Transcript Juvenile Idiopathic Arthritis

MSK Train the Trainer 1
Working Together to Help Children
with Juvenile Idiopathic Arthritis
Lori B. Tucker, M.D.
Clinical Associate Professor in Pediatrics
Division of Rheumatology
BC Children’s Hospital
Vancouver, BC
www.pspbc.ca
Faculty/Presenter Disclosure
Speaker’s Name: Speaker’s Name
Relationships with commercial interests:
- Grants/Research Support: PharmaCorp ABC
- Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd
- Consulting Fees: MedX Group Inc.
- Other: Employee of XYZ Hospital Group
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Disclosure of Commercial Support
This program has received financial support from [organization name] in the form
of [describe support here – e.g. educational grant].
This program has received in-kind support from [organization name] in the form
of [describe the support here – e.g. logistical support].
Potential for conflict(s) of interest:
- [Speaker/Faculty name] has received [payment/funding, etc.] from
[organization supporting this program AND/OR organization whose product(s) are
being discussed in this program].
- [Supporting organization name] [developed/licenses/distributes/benefits from
the sale of, etc.] a product that will be discussed in this program: [enter generic
and brand name here].
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Mitigating Potential Bias
[Explain how potential sources of bias identified in slides 1 and 2 have been
mitigated].
Refer to “Quick Tips” document
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Certification
 Up to 21 Mainpro+ Certified credits for GPs awarded upon
completion of:
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› At least 1 Action Period
› The Post-Activity Reflective Questionnaire (2 months after LS3)
 Up to 10.5 Section 1 credits for Specialists
› All 3 Learning Sessions (NOTE: Credits and payment will be based on
the exact number of hours in session)
› The Post-Activity Reflective Questionnaire (2 months after LS3)
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Update/revise
Action Plan
Report of AP1
experiences &
successes
Payment for:
PMV (optional)
LS1
Action Period 1
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Refine
implementation;
embed & sustain
improvements
attempted in
practice via
Action Plan +
AP2
requirements
Interactive
group learning
Finalize Action
Plan
Report of AP2
experiences &
successes
Payment for:
LS2
Action Period 2
LS3
Reflection
Interactive
group learning
Learning Session 3
Create Action
Plan (using
template)
Planning & initial
implementation
in practice;
review of Action
Plan &
improvements
attempted in
practice + AP1
requirements
Action Period 2
Interactive
group learning
Learning Session 2
Opportunity
for in-practice
visit to
introduce
applicable
EMR-enabled
tools &
templates prior
to LS1
Action Period 1
Learning Session 1
Pre-Module Visit
Learning Session & Action Period Workflow
Reinforce &
validate practice
improvements
GPs & Specialists
complete PostActivity
Reflective
Questionnaire
(PARQ) 2 months
after LS3 &
submit to PSP
Central
Payment Stream 1 (ideal)
Current Rates:
GPs
Specialists
MOAs
Hourly Rate
$125.73
$148.31
$20.00
Action Period 1
$880.10
$1,038.16
N/A
Action Period 2
$660.07
$778.62
N/A
Payment made after attending LS2
Payment made after attending LS3
GPs:
GPs:
PMV
= $125.73
LS2
= $440.05 ($125.73 x 3.5hrs max.)
LS1
= $440.05 ($125.73 x 3.5hrs max.)
AP2
= $660.08
AP1
= $880.10
LS3
= $440.05 ($125.73 x 3.5hrs max.)
TOTAL
$1,445.88
TOTAL
Specialists
Specialists
LS1
= $519.08 ($148.31 x 3.5hrs max.)
LS2
= $519.08 ($148.31 x 3.5hrs max.)
AP1
= $1,038.16
AP2
= $778.62
$1,557.24
LS3
= $519.08 ($148.31 x 3.5hrs max.)
TOTAL
TOTAL
MOAs
$1,816.78
MOAs
PMV
= $20.00
LS1
= $80.00 ($20.00 x 4hrs max.)
LS2
= $80.00 ($20.00 x 4hrs max.)
$100.00
LS3
= $80.00 ($20.00 x 4hrs max.)
TOTAL
TOTAL
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$1,540.18
$160.00
Objectives for This Talk
 To provide general background about
juvenile idiopathic arthritis (JIA).
 To establish relevance of JIA Module for
family physicians.
 To review key material in the JIA Module.
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Goals for the JIA MSK Module
 Improve the early recognition of juvenile arthritis.
 Provide clinicians with tools to assist in the diagnosis of MSK
complaints in children.
 Suggest pathways for referral of children with MSK complaints
when needed, and increase awareness among GPs of
accessibility of care for children and teens with arthritis in BC.
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A true story……MC
 11 year old girl, living in a rural community in BC
 Develops gradual stiffness in fingers, wrists and knees, with increasing pain.
No swelling is seen.
 Unable to play the violin, difficulty with writing at school.
 Seen in local ER and walk in several times.
 Investigation done….and told everything was normal.
› Xrays; ANA, RF, ESR done…….
 8 months after symptom onset, grandparents take her to their family dr.
 Urgent referral to pediatric rheumatology is placed.
 Patient is seen in 3 weeks- dx: polyarticular JIA
 Active joint count 18; unable to make a fist.
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Patient
FP
ER/walk-in
Paeds Ortho Rheum Other
Paed Rheum
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What is Juvenile Idiopathic Arthritis?
 Most common childhood chronic
disease causing disability.
 About 7/100,00 newly diagnosed
children with JIA per year.


