Case (CP64090) Have you got the time?

This lady had seen me before. A couple of years back with right sided hip pain predominantly but also multi joint pain including extremities and hypermobility. We were concerned enough to refer for rheumatology. She had subsequently been diagnosed with Rheumatoid Arthritis (RA). She is an active 57yrs old. She was referred to me for management of her symptoms rather than a specific joint. This is unusual as I work in a musculoskeletal service and not a rheumatological one.

She reports seeing a rheumatological physiotherapist initially after diagnosis and given some stretching exercises. The therapist went onto maternity leave and the replacement was not well received. She recalls being told the pain was due to her weakness and lack of movement and that she should do more and sit less. She took offence at this as she reports being active. At this point she asked her GP to send her through to see me again.

After reacquainting ourselves I asked what she is struggling with. She replies prolonged postures are becoming worse with time whether its sitting or standing. She reports multiple joint pain including back, bilateral shoulder, elbow, hands, knees and feet. She reports worsening coldness to her extremities and intermittent numbness or dullness to both feet and occasionally buttocks. She had characteristic global early morning stiffness over 30mins. Her goals are to be able to stand taller to prevent a forward lean and to be able to sit comfortably in a number of positions.

She is under her rheumatologist at 4 month intervals at present and describes taking the highest dose of methotrexate her consultant is happy with, she also takes sulfasalazine and hydroxychloroquine. She doesn’t feel this controls her symptoms well. She also takes ibuprofen and accompanying lansoprazole. She also takes Folic acid and has taken lisinopril for 3yrs (with good control of her blood pressure).

Her dad has history of 2x Myocardial Infarction (MI-first at 47yrs) and stroke whilst his father also had MI. Her mum has history of Raynaud’s disease and widespread Osteoarthritis. Both her mum and sister have diabetes.

She is right handed and works as a cleaning supervisor 25hrs a week. She has gradually increased up to this over the last 2yrs since her RA diagnosis and feels financially compelled to work. She reports when on holiday or days off work she has a big improvement in symptoms. She lives alone with 2 dogs who she walks frequently (3x/day). She does not smoke. She averages 4 glasses of wine/week. She has 1-2 cups of decaf tea or coffee/day. She has deteriorating sleep quality and quantity mainly through discomfort although some stress. She reports significant stress around her health and its impact on her life and reports periods of depression. She reports not cooking a lot due to discomfort so relies on convenience and pre-prepared foods. She reports excellent exercise levels, walks dog 3x/day, she likes to exercise 30mins/day on top of this, she reports step counter device always over 14,000 steps/day. She reports not relaxing well due to activity level and finds relaxation difficult generally even before diagnosis of RA.

On examination her BP was in normal range, she had good active range of movement at the lumbar spine with mild ache reported at end of range only. She had good passive range also although found it difficult to relax fully and tended to join in or control the movement. She had no swollen or red joints. She had some knee pain with supported squat with tendency to hip flex and lumbar extend.

Hopefully this gives you an insight into my encounter with this lady. I’m interested to hear from clinicians which information they attend to most. What really sticks out? What information that might be missing that you’d want? How would you approach ongoing clinical care if this person? What makes this case tough? What might be potential avenues to explore? What does the research say for this person?

These aren’t trick questions. I have not fixed this lady and am looking to catch you out or get the right answer. I’m interested in how people clinically reason. How others approaches may vary. How I might learn form this. I’ve thought about doing this type of thing more regularly if there was enough feedback and engagement. I have purposefully left out my treatment plan so that you can start from a clean slate although I realise even from my writing (which I have tried to keep to chronological verbatim order) this may be apparent. I’d particularly enjoy feedback for whom this case seems outside their scope to see if any differences emerge.

Be more human. Be less robot.

Thanks for reading this far.

 

Neil

Replies can be left to this post. Or via twitter @neil_maltby or facebook for longer response.

8 thoughts on “Case (CP64090) Have you got the time?”

