthritis.ca/home
Self Management Links

Vancouver - 895 W 10th Avenue, Vancouver, BC, V5Z 1L7

Victoria - 2680 Richmond Avenue, Victoria, BC, V8R 4S9

Penticton - 550 Carmi Avenue, Penticton, BC, V2A 3G6

Cranbrook - 13 – 24th Avenue North, Cranbrook, BC, V1C
3H9
Patient Education Program (all sites)
Free classes on a range of topics to help patients manage their
arthritis.
Outpatient Rehabilitation Services
(all sites)
Treatment services for children and adults with all forms of
arthritis. Referral is needed by family physician for physical and
occupational therapy. Referrals for nursing, and vocational
counseling can be from any health care professional. Referrals
for social work can be self-referred.
Specialized Programs / Services
(services vary by location)
Specialized programs and services that require rheumatologist
referral.
o Outpatient Day Programs
o Drug Monitoring Program (Vancouver and Penticton)
o Rapid Access for Diagnosis of Early Rheumatoid Arthritis
(Vancouver)
o Children and Young Adults Program (Vancouver, Victoria and
Penticton)
o Fibromyalgia Self- Management Program (Victoria and
Penticton)
Outreach Services
 Consultations, treatment and education services to
underserved rural communities provided by rheumatologists,
occupational therapists, and multidisciplinary teams
 Travelling Rheumatology Consultation Service - Pender
Harbour, Powell River, Comox, Campbell River, Port Alberni,
Alert Bay, Cranbrook, Valemount, Nelson, Castlegar, Trail,
Williams Lake, Burns Lake, Dawson Creek, Fort St. John,
Fraser Lake, Hazelton, Kitimat, Massett, New Aiyansh,
Prince George, Prince Rupert, Smithers, Terrace, and Queen
Charlotte City.
 Travelling Occupational Therapy Service - Bella Bella, Bella
Coola, Klemtu, 100 Mile House, Lillooet, Merritt, Williams
Lake, Hazelton, Prince George, Quesnel, Smithers, Terrace
5. OASIS – OsteoArthritis Service Integration System
Website:
Information and videos for people with OA who want to learn
about self-management strategies and joint replacement surgery.
 http://oasis.vch.ca/
Translated documents in Punjabi, Farsi, Traditional Chinese and
Simplified Chinese
Multidisciplinary Assessment
An assessment with a nurse, PT, and/or OT to create an Action
Plan for self-management of OA with referral to community
resources. Available in Vancouver, Richmond and West
Vancouver
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Self Management Links
Education Program / Resource
Primary Education Sessions
Description
Free education sessions for patients with OA to encourage selfmanagement. Topics include disease information, goal setting,
joint protection, exercise, pain management, nutrition and weight
control.
Listing of Community Services:
 http://oasisservices.vch.ca/search.aspx
Searchable database to link patients to hundreds of programs,
organizations and resources throughout BC
6. Patient Voices Network
Website:
 www.patientvoices.ca
Peer Coaching Program
The Patient Voices Network is led by BC Patient Safety Quality
Council in collaboration with Patients as Partners, Ministry of
Health.
Telephone based model where people can phone in to get
support and motivation towards healthy lifestyle changes. Free
but requires registration.
7. University of Victoria – Centre on Aging
The Centre on Aging at the University of Victoria is a
Website:
 http://web.uvic.ca/~pmcgowan/re multidisciplinary research centre established in 1992. Their
mandate is to promote and conduct basic and applied research
search/cdsmp/index.htm
throughout the lifespan.
Chronic Disease Self–Management
Free general education program for adults experiencing chronic
Program
health conditions (e.g., hypertension, arthritis, heart disease,
stroke, diabetes, etc.)
Chronic Pain Self- Management
Program
Free education program developed specifically for persons
experiencing chronic musculoskeletal pain.
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Self Management Links
Information Resources for Patients
Program / Resource
Description
1. Arthritis is Cured
www.arthritisiscured.org

2. Arthritis Research Centre (ARC)
www.arthritisresearch.ca

Arthritis Quick Reference tool - handout for physicians that
includes (1) arthritis indicators for RA and OA, (2) Red Flag
Indicators/Symptoms, (3) Course of Action for Physicians.
Also accessible to the public
Provides educational videos, decision tools (ANSWER, etc.),
research plain language summaries, a comprehensive list of
terms and acronyms to help patients/consumers disseminate
research results, and a support group (Consumer Advisory
Board) that publishes a quarterly newsletter.
3. Arthritis Resource Guide for BC


4. Back Care Canada
www.backcarecanada.ca/

5. Canadian Arthritis Patient Alliance
www.arthritispatient.ca

6. Cochrane Musculoskeletal Group
http://musculoskeletal.cochrane.org/

Links to resources based on patient’s input of geographical
location.
PDFs not easily accessible by arthritis patients as these
documents are only located under the “practitioner” tab.
Information addressing topics for people suffering from back
and leg pain in an easy-to-read and focused format
Support community to promote advocacy of arthritis to
improve the quality of life and care of people with arthritis
Dedicated to evidence-based research in the form of plain
language summaries. These summaries recap the main
ideas and results of systematic reviews in everyday
language. Also available, decision aids.
7. Guidelines and Protocols Advisory Committee (GPAC) – Patient Guidelines
http://www.bcguidelines.ca/gpac/pati  Patient information guides: Downloadable PDF files on a
ent_guides.html
variety of topics including RA and OA
8. Joint Health (formerly Arthritis Consumer Experts)
www.jointhealth.org
 Offers subscriptions to monthly newsletters, breaking news
subscriptions, podcasts, online video workshops, and
surveys regarding arthritis.
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Arthritis Resources and Supports (Note: Additional resource references are available in the patient section – sorted by topics such as nutrition, exercise, aids to daily living, pain management etc.) Program / Resource The Arthritis Society Getting A Grip The Arthritis Society http://www.arthritis.ca Description Medical and allied health program to increase the capacity of primary health care providers, communities and people with arthritis. 
Organisation provides patient and physicians education tools and resources. 


Downloadable patient education tools and links to community programs and resources 1.800.321.1433 Arthritis Consumer Experts Joint Health – changing arthritis Topics Consumer organization providing evidence‐
based information for patients on topics related to arthritis 













Focus on Osteoarthritis and Rheumatoid
Arthritis
Enhancing Physician Skills
Diagnosing Arthritis
Helpful Patient Advice
Resources for patients and physicians
Patient Partners Program
Hands on experience and practice with
arthritis patients for health professionals
Diagnosis and Management of Arthritis
Newsletter
Programs include
Arthritis Self‐Management Program
Chronic Pain Management Program
Arthritis Education Forums
Camp Capilano
Info line
Joint health website
Newsletter
Webcasts on a variety of topic including
practical issues related to living with arthritis
http://www.jointhealth.org/home.
cfm?locale=en‐CA Arthritis Resource Guide Patient Education Materials Allow patients and health care professionals 
to search for arthritis tools and resources in their local area 

Materials provided by VCH for non‐

commercial purposes. 

PDFs not easily accessible by arthritis 
patients as these documents are only Resources for Physicians, Nurses, OTs and
PTs
Type of Arthritis
Joints Affected by Arthritis
Disease or Symptom Management
Medication Info
Joint Protection
Wear and Care of Splints and Orthotics
located under the “practitioner” tab. RACE Line
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Program / Resource Guidelines and Protocols Advisory Committee (GPAC) Professional Guidelines http://www.bcguidelines.ca/gpac/i
ndex.html Return to OA Page
Return to RA Page
Description Downloadable PDF files available on a large number of health related issues and topics for health care professionals. Topics 


Guidelines are intended to give an 
understanding of a clinical problem, and 
outline one or more preferred approaches to the investigation and management of the 

problem. 





Mary Pack Arthritis Centre Arthritis Continuing Education (ACE) Program Pain BC Toolbox Provides learning opportunities for allied health professions throughout BC. Membership is free to physiotherapists, occupational therapists and nurses with an interest in rheumatic diseases. 




Arthritis Clinical Exchange
Newsletters
Clinical Consultation
Professional Resources
ACE Course “Introduction to the Assessment
and Management of Rheumatic Diseases”
Provides treatment options for pain beyond medications, surgery and injections 





Pain self management
Sleep
Mind‐Body medicine
Support
Exercise and activity
Lifestyle
Contains educational resources and tools for both patients and physicians, produced by a Canadian practicing rheumatologist and an associate professor of rheumatology. 


