Diagnoses and Management of Rheumatoid Arthritis

Assessment

Upon arrival, the consultation started with the patient illuminating the key presenting issue in her own words, the state of the problem, and the period of the symptoms aforementioned. The necessity to launch the presenting issue is essential for the doctor to distinguish between the people who require urgent attention and those scenarios that are non-urgent (Merriman and Tollafield., 2012).

A study by Grondal et al., (2008) disclosed that the severity of rheumatoid arthritis might vary among persons, thereby making the diagnosis and administration of the disorder a problem (The Royal Australian College of General Practitioners, 2009). During the epoch of comparative remission, presentation tends to be sporadic with the slow display of signs and symptoms over a while. The initial symptom of the illness is the stiffness that is characterized by pain on movement and joint tenderness. The rheumatoid arthritis pain because of joint inflammation is catapulted by the joint damage (Walsh & McWilliams, 2012). Notably, patients highlight at least one swollen joints, stiffness during the morning hours, and uncommon constitutional symptoms, including fatigue. The tiny joints of the foot deteriorate rapidly, and this impacts a significant number of joints compared to those within the hands (Hulsmans et al., 2000). The engagement of the joints during the preliminary stages of the illness might be asymmetric and Pollyarticular. However, the illness evolves as polyarticular entailing at least five joints proportionally (Isaacs, 2013). Nonetheless, synovitis and bursitis cause tremendous changes in the rheumatoid foot (Hooper et al., 2012). The changes in the roles and structure always impact gait and movement (Turner et al., 2006). Synovitis is often a sign of pathognomonic, which is crucial in this instance.

Currently, there is no specific criterion for carrying out a diagnosis of rheumatoid arthritis. The tender and swollen joints of the latest onset, extraordinary laboratory tests, and stiffness of the joints during the morning hours present the patient. However, this presentation is not specific to the illness. Swolen et al., (2016) claims that the other causes of arthritis are infectious arthritis, psoriatic arthritis, reactive arthritis, and osteoarthritis. There is a lack of a validated yet standardized foot assessment in MSK conditions. The American College of Rheumatology (ACR), /European League Against Rheumatism (EULAR) grouping criterion for the illness, can be used which are not deliberate to be diagnostic though can assist acknowledge the preliminary stages of the disease and have neem significant for the listing of the patients in clinical trials of the preliminary illness. Studies indicate that a score of six or more out of a possible is necessitated for a grouping of rheumatoid arthritis (Aletaha et al., 2010).

NICE (2009) recommends that therapeutic footwear and functional orthoses should be made present to patients that have rheumatoid arthritis. As the illness is in its preliminary phases, William et al., (2007) recommend the use of suitable footwear and orthoses when necessary. It is justified that when used correctly and efficiently that orthoses will not alleviate pain though they will sustain the structure of the foot, improve it, and attain stability of the joint (Woodburn et al., 2002). Asma was prescribed a ¾ length Black Slimflex insole with a whole poron cover to ease pressure at the forefoot with a high density (shore 65). These can be seen in Appendix 5.

RA classification criteria (Aletaha et al., 2010)

The in-depth history and clinical assessment of the individual forms the diagnosis of rheumatoid arthritis. Individuals suffering from this disease portray symptoms after several weeks or months. It is crucial to pick on the non-verbal cues and body language when the patient is defining their suffering. The effect of the foot problem and the perceptions of the patients are addressed. In addition, the skills during clinical diagnosis are imperative because it is not often suitable to refer an individual with MSK pain for diagnostic tests. The outcome is a waste of resources or sluggish treatment of the individual. Clinical diagnosis entails examining the patient in a logical way. The Appendix 1 displays the new patient form of Asma. Observing the foot well is instrumental in performing gait analysis. It is easy to detect abnormalities in the gait by looking at Asma when she is walking. Active and passive range of motion of the ankle and foot should be examined for the signs of restricted movement. When performing a physical assessment, it is vital to assess the changes in the neurology and review the evidence of nerve irritations. Diagnostic imagining might be requested to narrow down the differential diagnosis   (Peters, Adams & Schon, 2011; Pomeroy, Wilton & Anthony, 2015).