  1. This lady had seen me before. A couple of years back with right sided hip pain predominantly but also multi joint pain including extremities and hypermobility. We were concerned enough to refer for rheumatology. WOULD I BE RIGHT / WRONG TO QUESTION IF THIS HAD BEEN INVESTIGATED PRIOR TO YOUR REFERRAL? She had subsequently been diagnosed with Rheumatoid Arthritis (RA). She is an active 57yrs old. I WOULD BE INTERESTED TO KNOW WHAT HER ACTIVITIES ARE? ANY HABITS ASSOCIATED WITH THESE ACTIVITIES? I.E. MOVEMENT, RECOVERY, STRETCHES, PASSIVE TREATMENTS, CURRENT BELIEFS ABOUT HER ACTIVITIES. She was referred to me for management of her symptoms rather than a specific joint. This is unusual as I work in a musculoskeletal service and not a rheumatological one. IS RHEUMATOLOGICAL SENSITIVITY MANAGED IN A DIFFERENT WAY. YES, SPECIFIC SYSTEMIC DISEASE, YET FLARE UPS OCCUR LIKE MUSCULOSKELETAL PERSISTENT PAIN…
    IS THERE ANY CHANGE IN HER PHYSICAL WELL BEING? HAS SHE SEEN A CHANGE IN HER RA? ANY NEW ISSUES ARISEN?
    She reports seeing a rheumatological physiotherapist initially after diagnosis and given some stretching exercises. I’D BEEN KEEN TO KNOW WHY STRETCHES WERE PRESCRIBED AND WHAT IMMEDIATE EFFECT THEY HAD? I’D ALSO BEEN PROBING INTO HER UNDERSTANDING OF WHY THEY WERE GIVEN? CAN SHE MAKE SENSE OF IT, PERHAPS NOT BECAUSE OF HER FRUSTRATION.? The therapist went onto maternity leave and the replacement was not well received. She recalls being told the pain was due to her weakness and lack of movement and that she should do more and sit less. OH DEAR, THIS IS LIKE TELLING A BACK PAIN PATIENT THEY NEED TO DO MORE CORE STABILITY, THEIR CORE IS NOT STRONG ENOUGH THEY NEED TO DO MORE! She took offence at this as she reports being active. RIGHTLY SO! VALIDATION HERE! At this point she asked her GP to send her through to see me again.
    After reacquainting ourselves I asked what she is struggling with. I’D BE CURIOUS TO PROBE INTO WHY SHE FELT PROLONGED POSTURES WERE AN ISSUE, IS THIS SOMETHING NEW THAT SHE HAS NOTICED. HAS ANYTHING CHANGED IN HER CURRENT WORK LIFE BALANCE? She replies prolonged postures are becoming worse with time whether its sitting or standing. DURATION SHE CAN SIT FOR AND STAND FOR? I WOULD BE EXPLAINING ISCHAEMIC CHANGES THAT OCCUR FROM NOT MOVING AND THAT AN ALREADY SENSITIZED SYSTEM CAN BE PERPETUATED BY NOCICEPTION. She reports multiple joint pain including back, bilateral shoulder, elbow, hands, knees and feet. She reports worsening coldness to her extremities and intermittent numbness or dullness to both feet and occasionally buttocks. IS THIS A SIMILAR CHARACTERISTIC OF HER MOTHER’S PRESENTATION? NOT TO WANT TO CATASTROPHISE FOR HER BUT FAMILIAL HISTORY SHOWS MAY BE NECESSARY TO ELIMINATE OTHER BIOLOGICAL FACTORS. She had characteristic global early morning stiffness over 30mins. Her goals are to be able to stand taller to prevent a forward lean IS SHE AWARE OF A FORWARD LEAN OR IS THIS SOMETHING SHE HAS BEEN TOLD? and to be able to sit comfortably in a number of positions.
    She is under her rheumatologist at 4 month intervals at present and describes taking the highest dose of methotrexate her consultant is happy with, she also takes sulfasalazine and hydroxychloroquine. She doesn’t feel this controls her symptoms well. DOES SHE REQUIRE A MEDICAL REVIEW? DISCUSSION WITH GP ABOUT MEDS AND EFFICACY, MIGHT SEEM TOO EASY AN ANSWER BUT… She also takes ibuprofen and accompanying lansoprazole. JUST CURIOUS TO KNOW ABOUT THIS, DOES SHE GET ACID REFLUX? She also takes Folic acid and has taken lisinopril for 3yrs (with good control of her blood pressure).
    Her dad has history of 2x Myocardial Infarction (MI-first at 47yrs) and stroke whilst his father also had MI. Her mum has history of Raynaud’s disease and widespread Osteoarthritis. Both her mum and sister have diabetes. FAMILIAL HISTORY – IS THIS A POTENTIAL YELLOW FLAGS THAT CONTRIBUTE TO HER PRESENTATION? HOW MUCH DOES HER FAMILY EXERCISE? IS SHE THE MOST ACTIVE?
    She is right handed and works as a cleaning supervisor 25hrs a week. She has gradually increased up to this over the last 2yrs since her RA diagnosis and feels financially compelled to work. DO WE ASSUME THAT SHE IS UNDER PRESSURE FROM A FINANCIAL PERSPECTIVE? WHAT ARE THE REASONS FOR THIS? DOES SHE HAVE ANY INCREASE IN PRESSURES AT WORK? RESEARCH FROM WADDELL AND LINTON She reports when on holiday or days off work she has a big improvement in symptoms. AGAIN SEEMS TOO SIMPLE BUT A CHANGE IN LIFESTYLE AND BEHAVIOR ALLOWS THE DUST TO SETTLE. She lives alone with 2 dogs who she walks frequently (3x/day). She does not smoke. She averages 4 glasses of wine/week. She has 1-2 cups of decaf tea or coffee/day. She has deteriorating sleep quality and quantity mainly through discomfort although some stress. I WOULD WANT TO KNOW WHAT IS DRIVING THIS AND WHAT SLEEP HYGIENE HABITS SHE HAS BROACHED? PRE-COGNITIVE SLEEP AROUSAL ISSUES? THERE’S SOME INTERESTING RESEARCH BY TANG ET AL., 2012 ON PRE-SLEEP AROUSAL. She reports significant stress around her health and its impact on her life and reports periods of depression. She reports not cooking a lot due to discomfort so relies on convenience and pre-prepared foods. IS THIS RELATED TO HER LONG PERIODS OF STANDING OR IS THERE A MISMATCH IN PERCEIVED ABILITIES? I.E. CAN WALK IS ACTIVE ENJOYS EXERCISE LESS STRESS AND STRAIN ON STANDING COMPARED TO WHEN WALKING?? She reports excellent exercise levels, walks dog 3x/day, she likes to exercise 30mins/day on top of this, she reports step counter device always over 14,000 steps/day. She reports not relaxing well due to activity level and finds relaxation difficult generally even before diagnosis of RA. POTENTIAL CONTRIBUTING FACTORS, PROBING INTO HER UNDERSTANDING AND EMOTIONAL SUPPORT. DOES SHE NEED A PSYCH REVIEW TO ASSESS HER CONCERNS AND CURRENT MOOD? – RESEARCH HERE FROM ECCLESTON AND CROMBEZ AND ALSO VOWLES
    On examination her BP was in normal range, she had good active range of movement at the lumbar spine with mild ache reported at end of range only. She had good passive range also although found it difficult to relax fully and tended to join in or control the movement. She had no swollen or red joints. She had some knee pain with supported squat with tendency to hip flex and lumbar extend.
    Hopefully this gives you an insight into my encounter with this lady. I’m interested to hear from clinicians which information they attend to most. What really sticks out? What information that might be missing that you’d want? How would you approach ongoing clinical care if this person? What makes this case tough? What might be potential avenues to explore? What does the research say for this person?
    These aren’t trick questions. I have not fixed this lady and am looking to catch you out or get the right answer. I’m interested in how people clinically reason. How others approaches may vary. How I might learn form this. I’ve thought about doing this type of thing more regularly if there was enough feedback and engagement. I have purposefully left out my treatment plan so that you can start from a clean slate although I realise even from my writing (which I have tried to keep to chronological verbatim order) this may be apparent. I’d particularly enjoy feedback for whom this case seems outside their scope to see if any differences emerge.
    Be more human. Be less robot.
    Thanks for reading this far.