Disease information
Medication information
Physician tools
Treatment Options for Pain – Beyond Medications, Surgery and Injections http://www.painbc.ca/resources‐
for‐health‐care‐providers Rheuminfo Online Rheumatology Resource Guide Osteoarthritis in Peripheral Joints –
Diagnosis and Treatment
Arthritis Summary
Osteoarthritis Medications Table
History
Physical Examination
Alternate Diagnosis and Overall Assessment
Investigations
Follow‐ up Patient Assessment Form
Non Health Care Professional Guidelines
Calculation of Body Mass Index
Rheumatoid Arthritis: Diagnosis and
Management
Summary
Patient Guide
http://rheuminfo.com/ RACE Line
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Summary of Resources by Organization Education Program / Resource Return to RA Page
Description The Arthritis Society Downloadable PDF handouts, information about programs Website www.arthritis.ca The Arthritis Answers Line Lower Mainland: 604.875.5051 Other: 1.800.321.1433 A telephone service available in English, French, Cantonese, Mandarin and Punjabi. Regional Offices with arthritis libraries and resources in Vancouver, Victoria, Kelowna and Langley [email protected] Arthritis Self‐Management Program (ASMP) Improve understanding of arthritis, pain management and self‐management strategies. Program is taught by1‐2 trained volunteers who either have arthritis or are health care professionals. 6 sessions (2 hours, once/week), $25.00 per person. Chronic Pain Management Workshop Improve understanding of treatment and management of pain in arthritis. Workshop is led by ASMP leaders. Classes range from 10 – 14 people Lifestyle Makeover Challenge 4 week programs that encourage exercise and healthy eating to delay the onset and reduce pain of osteoarthritis Patient Education Forums Delivered by trained arthritis healthcare professional, forums educate people on specific arthritis‐related topics including disease and treatment information, nutrition and life‐
style management, etc. Joint Works and Water Works group exercise programs 45 min – 1 hr group exercise programs for people with arthritis, offered in various BC communities HealthLink BC www.healthlinkbc.ca 8‐1‐1 on your telephone to speak to a nurse, pharmacist or dietician Large online database offering general information on Osteoarthritis, Rheumatoid Arthritis and Low Back Pain among hundreds of other health issues. Translation services available in over 130 languages by request. RACE Line
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PATIENT HEALTH QUESTIONNAIRE (PHQ-9)
Print
NAME: ______________________________________________________________
Over the last 2 weeks, how often have you been
bothered by any of the following problems?
(use “✓” to indicate your answer)
t
ta
No
all
DATE:_________________________
alf
n hs
a
h
y
t a
re e d
Mo th
ys
da
al
r
ve
Se
y
er
ev
ly
r
a
Ne
1. Little interest or pleasure in doing things
0
1
2
3
2. Feeling down, depressed, or hopeless
0
1
2
3
3. Trouble falling or staying asleep,
or sleeping too much
0
1
2
3
4. Feeling tired or having little energy
0
1
2
3
5. Poor appetite or overeating
0
1
2
3
6. Feeling bad about yourself — or that
you are a failure or have let yourself
or your family down
0
1
2
3
7. Trouble concentrating on things, such as reading the
newspaper or watching television
0
1
2
3
8. Moving or speaking so slowly that other people could
have noticed. Or the opposite — being so fidgety
or restless that you have been moving around a lot
more than usual
0
1
2
3
9. Thoughts that you would be better off dead,
or of hurting yourself in some way
0
1
2
3
add columns:
(Healthcare professional: For interpretation of TOTAL,
please refer to accompanying scoring card.)
10. If you checked off any problems, how
difficult have these problems made it for
you to do your work, take care of things at
home, or get along with other people?
+
y
da
+
TOTAL:
Not difficult at all
_______
Somewhat difficult
_______
Very difficult
_______
Extremely difficult
_______
PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an
educational grant from Pfizer Inc. For research information, contact Dr Spitzer at [email protected]. Use of the PHQ-9 may only be made in
accordance with the Terms of Use available at http://www.pfizer.com. Copyright ©1999 Pfizer Inc. All rights reserved. PRIME MD TODAY is a
trademark of Pfizer Inc.
ZT242043
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Fold back this page before administering this questionnaire
INSTRUCTIONS FOR USE
for doctor or healthcare professional use only
PHQ-9 QUICK DEPRESSION ASSESSMENT
For initial diagnosis:
1. Patient completes PHQ-9 Quick Depression Assessment on accompanying tear-off pad.
2. If there are at least 4 ✓s in the blue highlighted section (including Questions #1 and #2), consider a
depressive disorder. Add score to determine severity.
3. Consider Major Depressive Disorder
— if
there are at least 5 ✓s in the blue highlighted section (one of which corresponds to Question #1 or #2)
Consider Other Depressive Disorder
—if
there are 2 to 4 ✓s in the blue highlighted section (one of which corresponds to Question #1 or #2)
Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician and a definitive diagnosis
made on clinical grounds, taking into account how well the patient understood the questionnaire, as well as other relevant
information from the patient. Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social,
occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a history of a Manic
Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of the depressive symptoms.
To monitor severity over time for newly diagnosed patients
or patients in current treatment for depression:
1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) at home
and bring them in at their next appointment for scoring or they may complete the questionnaire during
each scheduled appointment.
2. Add up ✓s by column. For every ✓: Several days = 1
More than half the days = 2
Nearly every day = 3
3. Add together column scores to get a TOTAL score.
4. Refer to the accompanying PHQ-9 Scoring Card to interpret the TOTAL score.
5. Results may be included in patients’ files to assist you in setting up a treatment goal, determining degree
of response, as well as guiding treatment intervention.
PHQ-9 SCORING CARD FOR SEVERITY DETERMINATION
for healthcare professional use only
Scoring—add up all checked boxes on PHQ-9
For every ✓: Not at all = 0; Several days = 1;
More than half the days = 2; Nearly every day = 3
Interpretation of Total Score
Total Score
1-4
5-9
10-14
15-19
20-27
Depression Severity
Minimal depression
Mild depression
Moderate depression
Moderately severe depression
Severe depression
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RACEconnect.ca
Monday to Friday 0800-1700
Local Calls: 604-696-2131
Toll Free: 1-877-696-2131
RAPID ACCESS TO
CONSULTATIVE EXPERTISE
Telephone advice for:
Nurse
Practitioners
Family
Physicians
• family physicians
• community specialists
• nurse practitioners
• house staff
S
Connect
Community
Specialists
RACE can help you:
• simplify the patient journey
• improve patient outcomes
• reduce system costs
• connect with specialists
RACE Specialists
TImely
House
Staff
RACE provides:
An opportunity to speak directly with specialists
Timely guidance and advice
Enhanced ability to manage the patient in your office
2
HRS
Assistance with plan of care
Learning opportunity
CME
Calls returned within 2 hours and commonly
within an hour
CME credit through “Linking Learning to Practice”
www.cfpc.ca/Linking Learning_to_Practice
Speak directly to a specialist:
VCH
• Nephrology
• Heart Failure
• Psychiatry
• Respirology
• Endocrinology
• Cardiovascular
• Risk & Lipid Management
• General Internal Medicine
• Geriatrics
• Geriatric Psychiatry
• Gastroenterology
VCH & FHA
Provincial Services
• Cardiology
• Rheumatology
• Child & Adolescent Psychiatry
• Chronic Pain
• Treatment Resistant Psychosis
Unanswered Calls?
If you call the RACE line and do not receive a call back within 2 hours, call: 604-682-2344 ext. 66522.
RAPID ACCESS TO
CONSULTATIVE EXPERTISE
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Self Management Links
PSM Action Plan
Supporting Self-Management
Goal Setting
The 3 questions:
1) What is it about your current health
that bothers or worries you?
2) How do you feel about this?
3) What is it that you can personally
do about this issue?
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PATIENT ACTION PLAN Date: _____________________ My goal: __________________________________________________________________ ___________________________________________________________________________ 1. First step to help me achieve my goal: Something I WANT to do this week:
___________________________________________________________________________ ___________________________________________________________________________ Describe your goal ‐ so that someone else can understand and see it: How often: _________________________________________________________________ When (time of day): _________________________________________________________ Where: _____________________________________________________________________ 2. Confidence rating: (0 ‐ 10) ________
How confident (sure) are you that you can do the whole plan on a 0‐10 scale? If confidence is less than 7, see problem solving suggestions 3. Follow‐Up: who are you going to talk to about how the plan went?