The physical examination of Asma should involve the inspection of both feet at open and closed chain to review the presence of abnormalities. The podiatrist might touch the bony priorities particularly the metacarpophalangeal joints (MCPJs) of hands as Asma encountering concomitantly highlighting the signs of palpable defects. The assessment allows more details from feeling and touching the foot to evaluate the texture of the tissue of the patient. Furthermore, the response of the patient to the touch can determine the source of the pain. NICE articulates that a positive outcome obtained over a squeeze test is highly representative of the presence of rheumatoid arthritis (Visser, 2005).

 Fig 1 Squeeze test of (A) metacarpophalangeal and (B) metatarsophalangeal joints (adapted from Arthritis Research UK www.arthritisresearchuk.org/arthritis-information/inflammatory-arthritis-pathway/step-one.aspx

From the case study, Asma does not suffer from any other medical disorder other than rheumatoid arthritis. The patients with RA have rising cardiovascular mortality and neuropathy when drawing a comparison with the population (Kitas & Gabriel, 2011;Wang et al., 2009). Hence, it is essential to perform a baseline neurovascular assessment (Kitas & Erb, 2003). The clinical signs and patients’ symptoms dictate the latter. Additionally, foot pulses should be examined through a portable Doppler which offers an objective gauge of vascular status. From a neurological examination point of view, the assessment of tendon reflexes where showed and sensation assessment with ten grams of monofilament as a minimum is required. The foot function index is required to gauge the effect of the problems that affecting the foot. The FFI is a reliable tool for patients that are suffering from rheumatoid arthritis (Agel et al., 2005; Kuyvenhoven, 2002). Another tool known as Salford Rheumatoid Arthritis Foot Evaluation Index can be used (Walmsley, Ravey, Graham, Teh & Williams, 2012).

It might be essential to make a preferred and differential diagnosis if further diagnostic assessment is necessitate affirming the findings. In the context of the complaints that were highlighted by Asma, the illness can replicate any condition causing acute or chronic arthritis. The getting rid of other illness is an essential step in performing a diagnosis of rheumatoid arthritis (Combe et al., 2007; Lugmani et al., 2006; SIGN, 2000). Systemic lupus erythematosus, psoriatic arthritis, fibromyalgia, gout, and metatarsalgia highlight some of the dominant differential diagnoses. Arguably, the lab data will be instrumental in conducting a diagnosis. The ultrasound is used in many clinics to launch whether joints are active. Another study demonstrated that ultrasound is used in many clinics to launch if the joints are active (Dale, Purves, McConnachie, McInnes & Porter, 2014) while in a preliminary rheumatoid arthritis trial (Haavardsholm, et al., 2016), a treat-to-target approach through ultrasound guidance was found to have added advantage when comprising it to an approach that was grounded on clinical findings. Notably, the bone density tests including the dual-energy X-ray absorptiometry (DXA) is essential to differentiate between osteopenia and rheumatoid arthritis.

Diagnosis

It is essential that the patient GP is contacted and that the information of the initial consultation are offered guaranteeing that the right referral pathways are upheld (NWCEG, 2014). In the referral to the GDP, there are signs and symptoms of rheumatoid diagnosis (RA). After this request is made to the patient, the blood is sent for analysis to confirm the suspected diagnosis. The blood tests can be used to gauge the particular levels of inflammatory markers in a personal system (Fischbach & Dunning 2009). The Appendix 2 displays what blood tests are used to assist guide the doctor towards the diagnosis of RA. It is vital to be knowledgeable that there is any blood test that can evaluate the presence or absence of rheumatoid arthritis. The specialists will use an integration of findings from the blood to come with a diagnosis.  The appendix 3 displays the clinical investigation of Asma after taking the tests.

Short, medium, and Long Term Podiatric Management

Information obtained from the history and assessment of the foot problem of an individual determines the advice and treatment by a podiatrist. The latter seeks to alleviate the pain affecting the foot, enhance the role of the foot, and safeguarding skin and other tissue from damage (NRAS, 2019). The management of Rheumatoid arthritis involves education the patient, hiring a multidisciplinary team, and carrying out a pharmacological treatment. Nonetheless, the treatment should take into account the needs of these individuals.

