Clinical case 1

Deborah is a 47 year old woman who was diagnosed with non-erosive RA 5 months ago. Since that time, she is on
NSAIDs and methotrexate. With this medication, the pain, stiffness and swelling of her hands, feet, and knees have
decreased markedly. When seeing her at the outpatient clinic, her DAS 28 score has decreased from 4.2 to 3.2. She
says her major problems in optimal functioning in her everyday life are due to recurrent pain in the wrists and feet and
lack of energy (fatigue).

1. What interventions do you consider inappropriate for Deborah?

a. Advise the patient to be careful with using her wrists/hands in activities to protect her painful wrists
True. There is no evidence to support careful use of joints because of pain. Normal activity and normal use of joints are
advocated.
b. Write a prescription for working wrist splints
True. Despite recurrent wrist pain, it would be ill-advised to prescribe working wrist splints in this case due to the early
stage of the disease and the good response to medication. Wrist splints might reduce pain, but immobilization of the
joint will reduce usage and activity of the joint, which will be an adverse effect.
c. Give her general advice on activity pacing and energy conservation
False. According to the patients experienced problem with fatigue that interfere and disrupts her everyday life, it can be
wise to refer the patient to an occupational therapist to learn about activity pacing and coping strategies for functioning
despite reduced energy.
d. Continue with questioning and clinical examination related to function in everyday life
False. Although this patient has a favourable response on anti-rheumatic drugs, she has complaints that may be
interfering with her daily activities. These complaints deserve more attention.
e. Refer her to an exercise program
False. All patients with rheumatic diseases should be given advice to exercise and do regular physical activity. If the
patient needs advise on this it will be wise to refer to a physiotherapist.
Deborah is married and mother of two teenage boys (15 and 17 years old. She is working 32 hours per week as a
secretary. She has pain in the wrists during household activities and at work. Her feet hurt when she walks more than 10
minutes. At physical examination, she has mild swelling of MCP II of the right and the left hand, pain on palpation and
maximal flexion and extension of the wrists and pain when squeezing the MTP joints of both feet.
2. Write down, while bearing in mind the framework of the ICF, the main areas regarding activities and
participation and contextual factors (environmental and personal factors) you would like to have more
information about and check out with our approach

Answer :
Several areas of interest should be addressed as they may influence your subsequent choices.
These include:
1.self-care: e.g toileting, dressing, washing
2.domestic life: e.g. doing housework, preparing meals, shopping
3.mobility: e.g. walking, driving, cycling, using transportation
4.work and employment: e.g. fine hand use, lifting and carrying objects
5.community life, recreation and leisure: e.g. sports
6.interpersonal relationships: e.g. spouse, family, friends, colleagues, employer
7.housing and household assistance: e.g. stairs, help of spouse and children or professional household help
8.adaptive devices and orthoses (at home and at work: e.g. wrist splints, special shoes, ergonomic computer

adaptations, ergonomic furniture)

9.self-management (e.g. knowledge on joint protection and energy conservation)
10.knowledge of resources for people with arthritis (e.g. relevant health professionals, information provided by patients'
organizations)
The patient's main limitations are with preparing meals, using the computer at work, and walking the dog for more than
10 minutes. She hasn't played tennis, her favourite sports, for more than 9 months because of pain and fatigue. She has
no adaptive devices, special shoes or orthoses. She is not aware of health professionals or health services for patients
with arthritis in her environment.
3. Please make a short description of the case summarising her function

Answer :
Here is a reasonable account of her problems: Limitations in household activities, mobility, work and leisure activities in
a woman with early arthritis responding well to disease modifying anti-rheumatic drugs. No usage of adaptive devices,
adaptations, community resources or health care services other than the rheumatologist.

4. Please write down, using the ICF model (Body functions and structures; Activities; Participation;
Environmental factors; Personal factors), the rehabilitation goals that you would discuss with the patient.

Answer :
Body functions and structures: reduction of pain in hands and feet and fatigue.
Activities and participation: decrease of perceived difficulty with preparing meals; increase of walking distance
outdoors up to 30 minutes; participating in exercise / sports activity. You could advise her to find another sport activity
that she enjoys and that will give her regular training
Contextual factors: appropriate usage of assistive devices, orthoses and help from other people with household
activities and work.