____________________________________________________________________________ ____________________________________________________________________________ 4. When are you going to check in?
____________________________________________________________________________ _______________________________________________________ Patient Signature Next
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PROBLEM SOLVING SUGGESTIONS If your confidence is low, or you encounter barriers completing your plan, try problem solving: 1. Identify the problem. Be specific! What’s getting in the way of being sure you can complete your plan before your start or carrying it out once you start. 2. List all possible solutions. Brainstorm ideas, from the ridiculous to the sublime. 3. Pick one. Sometimes a combination of a couple of ideas works. 4. Try it for 2 weeks. Give it a good test! 5. If it doesn’t work, try another. 6. If that doesn’t work, find a resource for ideas. Maybe a friend or a professional can help. 7. If that doesn’t work, accept that the problem may not be solvable now. Set it aside for now and work on something else. Reference for Action Plan and Problem‐solving: Centre for Comprehensive Motivational Interventions, www.centreCMI.ca Kate Lorig et al Living a Healthy Life with Chronic Conditions 2 ed., Bull Publishing, San Francisco, 2001. Return to page 1
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Brief Action Planning for Health Is there anything you would like to do for your health in the next week or two?
I have an idea about what I want to do I can’t think of any, I need ideas. Make a SMART plan Perhaps you’d like to work on one of the suggestions below or you have some own ideas of your own to put in the empty boxes: My idea is: Answer these questions about your idea: 1. What exactly do I want to do? Eating habits Physical activity 2. How long will I do this or how much will I do it? Stress 3. How often will I do it and when? 4. Where will I do it? Smoking Sleep 5. When will I start? Medications Example: I will walk 15 minutes five times a week on Mon-­‐Fri around the block starting tomorrow. OR I will measure portion sizes every dinner 3 nights a week on M, W, F starting Monday. Repeat your plan out loud beginning with “I will……” How confident on a scale from “0 to “10” do you feel about carrying out your plan?
(“0” means no confidence or not sure and “10” means you are very confident or very sure.) 0 | 1 | 2 | 3 | 4 | 5 | Confidence less than 7 What might increase your confidence? Consider these options or an idea of your own: o Adjust your goal if it is too big. o Think about barriers and how to overcome them. o Ask others to support you. o Think about the specifics of your plan and adjust it. o Maybe this plan isn’t a good place to start, or maybe now is not a good time and waiting is a good idea. If you modify your plan then ask yourself again, “How confident am I to carry out my plan?” if you are 7 or higher, move to checking on your plan (next box). 6 | 7 | 8 | 9 | 10 | Confidence 7 or higher You’ve made a good plan that is likely to b e successful for you! Checking in on your plan is important for learning and success. Consider a check-­‐in date: ___________ Would you like to involve someone to review your plan with you? If you decide to check in with someone else, who is it? __________________ . When you review your plan, think about your next steps and start again at the top. Based on a form c reated by M.Wiebe (2011) from Cole S, Gutnick D, Davis C, Reims K. Brief Action Planning, Centre for Comprehensive Motivational Interventions, www.centreCMI.ca Return to page 1
Self Management Links
The Brief Action Planning Guide (8 Nov 2012) A Self-­‐Management Support Tool for Chronic Conditions, Health and Wellness Brief Action Planning is structured around 3 core questions, below. Depending on the response, other follow-­‐up questions may be asked. If at any point in the interview, it looks like it may not be possible to create an action plan, offer to return to it in a future interaction. Follow-­‐up is addressed on page 2. Question #1 of Brief Action Planning can be introduced in any clinical interaction when rapport is good. 1.
Ask Question #1 to elicit ideas for change. “Is there anything you would like to do for your health in the next week or two?” a.
If an idea is shared, specify details as they apply to the plan (Help the person make the plan SMART -­‐ Specific, Measurable, Achievable, Relevant and Timed). “What?” “When?” (time of day, day of week, start date) “How much/long?” “How often?” “Where?” b.
c.
2.
3.
For individuals who want or need suggestions, offer a behavioral menu. i.
First ask permission to share ideas. “Would you like me to share some ideas that others I’ve worked with have tried?” ii.
Then share two to three ideas. “Some people I have worked with have ________, others have had success with _______ or _________.” iii.
Then ask what they want to do. “Do any of these ideas work for you, or is there something else I haven’t mentioned that you would like to try?” iv.
If an idea is chosen, specify the details in order to make the plan SMART (above). After the individual has made a specific plan, elicit a commitment statement. “Just to make sure we both understand the details of your plan, would you mind putting it together and saying it out loud?” Ask Question #2 to evaluate confidence. “I wonder how confident you feel about carrying out your plan. Considering a scale of 0 to 10, where ‘0’ means you are not at all confident and ‘10’ means you are very confident, about how confident do you feel about your plan?” The word “sure” may be substituted for the word “confident”. a.
If confidence level >7, go to Question #3 below. “That’s great. It sounds like a good plan for you.” b.
If confidence level <7, problem solve to overcome barriers or adjust plan. “5 is great. That’s a lot higher than 0, and shows a lot of interest and commitment. We know that when confidence is a 7 or more, people are more likely to be successful. Do you have any ideas about what might raise your confidence?” c.
If they do not have any ideas to modify the plan, ask if they would like suggestions. “Would you like to hear some ideas from other people I’ve worked with?” d.
If the response is “yes,” provide two or three ideas. “Sometimes people cut back on their plan, change their plan, or make a new plan. Do you think any of these might work for you or something else you’ve thought of?” e.
If the plan is altered, repeat Question #2 to evaluate confidence with the new plan. Ask Question #3 to arrange follow-­‐up or accountability. “Sounds like a plan that’s going to work for you. Would you like to set a specific time to check back in with me so we can review how things have been going with the plan?” Make the follow-­‐up plan SMART. www.centreCMI.ca 1 Return to page 1
Self Management Links
Follow-­‐up for Brief Action Planning 1. First ask, “How did it go with your plan?” 2.
a.
If successful recognize (affirm) their success. b.
If partially successful, recognize (affirm) partial success. c.
If little or no success, say, “This is something that is quite common when people try something new.” Then ask, “What would you like to do next?” a.
If the person wants to make a new plan, follow the steps on page 1. Use problem solving and a behavioral menu when needed. b.
They may want to talk about what they learned from their action plan. Reinforce learning and adapting the plan. c.
If the person does not want to make another action plan at this time, offer to return to action planning in the future. The Spirit of Motivational Interviewing The Spirit of Motivational Interviewing underlies Brief Action Planning. 1. Partnership: Work in collaboration. 2. Acceptance: Respect autonomy and the right to change or not change. 3. Evocation: Ideas come from the person, not the clinician or helper. 4. Compassion: Act with heart when providing assistance. This tool was developed by Steven Cole, Damara Gutnick, Kathy Reims and Connie Davis. www.centreCMI.ca 2 Return to page 1
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Brief AcCon Planning Flow Chart Developed by Steven Cole, Damara Gutnick, Connie Davis, Kathy Reims “Is there anything you would like to do for your health in the next week or two?” Have an idea? Not sure? Behavioral Menu Not at this Cme 1) Ask permission to share ideas. 2) Share 2-­‐3 ideas. 3) Ask if any of these ideas or something else might work. SMART Behavioral Plan Specific Measureable Achievable Relevant Timely “That’s fine, if it’s okay with you, I’ll check next Cme.” Elicit a Commitment Statement “How confident (on a scale from 0 to 10) do you feel about carrying out your plan?” Confidence ≥7 “That’s great!” Confidence <7 “A __ is higher than a zero, that’s good!” Problem Solving: “Any ideas about what might raise your confidence?” No Yes Specific Measureable Achievable Relevant Timely Behavioral Menu Restate new plan and ask about confidence again “Would you like to set a specific Cme to check back in with me so we can review how things have been going with the plan?” www.centreCMI.ca
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Follow-­‐up on the Brief AcCon Plan “How did it go with your plan?” Success ParCal success Did not try or no success Recognize success Recognize parCal success Reassure that this is common occurrence “What would you like to do next?” The Spirit of MoCvaConal Interviewing is the foundaCon of Brief AcCon Planning Partnership Acceptance Evoca5on Compassion Miller W, Rollnick S. MoCvaConal Interviewing: Preparing People for Change, 3ed. 2013. www.centreCMI.ca
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Health Passport Overview
What is the Health Passport?
The Health Passport is a comprehensive tool that has been designed to support individuals in
the management of their health care conditions. It can be used for any state of health from
healthy living choices for those who are generally healthy to people that are living with one or
more chronic illnesses such as arthritis.
How is the Health Passport useful to patients?
The Health Passport has a number of tools to support patient self management, including goal
setting, tracking the progress of a condition, preparing for medical visits and helping to find
information or education resources. Individuals will use the passport differently; some may fill it
out in its entirety or just use the sections that are most meaningful to them.
The Heath Passport has the following sections:
Section
Purpose
1. Introduction
1. To provide information on the Health Passport including
why and how to use it