Short-term

The short term management of rheumatoid arthritis involves giving psychological and social support to Asma (lugmani et al., 2006).   Such support is necessitated early in the illness based on diagnosis tolerance and throughout the spread of the illness as its effect becomes more obvious (RACGP, 2009). The BSR guideline suggests that persons should have social and psychological support to assist them remain in the workplace and engage in ordinary activities (Lugmani et al., 2006). The management of the deformed issues affecting the foot is the pharmacological even though conservative and surgical intervention might be shown (Combe et al., 2007). The non-pharmacologic pain management approaches contribute significantly to the patient care. The tolerance skills, acceptance of chronic care, and self-efficacy make an impact to improving the way of life of persons living with rheumatoid arthritis and psychological interventions including the cognitive behavioural therapy are crucial (Walsh & McWilliams, 2012).

Pharmocological management of rheumatic patients should be aggressive from the initial tome. The objective of this management is to suppress inflammation and to impede disability. It is vital to realize that it will be specialist to evaluate how aggressive the treatment will be grounded on the outcomes of both the earlier podiatric consultation and the clinical investigation. These results will help the rheumatologist give the verdict on the severity of the illness. Filkova et al., (2017) illuminates that because of the aggressive nature of some of the medications used that pharmacological complications are not dominant with patients suffering from RA.

Middle-term

The middle-term management is applied in case the symptoms of Asma are not enhancing. The steroid injection therapy would be the most appropriate plan for this case. It should be taken into account for targeting the localized, inflamed joints in the event that the illness is regulated though in the absence of infection (Ward et al., 2008). Injection therapy should be instrumental in providing podiatric management when integrating with efforts to rectify the structural deformity through orthoses (NWCEG, 2014). In this instance, lifestyle modification including the smoking cessation and thorough exercise can be significant.

Long term

The long-term management plan for treating Asma is performing a surgery on her. Surgical intervention might be taken into account when conservative intervention is not convincing in its potential to alleviate the pain in the foot and when to strive to get a long run prognosis. It might be suitable to refer the Asma to the specialist to seek opinion. Nice (2000) viewed that the long-term management plan is suitable when the patient has a deteriorating joint function, persistent localized synovitis, progressive deformity, and tenacious severe pain. The arguments behind the referral for surgery involve the presence of foot deformities, septic arthritis, and persistent pain (Loveday, Jackson & Geary, 2012). Surgical opinion should be taken into account for Asma if the optimum conservative management has failed to hold the symptoms to an approvable level. A likely anticipation is early synovectmaty in serious illness to impede the quick destruction of the joint (Canseco et al., 2011).

Patients’ Education and the Psychosocial Factors Influencing the Management and Outcome Measures of Intervention

            Patient education is a significant element in the management of the RA (Deighton, O’Mahony, Tosh, Turner & Rudolf, 2009). Every consultation is evolving as an opportunity for patient education and be grounded on an educational-behavioural approach. Educating the patient helps to create insights about the causes and course of the illness and disease management. In addition, it provides information about access to patient support groups, the most appropriate lifestyle choices, foot orthoses, maintain food hygiene, improve access to podiatry care, and give insights on the changes in foot health that should necessitate prompt investigation.

The patients who display severe symptoms in addition to those with medical management that exposes them to risk of the serious repercussions of foot infections should be administered by a podiatrist who specialises in treating rheumatoid arthritis. The rheumatologist nurse should be contacted as an issue of urgency when the patients who are being administered with biologic therapy start showing ulceration of the foot (Otter et al., 2004). A study by Firth et al. (2008) affirmed taht a holistic and combined MDT approach was effective to administer foot ulceration. Advice should be obtained from the rheumatologist on the management of the infected nails or if there is a necessity for performing surgery on the nail.

Irrespective of the interventions, frequent review appointments and open access to the podiatry service for any developing acute issues. The present evidence supports the use of serotonin reuptake inhibitors as the preliminary stages of pharmacotherapy for depression among patients suffering from rheumatoid arthritis.  The psychosocial interventions including the self-efficacy measures are probable to improve the effectiveness of the long run patient care that a previous episode history raises the ineffective toleration approach in establishing the stress or increased suffering (Bruce, 2008).

Asma is comparatively young and therefore we presume that she works. In that scenario, offering supporting letters for employers to assist the patients to access adaptations in their workplace to assist in their workplace to assist the issues of the foot. When there is the necessity, a referral to the psychologist for counselling would be significant. Hence, comprehending the stress in the life of Asma and discovering ways to assist her tolerate it would ensure successful treatment of the illness.