5. With respect to the patient's problems involving the usage of hands and wrists, please select the three most
appropriate and evidence based management strategies, and the arguments in favour and against each.
a. hand and wrist exercises
True. Although the specific evidence on hand exercises in RA is scanty, a daily program of ROM and strengthening
home exercises for the hands and wrists is to be advised.
b. wax baths or other superficial heat application
False. Heat or cold applications should preferably be used as an adjunct to an exercise program and not as a single
treatment.
c. ice packs
False. Heat or cold applications should preferably be used as an adjunct to an exercise program and not as a single
treatment.
d. TENS
False. This therapy is to be considered if other management strategies fail.
e. therapeutic ultrasound
False. The evidence for the effectiveness of therapeutic ultrasound in RA is scanty.
f. wrist working splints

True. Wrist working splints can reduce pain in the wrists during activities. Patients should be aware of the possible
negative effects on dexterity, the fact that most wrist working splints are not suitable for usage during wet and dirty
conditions, and the fact that wearing wrist working splints could be stigmatizing. Consider that working splits reduce
normal activity in the joint which can lead to reduced muscle strength and joint mobility when over used.
g. wrist resting splints
False. Wrist resting splints have not been found to be effective with respect to wrist pain in RA.
h. avoid using the hands and wrists as much as possible
False. Patients should not be advised to avoid activities. Normal activity is important to maintain optimal hand function.
i. adaptations to kitchen utensils and computer
True. There are various devices adaptations to kitchen utensils and computers available that can reduce strain on the
wrist joints. In this stage of the disease, refrain from permanent alterations to the house or equipment, as problems may
be transient.
j. working fewer hours at the office
False. Working fewer hours is not necessarily an appropriate solution. Taking more breaks, dividing the working hours
over more days and adaptations to equipment or furniture are examples of alternative options that could be tried first.

6. With respect to the patient's problems involving the feet, please select the two most appropriate management
strategies, and the arguments in favour and against each
a. Bespoke shoes with metatarsal bar
False. Although a metatarsal bar may reduce pressure on the metatarsal heads, bespoke shoes are only indicated if
other interventions have failed.
b. Bespoke shoes with wide toe-box and metatarsal bar
False. Although a metatarsal bar may reduce pressure on the metatarsal heads, bespoke shoes are only indicated if
other interventions have failed. As this patient does not have claw toes or hallux valgus, there is no specific indication for
a custom made wide toe-box.
c. Bespoke shoes with medial arch support
False. With the patient mainly complaining of metatarsalgia, currently there is no specific indication of a custom made
shoe with medial arch support.
d. Custom made rigid or flexible insoles
True. This could be an appropriate solution to reduce pressure under the metatarsal heads, given that the patient has
shoes that are wide enough to allow for an insert..
e. Off-the-shelf orthopaedic footwear
False. These shoes do not specifically provide a solution for the patient's metatarsalgia..
f. Elastic gymnastic shoes
False. These shoes have a thin sole, so that metatarsalgia is not likely to improve.
g. Sport shoes
True. This could be an appropriate solution for metatarsalgia, given that they adequately absorb and distribute plantar
pressure.
While discussing the patient's fatigue, she says she is indeed very tired, especially after dinner, and on the days that she
is working.

7. What would you advise her?

Answer : The pacing of activities (household activities and her paid job) deserves some attention. The patient should
consider spreading activities more evenly over the day and the week, to conserve energy. The patient could also
consider getting more help from her family or professional help to do household chores.
Moreover, the patients endurance with respect to physical activity could be enhanced by means of an exercise
programme aimed at increasing muscle strength, cardio respiratory fitness and range of motion. Care must be taken not
to increase strain on currently painful joints (wrists and feet) and to slowly, yet, progressively increase the intensity and
frequency.