2. To discuss some common health care terms such as
prevention and self management
2. About Me
3. To provide patients with a one page information sheet to
record their personal and health care information,
including allergies, medical conditions and medications
3. Working with My Health Care Team
4. To provide various self management tools including a
tracking diary, information on how to set goals, recording
test results and finding education resources
4. My Community Contact Information
5. To provide contact information for a list of national and
provincial health care resources
5. Miscellaneous
6. To provide some useful websites with information on
symptoms, tests, medications and making medical
decisions
6. Retired Health Records
7. To provide a section for patients to store older health
records for safekeeping and future reference
7. Forms for Photocopying
8. To provide a section for patients to store forms that are
used on a regular basis
How is the Health Passport useful to family physicians?
Although a patient-focused tool, the Health Passport can be useful to family physicians in two
ways: (1) as an optional tool to help patients coordinate and direct their self management
efforts; and (2) to serve as a reference point for various self management discussions and
interventions such as goal setting, tracking symptoms and drug interactions, recording test
results and finding community resources.
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Treatment Options for Pain – Beyond Medications, Surgery and Injections.
Options for Developing a Personal Toolbox of Pain Solutions.
Dr. Pam Squire, Dr. Owen Williamson, Dr. Brenda Lau, Diane Gromala, Ph.D, Neil Pearson, April 2011
Use knowledge about
chronic pain to validate
your experience, understand treatment options,
and empower you to be
your own best advocate.
Optimize your sleep —
it may improve energy
levels, pain coping and
mood.
Cognitive-based
psychotherapy (CBT)
cannot alter pain but
many, many people find
it dramatically alters how
much they suffer from
their pain. Use this and
other resources to help
with anxiety, depression,
anger, and fear.
Use gentle exercise
and progressively
increase activity to
optimize weight, reduce
stress and to improve
tolerance, fatigue, and
sleep.
Lifestyle changes
Eat well, use appropriate
alternative and complimentary medicine, find
help to quit smoking
and more.
Getting the right kind
of support from your
spouse and from others
who have chronic pain
can reduce the burden of
chronic pain and offer
alternative perspectives.
In this section, find
provincial phone numbers
for housing, help with
work, and help with
disability forms & options.
Mindfulness, yoga,
and breathing
exercises will reduce
your pain, calm your
nervous system, reduce
stress & improve
your sleep.
TABLE OF CONTENTS
Pain Self-Management & Pain Education Courses . . . p.2
Improving Sleep . . . p.5
Changing Your Mind – Changing Your Pain . . . p.5
Mind-Body Medicine for Pain Relief . . . p.7
Getting Help — Support for People With Pain & Disability . . . p.8
Exercise & Progressive Activity . . . p.10
Lifestyle Changes . . . p.11
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HOW TO USE THIS BOOKLET
Chronic pain is overwhelming, period.
No matter who you are, everyone with chronic pain feels this way at some point.
This information is about trying to change that. We recommend that you try things ONE SMALL BIT AT A TIME.
Otherwise, it may feel like an insurmountable challenge to try to address everything all at once.
However you came to have this pain Lous Heshusius says something that healthcare workers don't always consider.
Communities, homes, and workplaces can and do influence people's health decisions and experience. Your experience is
happening in a society that isn't ready for you. It will stigmatize you and in many ways can contribute to your disability. !0 years
ago obesity was labeled an personal problem and treatment focused solely on controlling what a person ate and how they
exercised. Today we understand the important contribution from society - food industry that promotes excessive portions, food
outlets that make high calorie, low nutrition choices the most available and communities and work places that make exercise
difficult.
People who report feeling the best find empathetic but slightly pushy specialists (this includes your doctor, physio, occupational
or exercise therapist, psychologists, etc). Like our top athletes, you need someone who knows how to push you a little bit when
you don't really feel like doing anything more . . . This is just like our athletes who have found that physical coaching wasn't
enough to do their best – they needed that PLUS psychological coaching, a great diet AND community support. Our athletes
had access to great coaching and programs but it wasn't until we as a country really supported our athletes Canada that we
"Owned the Podium".
So, you are unlucky to live now when society does more TO you than FOR you. BUT you can help us change that. START by
becoming a member of PainBC (It's free! All we need is your email address and name http://www.painbc.ca/ ) and help us
convince governments and Health Authorities to support people with pain. Go to the Canadian Pain Summit webpage and
register to make your voice heard. (A petition to the new government will begin right after the next elections- we need your
signature!!!)
file://localhost/p/::www.canadianpainsummit2012.ca:en:home.aspx
Everyone who wrote this document believes that you will can have the best life possible when you use BOTH medication and
some of the things we talk about in this booklet.
So . . .
Pick ONE area to start with and try something. Didn't help? At all? . . . DON’T GIVE UP ! ! !
When you feel the time is right, try again or try something new.
People who live well with chronic pain tell us that they did best when they felt like they were equal partners in managing their
pain. Most said that in the early days, they relied heavily on medications, surgery and needles, because they were anxious to
find a cure for the pain that had started to control and destroy their life. We don't for a minute want to tell you that you should
give up on that route BUT if you are doing this and are still struggling here are some things many patients have found helpful. As
Pete Moore writes about his pain toolkit,
“Pain self management is about learning new (or using old) skills, trying them out and see what works for you.
Pain is like a fingerprint, so each person may need to have individual skills to suit him or her.
Acceptance is not about giving up but recognizing that this is your pain to manage and you need to take more control.
Acceptance is also a bit like opening a door – a door that will open to allow you in to lots of self-managing
opportunities. The key that you need to open this door is not as large as you think.
All you have to do is to be willing to use it and try and do things differently.”
We hope that each week you and your health care partner can look at one “tool” you would like to work on and using the
resources provided in the next few pages, find some help to achieve your goals.
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PAIN SELF-MANAGEMENT AND PAIN EDUCATION COURSES
These courses offer information in pain education, coping strategies and support all in one place.
1. The Chronic Disease Self-Management Programs
In British Columbia go to this website:
http://www.coag.uvic.ca/community.htm
> click on the [community] button and then
> click on [CDSMP] and then click on the pink province shaped button labelled schedules on the top right side of the page
and choose the appropriate Health Authority for workshop schedules and the opportunity to volunteer as Leader.
These are free and consist of six, 90-minute sessions on pain self-management.
2. The Pain Toolkit. This is a great place to get started! It’s free and can be downloaded in a few minutes.
(But it is based in the United Kingdom, so it makes reference to links that are there.)
http://www.paintoolkit.org/
3. Private pain clinics often offer pain education sessions. WCB or ICBC or private insurance companies (the ones funding the
disability payments) can be contacted for payment options. Some examples of these clinics include: Orion Health:
http://www.orionhealth.ca/
4. St. Paul’s Hospital Pain Clinic offers pain education day programs. Click on Programs and Services to see available
programs. Patients may be referred there:
http://www.paincentresph.com/contact.html
5. Fraser Health will be opening the new outpatient pain clinic in the spring of 2011 (604-585-4450). For information on that
and other programs CALL General Information at 1-877-935-5669. The Fraser Health website is hopeless for pain information.
http://www.fraserhealth.ca/about_us/building_for_better_health/surrey_outpatient_care_and_surgery_centre/benefits_and_servi
ces
6. On Vancouver Island: go to the VIHA website on chronic pain at:
http://www.viha.ca/pain_program
VIHA has 3 pain clinic locations under a regional program in Victoria, Nanaimo and Comox.
The phone number for the Victoria Program is 250-519-1836 . The Nanaimo Pain Clinic has a pain education program. Call 1(250)-739-5978.
7. The Victoria Pain Clinic is a separate private clinic that offers individual, customized programs.They focus on non
medication solutions for pain. Contact the office at 1-(250)-727-6250 for details.
8. The BC Arthritis Society sponsors workshops on chronic pain & Fibromyalgia AND on all the types of arthritis and some
associated conditions ie. osteoporosisToll free phone 1-(800)-321-1433.
http://www.arthritis.ca
> search under [Fibromyalgia] for newsletters, library resources and forums.
9. Overcome Pain Live Well Again. These are presented as archived webcasts to help people understand pain and provide
optimistic guidance about pain self-management techniques. The podcasts include video footage of Neil Pearson speaking and
copies of his slides. They are available on the Canadian Pain Coalition (CPC) website under archived podcasts