Discussion

The necessity for timely access to podiatry services for individuals suffering rheumatology disorders is acknowledged with nationally polished guidelines including the standards of care for people with musculoskeletal foot health problems and RA Podiatry Rheumatic Care As sociation, 2008) though there is little evidence-based research to back up suggestions in early arthritis. Both the BSR and SIGN guidelines acknowledge podiatry input and suitable foot orthoses as significant and effective interventions in RA (SIGN, 2000; Lugmani et al., 2006).

The advantages of footwear have been acknowledged and suggested functional insoles and therapeutic footwear should be present for all persons with RA if included (NICE, 2009). It is shown that FO alleviate pain in the preliminary RA foot and have sustained impact on the structure of the foot and thus attain stability of the joints of the foot and enhance the mobility of the patient (Woodburn et al., 2002). The foot is more amenable to treatment in the preliminary stages before the progress of the irreversible damage and deformity of the joint (Van der Leeden, 2011; Woodburn et al., 2010). Hence, it is important that patients are referred for diagnosis of foot function. In addition to this, redistributing foot pressures might make an impact to the impending of breakdown of tissue and ulceration over high pressire regions of the foot. The relieving of pressure and functional orthoses have been illustrated in various studies to decrease the pressures of the forefoot should be available  (McCormick, Bonanno & Landorf, 2013; Otter et al., 2004; Redmond et al., 2009, Van der Leeden et al., 2008; Woodburn et al., 2002). Nonetheless, functional foot orthoses should be offered whereby there is no impact on the tarsal joints. Many studies highlight that there is better redistribution of plantar pressure in rheumatoid feet using insoles.

Based on the fluctuating disease course, it is problematic to standardize items and composition of foot orthoses as health status of the respondents will undoubtedly vary (Bowen, Burridge & Arden, 2005). The duration of the illness can be taken into account as a further repercussion that develops difficulties when treating it. Cushioning orthoses should be offered for those patients that suffer from structural foot deformity, painful signs and activity restraint (NWCEG, 2014). Notably, one study expressed early diagnoses patients documented a significant treatment impact with composite rigid orthoses (Woodburn et al., 2002). The findings of the study disclose that the late the duration of the illness, the less rigid the orthoses material design should be. It follows as the state of the illness advances, orthoses materials and design should entail to semi-rigid composite designs and to accommodate stuff for chronic illness. In addition, a more latest explorative examination recommended that semi rigid customized FOs can enhance pain and disability in individuals with established RA compared to typical insoles (Rome et al., 2017).

Siddle et al., (2013) highlights that the lasting impacts of sharp debridement of painful forefront plantar callosities in individuals with RA when used in relation with a combined therapeutic approach generated no further advantages over an integrated therapeutic approach. The scholars recommended that sharp debridement should be confined to the short run alleviation of serious pain and handle only the great risk presentations.

Woodburn et al., (2000) claimed that a decrease in plantar callus with sharp debridement alleviated the pain on the foot for nearly one week though it increased forefront pressures in ten from a possible fourteen feet. This was not statistically significant though shows that the decrease of callus over predominant metatarsal head results to the damage of the tissue. This is relevant with patients that suffer from decrease variability of the tissue and neuropathy (Woodburn et al., 2010). The callus removal over plantar metatarsal regions should be handled with caution by giving priority where it might be taken into account to have a protective role. When the callus is debrided, the pressure-alleviating insoles should be offered to safeguard the foot from the ulceration risk. The findings of the study by Davys et al. (2005) disclosed that an alleviation of pain in 38 respondents though deduced the impact was not higher than sham treatment. Localized pressure did not substantially enhance the subsequent treatment.  in the preliminary phases of the illness, many patients encounter forefront pain and changes to their foot as evident in the case study. Many manufacturers of retail footwear exist that are suitable for the foot health of the patients. The studies by Egan et al., (2003) and Farrow, Kingsley, & Scott, (2005) express that specialist footwear is probable to be advantageous in patients suffering from RA. Williams et al., (2006) and Fransen & Edmonds (1997) highlighted that the footwear made an impact to the alleviation of the pain and rising mobility among the patients suffering from RA though this impact is enhanced is enhanced when integrated with orthoses (Williams et al., 2006; Fransen & Edmonds, 1997).

