Rheumatoid Arthritis + Continuum of Care

Rheumatoid arthritis progresses through three stages: early synovitis, intermediate destruction, and late deformity. In the early stage, inflammation of the synovial lining occurs. This progresses to the destruction stage where there is erosion of cartilage and bone. Finally, in the late stage, there is deformity of the affected joints due to chronic inflammation and damage.

Possible triggers for rheumatoid arthritis include environmental factors, trauma, stress, diet, and viral infections. These triggers can initiate an autoimmune response in genetically susceptible individuals, leading to chronic inflammation and joint damage.

Common sites of involvement in rheumatoid arthritis include peripheral joints (metacarpophalangeal joints, proximal interphalangeal joints, metatarsophalangeal joints) and cervical joints (atlanto-axial). Involvement of these sites can lead to significant functional impairment and deformity, impacting the patient's quality of life.

Important subjective questions when diagnosing rheumatoid arthritis include history of trauma or overuse, affected joints, duration of symptoms, pattern of inflammation, exposure to infective agents, previous treatments, non-pharmacological interventions, and systemic features. These questions help in understanding the onset, severity, and potential triggers of the disease, guiding the diagnostic and treatment approach.

The ARA diagnostic criteria for RA require more than 4 criteria to be filled for a diagnosis, including specific signs and symptoms such as joint tenderness, heat/erythema, malaise, weight loss, and reduced function.

The aims of RA treatment include education and advice, pain relief, increasing and maintaining movement and strength, correcting and preventing deformity, improving function, and encouraging self-management.

Physiotherapy considerations for discharge in the management of RA include commencing at initial contact, reviewing regularly, involving and informing patients/family/carers, using a multidisciplinary team approach, allowing for flexibility, considering psychological, social, and cultural needs, setting SMART goals, providing home exercise programs, and organizing necessary equipment and referrals.

The Risk Assessment Prediction Tool (RAPT) is used for THR and TKR to predict and prepare for likely discharge destination based on the patient's condition and expected length of stay/prognosis.

Example: 70 y/o female post elective THR with specific short-term and long-term goals for independent ambulation and likely discharge destination home.

Information needed for discharge planning for a patient post ACL reconstruction includes support at home, ability to navigate stairs, driving capability, weight-bearing status, goals, discharge destination, current pain level, and any neurological symptoms.

Gutter frame and wheelchair may need to be considered as gait aids for a patient post fall off a ladder with a pelvic and distal radius fracture.

Subjective information required for a patient post ankle fracture (ORIF) includes ability to navigate stairs, living situation, pain level, and goals for discharge, as well as the likely discharge destination and any required follow-up or equipment.

The physiotherapy goals for a patient post ankle fracture (ORIF) in the context of discharge planning may include achieving independent ambulation and stairs negotiation, as well as preparing for discharge home or to an inpatient rehabilitation (IPR) facility.

Factors such as neural deficits, weakness of the unaffected leg, or unexpected complications may change the likely discharge destination for a patient post total hip replacement (THR).

Follow-up and equipment requirements for a patient post ACL reconstruction may include crutches, a home exercise program, a referral letter, and a knee brace.

The barriers to discharge for a patient post fall off a ladder with a pelvic and distal radius fracture may include the need for gait aids, reduced mobility, and challenges related to the patient's living environment, such as a double-story house.