http://www.canadianpaincoalition.ca/index.php/en/help-centre/conquering-pain
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PAIN EDUCATION WEBSITES
It is important to understand why pain can become chronic, why it doesn’t improve with time and why medications or surgery
often provide only partial and often temporary relief. We HAVE NOT included resources and websites for specific types of pain
as it would make this document a textbook but links for many different kinds of pain (i.e. Fibromyalgia, Complex Regional Pain
Syndrome, Diabetic Neuropathy) can be found on central websites like PainExplained http://www.painexplained.ca/ and others
listed in the green "Getting Help" section.
These sources of information are perfect for anyone who can’t get to a face-to-face workshop.
1. Med School for You has 8 video modules giving an overview of the whole CPSMP program which is available online for a
fee. To access very good info on the site click on Pain Syndromes underneath the Med School title for info on a complete list of
chronic pain conditions. This site is supported by the Canadian Pain Society (CPS) & the Canadian Pain Coalition (CPC).
http://www.medschoolforyou.com/
2. The Canadian Pain Coalition’s Conquering Pain for Canadians booklet and Conquering Your Pain video offer important
information for managing pain effectively.
http://www.canadianpaincoalition.ca/index.php/en/help-centre/conquering-pain
3. The Calgary Pain Centre has this lecture series online.
http://www.calgaryhealthregion.ca/programs/rpp/resources/lectures.htm
BOOKS ON PAIN SELF-MANAGEMENT
1. Managing Pain Before it Manages You by Margaret Caudill
This is a wellspring of wisdom and practical approaches that can help transform your life as well as your pain. Dr Caudill’s
enormous wealth of knowledge, extensive clinical experience and compassionate understanding combine to make this
the single best book on pain available today.
http://www.amazon.com/Managing-Pain-before-Manages-You/dp/0898622247
2. Pain Management for Older Adults: A Self-help Guide by Thomas and Heather Hadjiistavropoulos
http://www.iasp-pain.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=8240
3. Fibromyalgia & Chronic Myofascial Pain: A Survival Manual by D. Starlanyl and M.E. Copeland
(New Harbinger Publications, 2001).
4. The Fibromyalgia and Chronic Fatigue and Life Planner Workbook: Healing Resources for Patients, Family and Friends
by Dawn Hughes (Universal Publishers, 2001).
5. Yoga for Pain Relief: Simple Practices to Calm Your Mind and Heal Your Chronic Pain by Kelly McGonigal.
New Harbinger Publications Inc, 2009.
6. Mindfulness Meditation for Pain Relief: Guided practices for reclaiming your body and your life by Jon Kabat-Zinn.
7. Break Through Pain: A Step-by-Step Mindfulness Meditation Program for Transforming Chronic and Acute Pain by
Shinzen Young. Sounds True Inc., 2007.
8. Unlearn Your Pain. by Dr Howard Schubiner look at the website http://www.unlearnyourpain.com/
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BOOKS ON PAIN PATHOPHYSIOLOGY
Books for anyone who needs to understand more about the mechanisms of chronic pain.
1. Painful Yarns by Dr. Lorimer Moseley
This is a compilation of hilarious stories and images intended to help explain the complexity of pain.
These stories, while entertaining, are used as metaphors to explain key aspects of the biology of pain.
Painful Yarns is a perfect pre-read for Explain Pain.
http://www.amazon.com/Painful-Yarns-Lorimer-Moseley/dp/0979988004
2. Explain Pain by David Butler and Lorrimer Moseley
A humorous and maybe slightly irreverent explanation about chronic pain pathophysiology,
http://www.amazon.com/Explain-Pain-David-Butler/dp/097509100X
This links to a you tube video by the authors which discusses the book:
http://www.youtube.com/watch?v=qv7Y26miLDA
3. The Brain that Changes Itself: Stories of Triumph from the Frontiers of Brain Science by Norman Doidge. Penguin Books
2007.
BOOKS ON LIVING WITH PAIN FROM A PATIENT’S PERSPECTIVE (These are great books)
1. The Pain Chronicles by Melanie Thurnstrom (A U.S. author)
2. Inside Chronic Pain: An Intimate and Critical Account by Lous Heshusius. (A Canadian author) Cornell Press 2009.
3. Pain: The Fifth Vital Sign by Marni Jackson see http://marnijackson.com/
4. My Imaginary Illness: A Journey Into Uncertainty and Prejudice in Medical Diagnosis by Chloe Atkins
IMPROVING SLEEP
Chronic pain may interfere with the ability to sleep. Yet many people have terrible sleep habits or have sleep problems that are
sometimes overlooked, and those can also interfere with sleep. (Think of sleep apnea - a problem that causes you to briefly stop
breathing and maybe also snore because of opioids, restless legs, jerking limbs or have medication that causes insomnia)
Because the importance of sleep cannot be stressed enough, we strongly urge you to address any sleep-related issues you
may experience.
For more information on how to sleep well, look at the National Sleep Foundation’s webpage:
http://www.sleepfoundation.org
1. A Sleep Diary
To document your sleep so your health care provider can help determine your problem, complete a sleep diary.
A copy of one you can use is available at:
http://www.sleepeducation.com/pdf/sleepdiary.pdf
2. Everything you ever needed to know to sleep well.
CBT For Insomnia is an online program recommended by sleep experts at the University of British Columbia (UBC).
It costs $35.00, similar to the cost of 2 weeks of sleeping pills. It is for problems falling asleep and waking during the
night/early morning, for individuals who are not, and those who are, using sleeping pills. This program replicates the
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5-session cognitive behavioral program (CBT) for insomnia developed and tested at Harvard Medical School.
CBT has been shown to be one of the most effective and long-lasting treatments for people who don’t sleep well.
http://www.cbtforinsomnia.com/
3. To find a sleep lab near you, see: http://www.css.to/centers.html
If you are trying to stop sleeping pills that are benzodiazepines (like zopiclone/Imovane, clonazepam/Rivotril diazepam/Valium,
lorazepam/Ativan), go to this website and you can purchase the amazing manual for patients and physicians. The manual
contains all of the practical advice you and your physician need to help you stop these medications. It is written by Professor
Ashton, a world authority on the subject. And it costs less than the cost of one visit with a counselor.
http://www.benzo.org.uk/manual/index.htm
CHANGING YOUR MIND – CHANGING YOUR PAIN
Pain can destroy your life. Many patients feel like pain, like a mad dictator, is controlling their entire life.
Even with the best medical advice, the effect chronic pain can have on your life can be devastating.
Medications are often initially effective but for reasons not well understood, the effectiveness often wears off
over time, especially with opioid medications.
What patients have taught all of the health care providers who work with pain is that how much an individual
suffers from their pain is not always related to how severe the pain is. We don't mean to say that severe pain does not cause
suffering. It does. Eric Cassell writes that suffering occurs when there is a threat to the integrity of a person and if the person
cannot be made whole again then the suffering will continue. There are many different kinds of integrity (psychological, physical,
social, financial, spiritual.
Some times it is easier to change your concept of what you will accept - physically, financially, socially- and look for options to
cope with the change, than it is to regain what you had before.
To control the effect pain has on your life you need to first accept it is here for the time being.
We know that people who have spinal cord injuries, for example, have an injury that cannot be fixed.
For the ones who accept their disability, a wheelchair can be a life expanding solution. (ASSUMING that as a community we
have provided wheelchair access...back to how CRUCIAL social acceptance of a problem can be)
For those who cannot accept that they will never walk again, using a wheelchair is only a mark of failure.
Sometimes, chronic pain can be just as irreversible as a spinal cord injury.
We are not suggesting that you give up trying to find pain relieving or curing strategies.
But if you only rely ONLY on medications, surgery or injections to manage your pain, you might be missing out.
Psychologists can teach you a lot about how to have a life with chronic pain. See if you can get a referral to a
psychologist who has experience and knowledge about pain. Pain programs also have psychologists on staff —
if you can get into one of the good ones you are lucky (if you live in BC). Life coaches can also help you if you are feeling
stuck. Not everyone can use these strategies, but they have helped many of our patients.
Please try some of this before you say “not for me ”
Remember . . . START with ONE Change . . .
1. Ask about a referral to a good psychologist. Your employer may have an employee assistance program you can access
for free. Many extended health care plans will cover a referral to a psychologist with a masters or PhD if your physician writes
you a referral. Call the BC Psychological Association phone number: 604 730 0522, or email address at:
http://www.psychologists.bc.ca. They don't have all the psychologists listed in the Province.
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2. Centre for Clinical Interventions. This is a resource centre with many handouts that help people to change the way
they think. It also has psychotherapy course material for family physicians and might be helpful for physicians who are
interested in running group sessions on coping with pain.
http://www.cci.health.wa.gov.au/resources/consumers.cfm
3. The following are a list of some PhD psychologists who have had extensive experience with chronic pain. This IS
NOT a comprehensive list and our patients have found many other excellent psychologists to help them. Many