Persons who engage vigorously in the management of the illness affecting them have enhanced self-efficacy, better results, less pain, and decreased frequency of depression (Lorig, Ritter & Plant, 2005; Kjeken et al, 2006). The EULAR guideline references three RCTs which show that the written details might increase knowledge regarding the illness (Combe et al., 2007).

It is important to realize that the ankle and foot structures in Rheumatoid arthritis are prone to inflammation and are agreeable to both diagnostic and therapeutic corticosteroid injection. Helliwell et al., (2006) claim that the injection therapy plays a critical role in podiatric management by rectifying deformity using orthoses. Up to date, there is enhancement after corticosteroid injection such as the six months post injection.

Wienecke & Gotzsche (2004) addresses that non-steroidal anti-inflammatory drugs (NSAIDs) and cyclo-oxygenase-2 selective (COX-2) inhibitors treat patients that suffer from undifferentiated inflammatory arthritis (Wienecke & Gotzsche, 2004). Despite the fact that these medications have both anti-inflammatory and analgesics impacts, there is lack of proof that they impede the damage of the joints (;Luqmani et al, 2006; SIGN, 2000). As treatment in the preliminary stages of the illness, the use of analgesics in Rheumatoid arthritis is backed up by proof from RCTs in other disorders and publication biases might hide proof of inefficacy in arthritis (Walsh & McWilliams, 2012). The non-steroidal anti-inflammatory medications such as cyclo-oxygenase (COX)-2 selective enjoy strong proof of efficacy in Rheumatoid arthritis RA (NICE, 2009).

Corticosteroids help in alleviating pain, decrease lasting radiological damage, and decreasing swelling among individuals suffering from Rheumatoid arthritis. It consumes time for the impacts of DMARDS to be observed and steroid can offer relief whereas desiring for them to take the whole impact. After the commencement of the treatment, the steroids should not be used for more than 6 months (Smolen et al., 2014). DMARDS is the cornerstone of treating Rheumatoid arthritis. It is well established that damage of joints starts early in Rheumatoid arthritis and that early treatment with illness modifying drugs is the basis of a best practice approach to managing illness management (Lugmani et al., 2006; SIGN, 2011; van Dongen et al., 2007). Patients who are most probable to develop the disabling arthritis should begin the therapy quickly (Symmons & Silman, 2006). Currently, proof is increasing on the fact that the combination therapy is more effective than monotherapy among the patients (Emery & Suarez-Almazor, 2003). Decreasing inflammation is a primary treatment outcome in Rheumatoid arthritis. The 28 joint Disease Activity Score (DAS28) is a predominant outcome instrument of measuring joint inflammation in RCTs and is often used to notify the decisions pertaining treatment in clinical practice (Walsh & McWilliams, 2012).

In the recent time, a more targeted and aggressive pharmacologic technique has been driven towards the management of the illness with the familiarization of biologic agents (Smolen et al., 2010). Clinical remission is a reality due to the presence of new biologic agent to decrease the activity of the Rheumatoid arthritis. Custom orthoses is still a significant adjunct therapy because the individuals who have not responded to or are ineligible for biologic agents continue to have vigorous foot impairments, persons with increased illness asserts might have mechanical foot impairments that require treatment in combination with systemic administration (Woodburn et al., 2010), and tenacious ankle and foot issues still happen even after clinical remission is attained (Landewe et al., 2006). A study by Goldberg & Katz (2007) involved a meta-analysis of the analgesic impacts of omega-3 polyunsaturated fatty acids that offers strong proof for the role of omega-3 in alleviating pain. The SIGN (2000) guideline acknowledges a merit based on a decrease in tender joints and duration of morning stiffness grounded on a meta-analysis of patients through omega-3 supplements (Fortin et al., 1995). It is a fact that there is restrained evidence on the impact of the diet on Rheumatoid arthritis. The level of reception of the necessity to encourage patients to embrace a healthy diet and uphold a healthy diet is low. The SIGN guideline (2000) discusses the significance of upholding a healthy weight and body mass index in the management of patients suffering from Rheumatoid arthritis. There is insufficient studies on the effectiveness of specific diets in administering Rheumatoid arthritis and many studies have not documented body mass index as an outcome measure.