8. Would you refer this patient to other health professionals? Please write down which and why.

Answer :
How far should the rheumatologist go in taking full responsibility for such patients will depend on his/her knowledge,
interest, time and available resources? Ideally, all patients would have access to the most well trained professional but,
because this is not possible, individual decisions need to be made. There can be large differences across European
countries and regions in the roles of these different health professionals.
Occupational therapist: This health professional could give education, advice and skills training when patients
experience difficulties in performing everyday life activities (work, home, leisure activities). Relevant interventions are
ergonomic principles, activity pacing, orthoses, assistive devices and adaptations in the home and working situation.
Physical therapist: This health professional could advise on an exercise programme tailored to the problems and needs
of this patient, teach the patient self-management skills regarding exercise, physical activity and sports, and give an
advice on the most suitable sports and leisure activities given her current. The core of the exercise programme should
comprise aerobic exercises, muscle strengthening exercises and flexibility exercises.
Clinical nurse specialist: This health professional could provide self-management support, education and monitor
medications. Clinical nurse specialists address topics like how to cope with the physical and psychosocial coping with
the consequences of living with the disease in general.
Podiatrist: In case the patient is in need of a more extensive shoe advice or is motivated to use shoe inserts for
metatarsalgia, referral to a podiatrist can be considered.
Social worker: Referral to a social worker is to be considered in case of a need for assistance with e.g. financial
consequences of the disease and/or its treatment, formal education or work, or consequences for interpersonal
relationships.
Occupational physician, vocational counsellor or other (health) professional engaged in vocational rehabilitation: This is
relevant if the patient may needs a more thorough assessment, counselling or adaptations concerning work-related
problems. These requirements need to be discussed with her employer. With this process, some support by a (health)
professional can be considered.
Multidisciplinary team: Referral to a multidisciplinary team is to be considered in case treatment by individual health
professionals (simultaneously or in succession) has failed and there is a need for more thorough multidisciplinary and
multidimensional goal directed biopsychosocial approach.
Clinical case 2
Peter is a 66 year old, retired salesman, living with his wife. For the past 2 years he has had intermittent pain in the left
knee. The pain has increased over the last 3 months and wakes him up several times at night. His left knee is stiff in the
morning and after periods of rest during the day. Occasionally, his right knee also hurts.
Peter loved to play golf, but has given it up because he can no longer walk more than six holes. His general practitioner
ordered a radiograph of the knees, which showed some joint space narrowing and subchondral sclerosis of the
tibio-femoral joints of his left knee (especially the medium compartment and to a lesser extent the same structures of his
right knee).
His general practitioner advised him to use acetaminophen 500mg up to 6 tablets per day, but Peter is reluctant to do

so.
On physical examination there is mild swelling of the left knee, some limitation of flexion and extension and mild varus
deformity. There are no abnormalities on examination of other joints. Peter is 1.72 m tall, and his weight is 98 kg.

1. Write down the main items you would like to address regarding Peter's functioning and contextual factors
and check out with our approach.

Answer :
Several domains would need clarification in order to make the best treatment decisions:
1.walking distance: outdoors, on flat surface
2.climbing stairs: climbing and descending chairs
3.other leisure activities than golf: sports, hobbies, charity work
4.housing: stairs outside and inside home
5.shoe adaptations and/ or walking aids
6.exercise therapy: previous usage and effects
7.medication: attitude towards medication, perceived effects
8.diet: attitude towards weight loss and diet, eating habits and previous attempts to lose weight
His maximal walking distance is 2 kilometres and he has difficulty climbing and descending the two flights of stairs in his
home. Apart from limitations with playing golf, he is limited in walking around during city trips and excursions in the
countryside. He has not tried using a walking aid or exercises. He is motivated to lose weight but afraid of the side
effects of any medication.
2. Please write down, using the ICF model potential treatment goals that can be discussed with the patient. The
ICF distinguishes various aspects of functioning (Body functions and structures; Activities; Participation) as
well as contextual factors (Environmental and Personal factors).

