Why Should All MSK Clinicians Care About Rheumatology???
Hello there Rheumatology Fans,
Here are a few key points about Rheumatological conditions:
They Masquerade as common musculoskeletal conditions like back pain and tendon pain
Delays to diagnosis result in worse outcome measures across pretty much every category you think of
It is 2023 and we are STILL struggling to get people with Rheumatological conditions in front of a Rheumatologist in a timely manner
The little article I mentioned is this one CLICK HERE written by Karl Gaffney, Dale Webb (from NASS) and Raj Sengupta. 3 people who know rather a lot about AxSpA and its challenges. To oversimplify a summary of their article, we aren’t getting better at getting AxSpA patients diagnosed than we were 10+ years ago and there are barriers at every stage of the persons journey.
Lets zoom in on the MSK Therapist role in all this, we cannot claim to be anywhere ahead of the curve as a cohort. We are responsible for seeing a great number of back pain and tendon pain patients often as the first point of contact. If not the first contact then likely the first MSK specialist contact. We need to ensure we are considering Rheumatological disorders as the cause of the attending persons symptoms. As far as I can work out Therapists around the world ensure they consider Cauda Equina Syndrome as a possibility in all back pain or leg pain attendees (even if it is only for a brief second) and I think we should have similar vigilence for Rheumatological causes.
On my courses we talk about a form of stratification in our clinical case loads. Take Ulcerative Colitis for example, this will raise your index of suspicion for a Spondyloarthritis significantly compared to someone with no inflammatory co-morbidity (~25% vs ~1%). Without an awareness of these kinds of relationships missed and delayed diagnoses are rife.
There is a flip side to this, we can’t just have a low threshold for referral to Rheumatologists. Depending upon where you sit in the patient pathway you will possibly need the assistance of others to get the referral or necessary investigations sorted, then obviously the Rheumatologist to see them. This is a use of resources and we need to be appropriately judicious with their use. Knowing who not to refer is equally as important as knowing who to refer, or what investigations or help would be useful to make a better informed decision. Further to this, conditions like Gout and Polymyalgia Rheumatica are kept in Primary Care for the most part.
If we are obtaining investigations do we know how to interpret these with consideration to false positives, false negatives and the context of the referring symptoms. The number of times I have seen an Anti-CCP ordered for a patient with bilateral heel or back pain, or a lumbar spine xray for inflammatory sounding back pain. I have also seen many times a referral not made despite very convincing symptoms but negative inflammatory markers.
Please don’t think I am being critical of individuals here, I am trying to illustrate the challenges associated even when the condition is appropriately recognised.
So what I want you to think about is this. How interested are you in Rheumatology? Or maybe more accurately where does your interest end? What would happen if you referred a patient you thought had a Rheumatology issue and it got rejected, what would you do? Would you be able to recognise the correct investigations for their presentation and understand the interpretation? What would you do if you weren’t sure what someones diagnosis was? If the person came back after being diagnosed would you know how to help them?
I think if we consider not only our part within the pathway but also how we are utilising the pathway around us. This will be a good start for most of us as we try to improve the patient experience. The often quoted delays to diagnosis of average 8+ years or in the article above the mean delay of 6.7 years is obviously highly problematic and we all need to care about our role in this.