The BSR guideline suggests that aerobic exercise should be motivated whereas being cognizant of decreasing short run exacerbation of illness. It references the studies of De Jong et al., (2003) and Stenström & Minor (2003) that demonstrate that exercises can be taken irrespective of the present of illness exacerbation in a short period. The lasting impacts are still not acknowledged in this instance. The EULAR guideline defines various therapies including laser therapy, acupuncture, transcutaneous electrical nerve stimulation (TENS), use of compression gloves, and use of splints and orthoses(Combe et al., 2007). Notably, the BSR guideline highlights a diversity of alternative therapies such as massage and the alexander approach. Whereas other studies documented the presence of short run pain alleviation for some of these interventions, there is no proof for long term merits and suggestions for use of such interventions as only as adjuncts to pharmaceutical therapies (Lugmani et al., 2006).

Conclusion

Rheumatoid arthritis is deadly diseases that necessitate early diagnosis and management. It stresses on the necessity for early referral to the suitable healthcare practitioners in relation with the NWCEG (2014) and NICE (2014) referral pathways. Whereas addressing the significance of early aggressive pharmacological intervention, it emphasizes that conservative measures should be over examined. Cautious conservative management will enhance the quality of life of the patient during remission and flare moments and might lower the spread of the illness. Patient education education is a significant aspect and keeping patients both motivated and engaged in the treatment of RA to yield better outcomes. It is crucial to recall that a holistic approach would be vital when administering the RA. The patient is anticipated to observe the best likely results from the multifactorial illness.      

Appendix

Appendix 1: Patient Assessment Form

Presenting problem:         Pain and stiffness in the lesser metatarso-phalangeal

joints of both feet. Longer term pain in the 1^st MTPJs

which is her main concern as it limits her footwear

choices and she is worried that the joint seems to be

getting bigger. The generalised pain in the lesser

MTPJs is also becoming more noticeable. The 1^st MPJT

pain has been going on for close to a year with the

lesser joint pain now close to four/five months.

Pain Score:                             1^st MPJT – 5 on the (NRS)

Lesser MPJTs 8 on the (NRS) – More painful in

Morning pain and stiffness typically lasting one hour.

Medical History:                  No known illnesses/ Paracetamol for pain

Family History:                    Grandmother had history of Arthritis, although

patient is  unsure of which type.

Social History:                     Alcohol intake – Zero units

Smoker – No

Vascular Assessment:                                           Palpable

Left foot:   Dorsalis Pedis   Ö     Posterior Tibial   Ö

Right foot: Dorsalis Pedis   Ö     Posterior Tibial   Ö

Neurological Assessment:  A full neurological assessment was carried out

starting with the 128hz tuning fork, which showed

vibration sensation to be intact at B/1^st apices and.

both medial malleoli.

The temperature gradient was warm to warm from

proximal to distal, (tibial tuberosity to all apices).

The 10gram monofilament showed absent sensation

at B/1^st MPJTs. All other sites, B/1^st apices,, B/5^th

MPJTs and B/plantar calcaneal areas. The tendon

Hammer was uses on two common sites, the Patellar

tendon and the Achilles tendon. Both showed positive

reflexes, with knee extension and foot plantarflexion

respectively

 Skin:                                   Skin appearance normal.

Nails:                                       Sporadic Onycomycosis present BF

Activity levels:                     Likes to swim, tries to avoid running as her feet tend

to be painful for days after.

Footwear:                               Slip on plimsoles  – deemed unsuitable

MSK Assessment:                NON Weigt bearing  – Look Feel and Move  the

joints of the foo look for any  signs of

synovitis,, tenosynovitis , assess foot position,

deformities and Rang of motion ROM at painful

swollen joints. Noticeable factors were pain upon

the transverse squeeze test, pain elicited upon

dorsiflexion and plantarflexion of the lesser MPJTS

B/F ,and the development of what seems to be

bilateral  Hallux Valgus, with the left foot

in particular showing a very clear “Brevis Butress

Effect”. (First and second toe make contact).

Occupation/ Other               Works in retail and spends all day on her feet.

Been off lately as feeling “pretty down”.

Appendix 2

Appendix 3

Appendix 4

Appendix 5:

Appendix 6

Figure 1 Foot health screening pathway for people with RA foot‐related problems retrieved from Guidelines for the management of foot health for people with RA.

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