    HI NEIL
    THIS LADY SOUNDS LIKE SHE IS HAVING A BIT OF A TOPSY TURVY TIME. FOR ME REMAINING ACTIVE IS OF HIGHEST IMPORTANCE AND LOTS OF VALIDATION AND POSITIVE REINFORCEMENT NEEDED THERE.
    ASIDE FROM SOME OF THE BIOMEDICAL QUESTIONS I OFFERED I WOULD BE MORE INCLINED TO PROBE INTO THE ASPECTS OF HER LIFE THAT HAVE CHANGED (IF THEY HAVE) AND HOW THIS HAS CONTRIBUTED TO HER STRESS LEVELS. WHY THIS HAS OCCURRED AND WAYS OF EXPLORING MEANS OF HELPING HER TO COPE SOMEWHAT BETTER.
    I GET THE SLIGHT FEELING THAT SHE WANTS SOME VALIDATION ABOUT HER CURRENT PAIN EXPERIENCES, ADDRESSING SOME OF HER CONCERNS ABOUT POSTURE AND HOW STRESS LEVELS AND DISTURBANCE OF SLEEP CAN BE CONTRIBUTING FACTORS AND ALSO VICE-VERSA. I ALSO FEEL SHE MAY REQUIRE SOME GUIDANCE ABOUT WHAT SHE CAN DO TO MANAGE A FLARE UP? WHETHER THIS BE ADDRESSING HER SLEEP PATTERNS, HELPING TO GAIN SOME UNDERSTANDING OF HER SITUATION AND CONTRIBUTING FACTORS TO THAT, FINALLY HOW THIS CAN CONTRIBUTE TO HER PAIN.