Prevalence about 1/1,000 children
= 1,000 children in BC with JIA.
7 subtypes.
 Disease begins at any time during
childhood or adolescence.
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Juvenile Idiopathic Arthritis
 Child under 16 years old
 At least one joint with objective signs of arthritis:
› Swelling, or two of the following: pain with movement, warmth
of the joint, restricted movement, or tenderness
 Duration of more than 6 weeks
 Other causes have been excluded (ex. Infections, Lupus and
other connective tissue diseases, malignancies)
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Why do I need to learn about JIA?
I will never see a case of this…….
 Have you seen a case of JIA or other autoimmune disease in a
child?
 Have you seen a child with a limp or MSK pain?
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Few know that JIA even exists….
 81% of Canadians say they know
almost nothing about JIA.
 Only 30% had ever seen, read, or heard
anything about JIA.
› Compared with 45-70% for other chronic
conditions such as asthma, cancer, diabetes,
HIV, CF, cerebral palsy, heart conditions.
Ipsos-Reid, 2010
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Common Diagnostic Myths About Arthritis in
Childhood……
 All kids with JIA have fevers.
 All kids with JIA have rashes.
 A child with joint pain (but no arthritis) must have JIA.
 All arthritis is painful.
 If a child has a positive rheumatoid factor, they must have
arthritis.
 If x-rays are normal, there is no arthritis.
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The JIA Module:
Helping you with Diagnostic Pathway
Child with MSK complaint presents to GP office
Medical history
Physical examination
Red Flags??
Laboratory testing and imaging as
indicated
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Physical Examination of the Child with an MSK
Problem
 Assess general health status.
 Child friendly approach.
 Do a complete physical examination.
 All joints should be examined, even if
complaints are referred to only one.
 Keep developmental norms in mind.
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Watch for Red Flags
 Child is unwell.
› Fever, weight loss, weakness
 Bone pain or night pain.
 Regression of motor milestones.
 Significant functional disability.
› Child not ambulating
› Child missing school or activities
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What is pGALS?
 Evidence based screening MSK assessment for school aged
children based on the adult GALS (Gait, Arms, Legs, Spine)
screen
 Validated with excellent sensitivity and specificity
 Basic clinical maneuvers completed in an average of 2 minutes
 http://www.arthritisresearchuk.org/health-professionals-andstudents/video-resources/pgals.aspx
Foster HE. Arthritis Care Res 2006.55:709-716.
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Documentation of pGALS Screen
pGALS Screening Questions
Any Pain?
Right knee
Any Difficulty Dressing?
No
Any Difficulty Walking?
Yes
Appearance
Gait
Movement
Normal
Arms
Normal
Normal
Legs
Abnormal
Abnormal
Spine
Normal
Normal
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The pGALS Screen
 Gait
 Observe the child walking and turning
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The pGALS Screen
Arms
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The pGALS Screen
Legs
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The pGALS Screen
Spine
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When to Refer to a Pediatric Rheumatologist……
 Child or teen with joint pain, swelling, stiffness, or dysfunction
which has lasted more than 2 weeks and is unrelated to trauma.
 Child with signs and symptoms suggestive of a generalized
connective tissue disease or autoimmune condition.
› Systemic lupus, dermatomyositis, vasculitis, periodic fever
syndromes
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What if you are not really sure….
General pediatric evaluation is
often an excellent interim step.
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Where can I refer my patients for help?
Pediatric Rheumatology Teams in BC
 Vancouver:
› David Cabral, Lori Tucker, Jaime Guzman, Kristin Houghton,
Kim Morishita, Ross Petty
› Pediatric physiotherapist, occupational therapist
› Social worker
› Pediatric rheumatology nurses
 Penticton:
› Katherine Gross, M.D.
› Nurse and physio/OT
 Victoria:
› Roxana Bolaria M.D.
› Nurse and physio/OT
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What about when my patient does have JIA?

Work together as partners to provide care.
› Assist in arranging community services.
› Administer injectable medications i.e. methotrexate
› Monitor for side effects of medications.
› Assist parents with school issues if necessary.
› Provide immunizations, or modify schedule as outlined by pediatric
rheumatology team.
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Thank you
Questions
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