extended health plans and WCB will cover referrals for a few brief sessions to help get you started or give you a few
refresher points when you need them.
Dr. Elizabeth Bannerman 1-(604)-592-8348
Dr. Wesley Buch 1-(604)-592-8348
Dr. Ingrid Federoff 604-506-8112
Dr. Owen Garrett 1-(604)-294-4295
Dr. Judy Le Page 1-(604)-803-4761
Dr.Tony Le Page 1-(604)-803-4578
Dr. Brian Grady 1-(250)-592-4281 (on Vancouver/Gulf Islands)
4. For a list of other Vancouver area counselors and psychologists with an interest in Pain Management:
http://www.counsellingbc.com/areas/Chronic+Pain 5. Life Coaching. We like Dr Rahul Gupta, a family physician who has additional expertise working with patient's with
chronic pain and is an ICF certified life coach. Contact him for more information wherever you live at:
http://www.voice2vision.net 6. Here to Help. This site provides comprehensive information on mental health and addiction issues and focuses on providing
information that is based on the best research possible.
http://www.heretohelp.bc.ca/about DOWNLOADABLE INFORMATION
1. Psychology of Pain is a blog created by Gary B. Rollman, Professor of Psychology at the University of Western Ontario
and the former President of the Canadian Pain Society. This blog contains links to many useful pain resources and
discussions on a number of pain issues.
http://psychologyofpain.blogspot.com/
2. Centre for Clinical Interventions. This is a resource centre with many handouts that help people to change the way
they think. It also has psychotherapy course material for family physicians and might be helpful for physicians who are interested
in running group sessions on coping with pain.
http://www.cci.health.wa.gov.au/resources/consumers.cfm
3. Cognitive behavioural therapy (CBT). Because of the chronic and persistent pain and fatigue, it is easy to get into habits
of activity and rest that may not be the best way to deal with the pain and fatigue. Cognitive behavioural therapy (CBT) can
help to identify if you have unhelpful ways of thinking and acting, and help you make healthy and positive changes that can
reduce pain and fatigue. This is a self-help website for people that feel stuck that offers people strategies for change.
http://www.getselfhelp.co.uk/chronicfp.htm
HELP WITH MOOD
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1.Mental Health Support through the Bounce Back Program in British Columbia. It requires a referral by a physician.
Bounce Back: Reclaim Your Health is a new program designed to help people experiencing symptoms of depression
and anxiety that may arise from stress or other life circumstances. The BC Ministry of Health Services funds the project.
Call 1-(604)-688-3234 or 1-(800)-555-8222 extension 235.
http://www.cmha.bc.ca/bounceback
Bounce Back offers two forms of help:
1. The first is a DVD video providing practical tips on managing mood and healthy living.
2. The second is a guided self-help program with telephone support. A 6-minutes preview of the video is on the
webiste.
2. Positive Coping with Health Conditions: A Self-Care Workbook (Dan Bilsker, PhD, RPsych, Joti Samra, PhD,
RPsych, Elliot Goldner, MD, FRC(P), MHSc) is a free self-care manual authored by scientist-practitioners with expertise in issues
relating to coping with health conditions such as low mood, worry and tensions. This manual is designed for individuals who
deal with health conditions, including patients, physicians, psychologists, nurses, rehabilitation professionals and researchers.
http://www.comh.ca/pchc/index.cfm
MIND–BODY MEDICINE FOR PAIN RELIEF
.
MINDFULNESS-BASED STRESS REDUCTION
I once asked one of my patients if doing meditation made her pain any better. She was a 65-year-old grandmother
who had severe pain from spine arthritis. She thought for a moment and then said this:
"Dear, I'm not sure if my pain is any better but I am much better with my pain." (Note from Dr Squire-I think she was
actually talking about combining meditation with marijuana but then many things we do have synergy and she did live in Sechelt)
Meditation
Learning meditation is like learning to play an instrument. It takes coaching and practice.
Books and CD’s are helpful, but are no replacement for face-to-face teaching. Going to group meditation courses is a
great way to get out. Many yoga studios, community recreation centres and libraries offer these kinds of courses.
Search online for local courses and practice!
Mindful Living is in Vancouver. Contact them at:
http://www.mindful-living.ca/index.html
Yoga & Tai Chi
Gentle, and restorative yoga practices have been shown effective for helping to decrease pain, improve function and decrease
the psychological and social impact of pain. Many centres have designed classes to accommodate people who have limitations.
Tai Chi has also been demonstrated to be helpful.
BOOKS AND GUIDED CD’S
When face-to-face learning is not an option.
1. Pain Speaking by Jackie Gardner-Nix. Jackie is a Canadian physician with a special interest in pain management. These two
CDs are a companion to The Mindfulness Solution to Pain book. We really like them.
Both CDs and book can be ordered through:
http://www.neuronovacentre.com/books-and-audio/pain-speaking-audio-cd.
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2. Dissolving Pain by Les Fehmi PhD and Jim Robbins. This book also includes a CD of guided exercises:
http://www.amazon.com/Dissolving-Pain-Brain-Training-Exercises-Overcoming/dp/1590307801
3. Mindfulness Meditation for Pain Relief: Guided Practices for Reclaiming Your Body and Your Life by Jon Kabat-Zinn.
This two-CD Audio book, with short meditation exercises, is available to buy through Chapters. Many libraries carry all of the
books written by Kabat-Zinn. These are links to YouTube videos on Kabat-Zinn and mindfulness:
http://www.youtube.com/watch?v=3nwwKbM_vJc
http://www.youtube.com/watch?v=rSU8ftmmhmw&feature=channel
MIRROR THERAPY
For patients with phantom limb pain or complex regional pain syndrome there is published evidence that using mirror boxes
can reduce pain and improve function. A special mirror box is used. The normal arm or leg moves in the mirror box but
what your eyes and brain see looks is the abnormal limb moving (the mirrors reverse the image so your left arm looks like your
right arm. How this works is not well understood. Physiotherapists provide this therapy. Call your local hospital physio
department or the provincial physiotherapist association to find out if it's available in your community. More explanation is on
the NOI group's website (NOI is the Neuro Orthopedic Institute in Sydney Australia lead by some of the world-renowned
physiotherapists who pioneered this work):
http://www.noigroup.com/
GETTING HELP – SUPPORT FOR PEOPLE WITH PAIN AND DISABILITY
We HAVE NOT included resources and websites for specific types of pain as it would make this document a textbook but links
for many different kinds of pain (i.e. Fibromyalgia, Complex Regional Pain Syndrome, Diabetic Neuropathy) can be found on
central websites like the Canadian Pain Society's PainExplained and others listed below.
WEBSITES BY PATIENTS FOR PATIENTS TO PROVIDE SUPPORT AND INFORMATION
1. The Chronic Pain Association of Canada (CPAC) is committed to advancing the treatment and management of chronic
intractable pain, developing research projects to promote the discovery of a cure for this disease, and educating both the health
care community and the public to accomplish this mission. The cost is $15.00 per year.
Phone: 1-(780)-482-6727 Email: [email protected]
http://www.chronicpaincanada.com/
2. The Canadian Pain Coalition (CPC) is a partnership of patient pain groups, health professionals who care for people in pain,
and scientists studying better ways of treating pain. The CPC's purpose is to promote sustained improvement in the treatment
of all types of pain and its main goal is to have pain recognized as a health priority in Canada.
http://www.canadianpaincoalition.ca/
GENERAL WEBSITES for CHRONIC PAIN INFORMATION
1. The Canadian Pain Society has a website for pain information for patients and healthcare providers:
http://www.painexplained.ca/
2. PainBC. The website of the BC pain Society. Look for new information every month:
http://www.painbc.ca/
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3.The Association Quebecoise de la Douleur Chronique (AQDC), (The Quebec Pain Association), is committed to improving
the condition of people suffering from chronic pain in Québec and reducing their isolation. http://www.chronicpainquebec.org
4. The international Association for the Study of Pain (IASP)
http://www.iasp-pain.org
GENERAL SUPPORT FOR A VARIETY OF PROBLEMS IN THE LOWER MAINLAND, BRITISH COLUMBIA
1. Patient Voices Network. Peer-counseling and family support.
1-(604)-742-1772 Toll free: 1-(888)-742-1772
http://www.patientvoices.ca
2. Sources. Community centres – support for patients and families.
1-(604)-531-6226
http://www.sourcesbc.ca
3. Family Caregiver Network Society. Support for families of patients with disabilities.
Support is available Monday through Friday between 8:30 a.m. and 4:30 p.m.
1-(877)-520-FCNS (3267)
http://www.fcns-caregiving.org
4. The Social Planning and Research Council of BC (SPARC BC) – who you contact to get a Disability Parking pass.
1-(604)-718-7744 Parking Permit
http://www.sparc.bc.ca
5. Workers Advisor Group. Please call for an appointment ONLY for issues related to Worksafe BC.
Office Hours: 8:30 – 4:30 Monday to Friday.
1-(800)-663-4261
http://www.labour.gov.bc.ca/wab
6. BC Coalition of People with Disabilities’ Advocacy Access Program.
Their mission is to raise awareness around issues that affect the lives of people who live with a disability.
They also work to secure the necessary income supports for people with disabilities to live with dignity, and increase their
ability to participate and contribute in their communities. They provide individual and group advocacy for people with