    GOOD LUCK WITH THIS NEIL AS I KNOW THE TIME CONSTRAINTS IN THE NHS MAKE CLINICAL TIME VERY DIFFICULT. PERHAPS A PRIORITIZED WEEKLY FOLLOW UP EITHER FACE TO FACE OR VIA TELEPHONE AS I SUSPECT SHE MAY NOT TAKE KINDLY TO BEING SEEN IN 4 WEEKS OR SO DUE TO THE PREVIOUS PHYSIO EXPERIENCE.

    NOT SURE IF THAT HELPS BUT, THIS IS GREAT FOR MY LEARNING TOO AND WOULD LOVE TO HEAR FROM OTHERS IF THERE IS ANYTHING I MAY HAVE MISSED?
     
    Neil
    Replies can be left to this post. Or via twitter @neil_maltby or facebook for longer response.

    Liked by 1 person

    1. Wow! Thanks for taking time for the detailed reply mate!

      The RA diagnosis was from previous episode 2yrs ago.
      Her main activities are jog/bike. Didn’t prove further for routine (great idea).
      No change in RA over 2yrs but never been happy with control despite increased meds.
      She felt OK about the stretches but no benefit.
      Good point about her frustration clouding things. I’d agree with this!
      Her prolonged standing/sit postures have been reduced over time.
      Her work has increased steadily over 2yrs due to financial pressures.
      Agree about possible vascular involvement (why I checked BP on Ax).
      She feels unable to stand tall especially after sitting. The forward lean is response to pain/stiffness.
      She is under regular review and not long has her last one. Scratching their heads by the sound of it.
      She gets acid reflux since starting her RA meds.
      She is very active (not sure on family).
      She reports being financially under pressure as lives alone and has mortgage etc.
      She hasn’t tried any sleep strategies yet.
      Cooking inhibited by standing but also hand pain and difficulty gripping.

      Thanks again for your input. Love hearing how people reason!

      Liked by 1 person

      1. You’re welcome Neil, I’m not sure how much it helped? I hope it wasn’t too overwhelming? I looked at some of the tweets online and I would agree with the mismatch between values and goals. I think it goes further than that as there are a number areas you could probe and certainly address. The beauty of having a biopsychosocial approach to your clinical work. Best of luck. Look forward to reading the follow up post.

        Liked by 1 person

  2. Hi Neil,
    Interesting case. Just thinking that her poor sleep, low mood and high levels of stress could be significant pain drivers for this lady. She seems to be struggling to accept the RA diagnosis and what this may mean for her in the future? She does appear to be maintaining a good level of physical activity which is great. Maybe she is looking for validation and support in order to cope with this relatively new diagnosis? Thanks, Mary G

    Liked by 1 person

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