Answer :
Here are some wise objectives:
Body functions and structures: reduction of pain and stiffness of the left knee (8 weeks), reduction of body weight by
20 kg (1 year)
Activities and participation: improvement of walking outdoors and climbing and descending stairs
Contextual factors: appropriate usage of walking aids, shoewear, appropriate usage of potentially effective pain
medication
You give the patient information on the potential beneficial effects of acetaminophen on pain but not stiffness in OA and
the possible side effects.
3. Which one of the following non-pharmacological interventions would you consider first? Why?
a. Cognitive-behavioural therapy
False. Not at this stage. Cognitive-behavioural therapy is to be advised in case attempts to behavioural changes (e.g.
increasing physical activity or reducing weight) have failed or in case of marked anxiety or depression.
b. Exercise therapy
True. This patient has not had exercise therapy yet, whereas this was found to be an effective therapy to reduce pain
and improve function in patients with knee OA.
c. Referral for low level laser therapy
False. The literature suggests no effect of low level laser therapy in knee OA.
d. Referral for pulsed electromagnetic wave therapy

False. As the results of clinical studies overall indicate no effect of pulsed electromagnetic wave therapy on pain and
function in knee OA, this is not a good treatment option.
e. Taping the patella
False. Taping the patella is indicated in case of patello-femoral OA.

4. Write down the main elements of an exercise program you would advise for this patient

Answer : Usually, comprehensive exercise programs for knee OA comprise aerobic exercise, ROM exercises, muscle
strengthening exercises (M. Quadriceps), and functional training. Currently, there is little evidence regarding the optimal
intensity and frequency of exercise therapy for knee OA.
In general, it is to be advised to slowly increase the intensity.
Exercises are often combined with patient education on e.g. coping with pain and functional limitations, how to acquire
and maintain a sufficient level of physical activity, and on weight reduction. In this patient, guidance on physical activity
should include the exploration of possibilities to continue playing golf or to find an acceptable alternative sport.
It depends on the local availability of exercise resources and the preferences of the patient which forms of exercise are
to be advised (e.g. group or individual, land-based or water-based, health care or community resources).

5. Which two adaptive devices, home adaptation or orthosis you would advise the patient at this stage?
a. Knee brace
False. Definitely not. Knee braces are merely to be prescribed in knee OA in case of lateral instability and/or deformity.
b. Laterally wedged insole
True. This patient has slight malalignment of the knees (varus malalignment). A laterally wedged insole is to be
considered in case of mild, unicompartmental (medial) knee OA, to reduce the load on the medial compartment.
c. Medially wedged insole
False. This patient has no malalignment of the knees, so that there is no indication for insoles.
d. Walking cane (left hand)
False. As this patient has most complaints in his left knee, the cane should be used contra laterally.
e. Walking cane (right hand)
True. Support is to be carried contralateral to the painful leg.

6. The patient asks your advice regarding the usage of heat or cold applications and the usage of TENS. What
would you say?

Answer : In the literature, the evidence for the effectiveness of heat or cold applications in knee OA is scanty, mainly in
favour of locally applied cold. However, individual patients may benefit from local heat or cold. An advantage of local
heat or cold is that it can be applied by patients themselves at any time they like.
With respect to TENS, its effect in addition to exercise and education is questionable. TENS is overall safe but "is best
avoided" in patients with pacemakers or implantable cardioverter-defibrillators (ICDs). Moreover, there are other
contraindications for its usage, such as placement on broken skin areas or wounds, so that patients should be carefully
instructed.

7. What life style changes need to be considered by this patient?

Answer : Given the patient's overweight, which is a risk factor for progression of knee OA, life style advice should not
only comprise physical activity but address the patient's diet as well.
Whether this patient should be referred for professional support with reducing his weight depends on factors such as the
patient's intrinsic motivation, history of dieting, and social support. Cognitive behavioural therapy may be beneficial for
improving adherence or maintaining changes in activity or eating patterns.

8. Do you believe that this patient should be referred to another health professional? Which one and why?

Answer : This patient could benefit from a referral to a physical therapist to obtain advice and guidance regarding the
type, intensity and frequency of exercises to be performed and suitable sports. Referral to an (osteo)arthritis exercise
group could be an alternative, if this is available. A greater amount of physical activity may contribute to weight loss.
This patient is motivated to lose weight, and could first try to become more physically active with the help of a physical
therapist and modify his eating habits by himself. In case this is not effective, a referral to a dietician can be considered.