disabilities and develop educational publications for people with disabilities, governments and the public, and sharing
self-help skills with individuals and disability groups. They also help you fill in forms for tax rebates or government disability.
Please call for an appointment. Office Hours: 8:30 – 4:30, Monday to Friday.
1-(604)-872-1278 Toll free: 1-(800)-663-1278
http://www.bccpd.bc.ca/contactus.htm
7. BC Housing. Information on rental subsidies and light housekeeping. 1-(800)-257-7756
http://www.bchousing.org
8. Disability Resources Guide. Below are a summary of some helpful contacts from a useful book called the Disability
Resources Guide. It is produced by the group Opportunities for the Disabled Foundation, who can be reached at
1-(604)-437-7780. Disability is not just about changed physical abilities. It is about changed personal situation which creates
barriers to what you want to achieve.
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Because financial concerns become part of those barriers, please also consider contacting the PLAN institute for Caring
Citizenship, where creative and practical solutions can be learned from others who have conquered your same issues.
1-(604)-439-9566.
www.planinstitute.ca
www.PLAN.ca
9. SEEDS. An Employment Insurance (EI)-based funding program for starting up a business.1-(604)-590-4144
http://www.seedsbdc.com
10. The Neil Squire Society. The Neil Squire Society is the only national not-for-profit organization in Canada that has for over
twenty-five years empowered Canadians with physical disabilities through the use of computer-based assistive technologies,
research and development, and various employment programs. Through our work, we help our clients remove barriers so that
they can live independent lives and become active members of the workplace and our society. Specializing in education and
workplace empowerment, the Society has served over 20,000 people since 1984.
www.neilsquire.ca Toll free: 1-877-673-4636
EXERCISE AND PACING
Our patients and studies both tell us that for many people who have chronic pain, trying to get regular exercise is a challenge,
because of the uncertainty of how it will affect their pain levels. This phenomenon is termed “kinesiophobia” and means fear fof
movement. However, just as we need food, we also need exercise – you will be strengthening your body so it can fight pain.
You may also find that it will increase your stamina, reduce fatigue and help with depression. So if you start to exercise regularly
and you have a setback, don’t be discouraged! Try different kinds of low-impact exercises – such as walking or yoga – to see
which ones work best for you. On “bad days,” it is also helpful to visualize yourself exercising, and try breathing exercises – this
helps to keep your body ready for exercise in small but regular steps.
Exercise guideline
These are some simple guidelines to assist you with being more successful when you exercise and work towards increasing
your activities.
1. The first thing is to find your baseline.
This is the amount of activity or exercise that you know is safe for your body, and you know will not make you “pay for it later.”
Even if this is a very small amount of activity, this is where you need to start.
2. Push yourself just a bit, to where there is a small increase in your pain. Then, to make it successful you need to do three
things: work on keeping your breath calm, your body tension low, and at the same time monitor your pain.
If you ignore your pain, you won't know if you are pushing too much.
If you pay too much attention to it, that will increase your pain.
To help find that balance, try dividing your attention between the activity you are doing, keeping your breathing calm, keeping
your body relaxed and attending to your pain a little bit.
If you are like most people, you will have noticed that ignoring the pain doesn't help you get better. You just pay for it later.
3. Practice this more and more. Then you can try pushing further into the pain. Keep working on calm breath and calm body to
get good benefits.
4. Choose an activity you want to do. If you don't want to do any activity, pick something that will make your life easier, more
fun, or help you reconnect with friends. Then do it a little bit.
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Everyday.
When it gets a little easier, do a little more. Take your time.
Be persistent and patient.
It takes practice to change your nervous systems and your body when you have persistent pain.
1. Restorative yoga is available at many different yoga centers and is designed to accommodate people who cannot
do the common poses. Call your local recreation centre or yoga studio to find courses offered near you. If you need to do this
from home, you can order DVD's that have follow along programs. Neil Pearson has developed one that is designed specifically
for people with chronic pain (see his website lifeisnow) but our patients have tried others and many have really enjoyed the
sense of peace and accomplishment. To read about one patients' experience with how yoga transformed her pain:
http://myyogamypain.blogspot.com/2011/03/my-roots.html
2. BC Leisure Access Program
This program provides subsidized access to recreation centres. Sign up for anything that looks appealing.
Hours of operation: Monday to Friday, 8:30am–4:30pm. 1-(604)-257-8497.
http://vancouver.ca/parks/rec/lac/index.htm
LIFESTYLE CHANGES
IMPROVING GENERAL LIFESTYLE CHOICES
BestLifeRewarded™ is the first-ever Canadian loyalty program that actually rewards people for getting healthy. There is no
cost to join or stay in the program and they state they have zero tolerance for sharing your private information.
http://www.bestliferewarded.com
DIET
There is evidence from a few small trials that patients with nerve pain from diabetes had reduced pain when they followed
a low-fat, high-fiber, total vegetarian diet. Nerves and other tissues need nutrients to rebuild and a good diet is a great
place to start.
Dr Kal's weight loss website: This is a US website but the advice is free. If you are overweight and are looking for an
innovative way to help you learn how to change how you think to change how you eat then look at Dr Kal's weight loss site. Dr
Kal was an obese physician who became scared during a rotation in a stroke unit at a hospital. He learned what it took to
change and created a business around it and sold that information for 2 years. Now he is giving it away and we like his
information and the price. http://www.drkalsweightlosstips.com/free-weight-loss-plan.html
LOCAL RESOURCES FOR EATING WELL
Harvest box program. This provides low cost fresh produce for families in Delta, Surrey, White Rock and Langley.
Harvest Box occurs once a month (last Thursday of the month), except December.
1-(778)-228-6614
http://harvestbox.com/index.html
STOP SMOKING
QuitNow By Phone is a confidential, quit smoking support service available to British Columbians. Call Toll-Free to 1-877-4552233 and speak to a professional quit specialist who will guide and support you through your quitting process. Translation
services are available. The BC Ministry of Health has a great web site filled with the same resources- everything you'll need to
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help you quit smoking! http://www.health.gov.bc.ca/tobacco/cessation.html
SUPPLEMENTS THAT MAY RELIEVE NERVE PAIN
These supplements are the only ones that have some medical evidence to support this recommendation.
1. Alpha Lipoid Acid (ALA) is an antioxidant that protects nerves and their blood supply. There are at least 3 good trials that
show pain relief in patients with nerve damage from neuropathy. Most of the studies used 600mg once a day. Do a 3-week trial
to assess it, increasing it if you need to and can tolerate it up to 600 mg three times a day. Side effects included nausea,
vomiting and diarrhea. In high doses (>600mg/day), it can lower blood sugars so diabetics may have to be careful. It is found
naturally in liver, broccoli and spinach.
2. Acetyl-L carnitine (ALC) has multiple mechanisms. There is some evidence that it may help you if you have diabetic
neuropathy or nerve damage after chemotherapy. Other causes of nerve pain have not yet been researched, but it may be
helpful. The doses in studies have ranged from 1000–2000mg per day. Side effects were mild but included stomach discomfort,
restlessness and headaches.
3. Vitamin E is another antioxidant. At least 3 trials have demonstrated that using it while receiving (not after) a nervedamaging chemotherapy agent called paclitaxel significantly reduced nerve pain. The doses used ranged from 400mg once
a day to 300mg twice a day.
GENERAL SUPPLEMENT ADVICE
These supplements have research that supports these recommendations.
1. Vitamin D is technically a hormone but almost everyone in Canada has lower than recommended levels. It is important for
building strong bones.Recommendations are to take 1000 IU per day. This is especially important if you take opioids for pain as
they can affect your hormones and lower your body's ability to effectively build bone.
2. Calcium is also important for maintaining good bone health For more information on measuring your bone density go to
http://www.bcguidelines.ca/patient_guides.html. For information on calcium in food and supplements go to
http://www.osteoporosis.ca If you are on opioids it is probably a really good idea to take at least one calcium tablet containing
500mg of elemental calcium per day. We recommend you take on combined with magnesium as the magnesium counteracts
the constipating effect of the calcium.
3. Omega 3 Fatty Acids have been shown to reduce the amount of anti-inflammatories needed by patients with rheumatoid
arthritis and was helpful when used by patients with neck and low back pain. The recommended dose is 500mg per day of EPA
and to but molecularly distilled versions to avoid mercury and PCB's (such as webber naturals Omega-3 premium).
4. Magnesium Citrate 250 mg bid. Magnesium is necessary to relax smooth muscles and plays an important function in
blocking pain transmitting receptors called NMDA receptors. One study demonstrated that patients with Fibromyalgia who had
low levels of magnesium were more likely to report fatigue.
DENTAL CARE
Dentistry from the Heart. Free dental work on Saturday 8:30am to 5:00pm.
1-800-518-3109.
http://www.dentistryfromtheheart.org
RECREATION – THINGS YOU CAN DO
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Pain management from a recreational perspective.
1. Vancouver Park Board’s Leisure Access Card — subsidized access. Phone 604-257-8497 to apply.
http://vancouver.ca/parks/rec/lac/index.htm
2. The Kansas Foundation for Medical Care has a great brochure you can download. It has suggestions for recreational
ideas that may help you feel better – including laughter, aromatherapy, stress management, aquatics, pets, music and many
other topics and ideas. This is primarily aimed at older individuals. Go to:
[Non-Pharmacological Approaches to Pain Management]
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Print
OPIOID MANAGER
Initiation Checklist
Goals decided with patient:
The Opioid Manager is designed to be used as a point of care tool for providers
prescribing opioids for chronic non cancer pain. It condenses key elements from
the Canadian Opioid Guideline and can be used as a chart insert.
Are opioids indicated for this
pain condition
A
Explained adverse effects
Item score Item score
if female if male
Item (circle all that apply)
Patient given information sheet
Signed treatment agreement (as needed)
Urine drug screening (as needed)
Overdose Risk
Provider Factors
- Incomplete assessments
- Rapid titration
- Combining opioids and
sedating drugs
- Failure to monitor dosing
- Insufficient information
given to patient and/or
relatives
- Start low, titrate gradually,
monitor frequently
- Codeine & Tramadol - lower risk
- Careful with benzodiazepines
- CR formulations - higher doses than IR
- Higher risk of overdose - reduce initial
dose by 50%; titrate gradually
Prevention
- Avoid parenteral routes
- Assess for Risk Factors
- Adolescents; elderly - may need
- Educate patients /families about risks
consultation
& prevention
- Watch for Misuse
Opioid Factors
Stepped Approach to Opioid Selection
Mild-to-Moderate Pain
First- line: codeine or tramadol
Opioid Risk Tool
By Lynn R. Webster MD
Explained risks
Patient Name:
Pain Diagnosis:
Date of Onset:
- Elderly
- On benzodiazepines
- Renal impairment
- Hepatic impairment
- COPD
- Sleep apnea
- Sleep disorders
- Cognitive impairment
Date
Explained potential benefits
Before You Write the First Script
Patient Factors
Y N
Severe Pain
Second-line: morphine, oxycodone or hydromorphone First-line: morphine, oxycodone or hydromorphone
Second-line: fentanyl
Third-line: methadone
1. Family History of
Substance Abuse:
Alcohol
Illegal Drugs
Prescription Drugs
1
2
4
3
3
4
2. Personal History of
Substance Abuse:
Alcohol
Illegal Drugs
Prescription Drugs
3
4
5
3
4
5
3. Age (mark box if 16-45)
1
1
4. History of Preadolescent
Sexual Abuse
3
0
5. Psychological Disease
Attention Deficit Disorder,
Obsessive-Compulsive Disorder,
or Bipolar, Schizophrenia
2
2
1
1
Depression
Total
B
Initiation Trial A closely monitored trial of opioid therapy is recommended before deciding whether a patient is prescribed opioids for long term use.
Suggested Initial Dose and Titration (Modified from Weaver M., 2007 and the e-CPS, 2008) Notes: The table is based on oral dosing for CNCP.
Brand names are shown if there are some distinct features about specific formulations. Reference to brand names as examples does not imply endorsement of
any of these products. CR = controlled release, IR = immediate release, NA = not applicable, ASA: Acetylsalicylic Acid
Minimum time
Suggested
interval for increase dose increase
Opioid
Initial dose
Codeine (alone or in
combination with
acetaminophen or ASA)
15-30 mg q.4 h.
as required
7 days
CR Codeine
50 mg q.12 h.
2 days
50 mg/day up to maximum of
300 mg q.12 h.
7 days
1-2 tab q. 4-6 h. as needed
up to maximum 8 tablets/day
Tramadol (37.5 mg) +
1 tablet q.4-6 h.
acetaminophen (325 mg) as needed up to 4/day
CR Tramadol
IR Morphine
CR Morphine
IR Oxycodone
CR Oxycodone
IR Hydromorphone
CR Hydromorphone
15-30 mg/day up to maximum of
600 mg/day (acetaminophen dose
should not exceed 3.2 grams/day)
Minimum daily dose
before converting IR to CR
100 mg
Initiation Trial Chart
3 tablets
a) 7 days
b) 2 days
c) 5 days
Maximum doses:
a) 400 mg/day
b) 300 mg/day
c) 300 mg/day
5-10 mg q. 4 h. as needed
maximum 40 mg/day
10-30 mg q.12 h.
Kadian®: q.24 h.
Kadian® should not be started in
opioid-naïve patients
7 days
5-10 mg/day
Minimum 2 days,
recommended: 14 days
5-10 mg/day
5-10 mg q. 6 h. as needed
maximum 30 mg/day
10-20 mg q.12 h.
maximum 30 mg/day
1-2 mg q. 4-6 h. as needed
maximum 8 mg/day
3 mg q. 12 h.
maximum 9 mg/day
7 days
5 mg/day
Minimum 2 days,
recommended: 14 days
10 mg/day
NA
7 days
1-2 mg/day
6 mg
Minimum 2 days,
recommended: 14 days
2-4 mg/day
NA
400
300
200
100
Yes, No, Partially
Goals achieved
Pain intensity
Functional status
Adverse effects
20-30 mg
NA
0 = None
1 = Limits ADLs
2 = Prevents ADLs
20 mg
NA
D/M/Y D/M/Y D/M/Y D/M/Y
Date
Opioid prescribed
Daily dose
Daily morphine equivalent
NA
a) Zytram XL®: 150 mg q. 24 h.
b) Tridural™: 100 mg q. 24 h.
c) Ralivia™: 100 mg q. 24 h.
Total Score Risk Category:
Low Risk: 0 to 3, Moderate Risk: 4 to 7, High Risk: 8 and above
Complications?
Other Monitoring
Watchful Dose
> than 200
Improved, No Change, Worsened
Nausea
Constipation
Drowsiness
Dizziness/Vertigo
Dry skin/Pruritis
Vomiting
Other?
(Reviewed:Y/N)
To access the Canadian Guideline for Safe and Effective Use for Non Chronic Cancer Pain, to download the
Opioid Manager and to provide feedback visit http://nationalpaincentre.mcmaster.ca/opioid/
May 2010
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C
Maintenance & Monitoring
Maintenance & Monitoring Chart
Morphine Equivalence Table
Opioid
Equivalent Conversion
Doses (mg) to MEQ
Morphine
30
1
Codeine
200
0.15
Oxycodone
1.5
20
Hydromorphone
6
5
Meperidine
300
0.1
Methadone & Tramadol Dose Equivalents unreliable
60 – 134 mg morphine = 25 mcg/h
135 – 179 mg = 37 mcg/h
180 – 224 mg = 50 mcg/h
225 – 269 mg = 62 mcg/h
270 – 314 mg = 75 mcg/h
315 – 359 mg = 87 mcg/h
360 – 404 mg = 100 mcg/h
Transdermal
fentanyl
Switching Opioids:
If previous opioid
dose was:
Then, SUGGESTED
new opioid dose is:
High
50% or less of previous opioid
(converted to morphine equivalent)
Moderate or low
60-75% of the previous opioid
(converted to morphine equivalent)
D
D/M/Y D/M/Y
Date
Opioid prescribed
Daily dose
Daily morphine equivalent
Goals achieved
Pain intensity
Functional status
Adverse effects
0 = None
1 = Limits ADLs
2 = Prevents ADLs
Complications?
Other Monitoring
400
300
200
100
Yes, No, Partially
D/M/Y
D/M/Y
Improved, No Change, Worsened
Nausea
Constipation
Drowsiness
Dizziness/Vertigo
Dry skin/Pruritis
Vomiting
Other?
(Reviewed:Y/N)
Examples and Considerations
Pain Condition Resolved
Patient receives definitive treatment for condition. A trial of tapering is warranted
to determine if the original pain condition has resolved.
Risks Outweighs Benefits
Overdose risk has increased.
Clear evidence of diversion.
Aberrant drug related behaviours have become apparent.
Adverse Effects
Outweighs Benefits
Adverse effects impairs functioning below baseline level.
Patient does not tolerate adverse effects.
Medical Complications
Medical complications have arisen (e.g. hypogonadism, sleep apnea,
opioid induced hyperalgesia)
Opioid Not Effective
D/M/Y
Watchful Dose
> than 200
When is it time to Decrease the dose or Stop the Opioid completely?
When to stop opioids
D/M/Y
Opioid effectiveness = improved function or at least
30% reduction in pain intensity
Pain and function remains unresponsive.
Opioid being used to regulate mood rather than pain control.
Periodic dose tapering or cessation of therapy should be considered to confirm
opioid therapy effectiveness.
How to Stop – the essentials
Aberrant Drug Related Behaviour (Modified by Passik,Kirsh et al 2002).
Indicator
Examples
*Altering the route of delivery
• Injecting, biting or crushing oral formulations
How do I stop? The opioid should be
tapered rather than abruptly discontinued.
*Accessing opioids from
other sources
How long will it take to stop the
opioid? Tapers can usually be completed
between 2 weeks to 4 months.
• Taking the drug from friends or relatives
• Purchasing the drug from the “street”
• Double-doctoring
Unsanctioned use
• Multiple unauthorized dose escalations
• Binge rather than scheduled use
Drug seeking
•
•
•
•
Repeated withdrawal symptoms
• Marked dysphoria, myalgias, GI symptoms, craving
Accompanying conditions
• Currently addicted to alcohol, cocaine, cannabis or other drugs
• Underlying mood or anxiety disorders not responsive to treatment
Social features
• Deteriorating or poor social function
• Concern expressed by family members
Views on the opioid
medication
•
•
•
•
When do I need to be more cautious
when tapering? Pregnancy:
Severe, acute opioid withdrawal has been
associated with premature labour and
spontaneous abortion.
How do I decrease the dose?
Decrease the dose by no more than 10% of
the total daily dose every 1-2 weeks. Once
one-third of the original dose is reached,
decrease by 5% every 2-4 weeks. Avoid
sedative-hypnotic drugs, especially
benzodiazepines, during the taper.
Recurrent prescription losses
Aggressive complaining about the need for higher doses
Harassing staff for faxed scripts or fit-in appointments
Nothing else “works”
Sometimes acknowledges being addicted
Strong resistance to tapering or switching opioids
May admit to mood-leveling effect
May acknowledge distressing withdrawal symptoms
* = behaviours more indicative of addiction than the others.
National Opioid Use Guideline Group (NOUGG)
To access the Canadian Guideline for Safe and Effective Use for Non Chronic Cancer Pain, to download the Opioid Manager and to provide feedback visit http://nationalpaincentre.mcmaster.ca/opioid/