Rheumatology Advance Access originally published online on February 28, 2007
Rheumatology 2007 46(5):890-891; doi:10.1093/rheumatology/kel438
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
The rehabilitation model rules in RA until biomedicine transforms tomorrow's rheumatologist into a real thaumaturgus
Department of Rheumatology, Ysbyty Gwynedd, Bangor LL57 2PW, UK
SIR, In their leading article, Bertinotti et al. [1] discuss the new assessment tools for clinical trials and individual patient evaluation in rheumatoid arthritis (RA). They observe that the doctors’ and patients’ points of view often do not match, with doctors focussing on measuring disease activity, which is of little interest to their patients who only want to improve their state of health. They discuss the problems associated with trying to unify the efficacy/outcome data with patient's need and, in particular, his/her quality of life.
The authors then go on to discuss the OMERACT core set, the ACR20 and the Disease Activity Score (DAS), which are made up of both subjective and objective measures. For example, the DAS is comprised of two objective measures (number of swollen joints and ESR or CRP) for the doctors and two objective measures (number of tender joints and patient's assessment of global health status) for patients [2]. This was designed for clinical trials but is now used in the clinic as part of the BSR guidelines for starting and continuing anti-TNF therapy [3].
Combining these two types of measures can cause problems, especially if we are to base our clinical decisions about DMARD management upon them. For example, when the DAS is measured in patients with fibromyalgia (and no RA) they score so highly on the subjective measures that in spite of an absence of joint swelling and a normal ESR, their DAS scores are as high as patients with moderately active RA [4]. About 20% of patients with RA also have fibromyalgia which will confound the meaning of the outcome measure in these cases [5].
The desire to include the patient's view in the medical assessment of RA has led to the present day confusion described in the editorial. This comes to no surprise to one mentioned in despatches as a rheumatologist ‘of past decades’ in my ‘long lethargy’ caused ‘by the absence of effective drugs’. In these distant times rheumatology was closely linked to rehabilitation. Indeed my certificate of specialization declares me to be trained in Rheumatology and Rehabilitation. We were all too well aware that we did not have a medical cure for the patient with chronic RA and our multidisciplinary teams managed such patients by means of the bio-psycho-social rehabilitation model [6].
Put simply this postulates that pathology (e.g. active synovitis) gives rise to impairment (e.g. loss of joint movement); which leads to disability (e.g. reduced mobility); which results in handicap (say not being mobile enough to get to the workplace and so not fulfilling the role of the worker). In this model different outcome measures are used to measure its different functions. For example, pathology—ESR and swollen joints; impairment—range of joint movement; disability—HAQ; and handicap—a patient-generated measure like the Patient Generated Index (PGI) [7]. The functions are also used as a focus of the rehabilitation plan. For example, DMARDs are used to minimize the ESR and number of swollen joints; physiotherapy is used to try to maximize the range of joint movement; gait retraining, a walking stick and car modification is used to improve mobility so that the patient can return to whatever activities he/she has chosen in her PGI [6]. The bio-psycho-social approach ensures that factors not directly associated with the pathology such as pain, fatigue, deformity, depression, family factors and coping style, etc. are considered.
This model with its different outcome measures and focuses for a rehabilitation plan is far more likely to meet the need of the patient. Today's rheumatologists are much closer to the thaumaturgus (miracle worker) quoted by Bertinotti et al. than those of past decades. We have powerful designer drugs that have a dramatic effect on the pathology of RA. Unfortunately, we do not yet have a cure and almost every patient still has a degree of impairment, disability and handicap. Until we are able to eradicate RA we need to apply the biomedical model strictly to the drug treatment and concentrate only on the pathology by using measures such as number of swollen joints, volume of synovial hypertrophy measured by ultrasound or MRI and acute phase reactants. To meet the patient's needs we should move to the bio-psycho-social rehabilitation approach to facilitate the multidisciplinary team in minimizing the patient's handicap.
When biological science has developed treatment to obliterate RA, so that the rheumatologist is a real thaumaturgus, the medical model on its own will suffice, until then we need to use separate outcomes measures for the doctor and the patient. Combining them sometimes results in confusing signals that are all too easy for the biomedically based doctor to misinterpret and leave the patient unheard.
The author has declared no conflict of interest.
 |
References |
|---|
 Top References |
|---|
- Bertinotti L, Nacci F, Matucci-Cerinic M. (2006) The measurement of outcome and the rheumatoid arthritis core set to lift the prejudice of the ‘thaumaturgus cliché’. Rheumatology 45:1055–7.
[Free Full Text] - Van der Hiejde DMFM, Van't Hof M, Van Riel PLCM, Van de Putte LBA. (1993) Development of a disease activity score based on judgement in clinical practice by rheumatologists. J Rheumatol 20:579–81.[Web of Science][Medline]
- Ledingham J and Deighton C. (2005) Update on the British Society for Rheumatology guidelines for prescribing TNF
blockers in adults with rheumatoid arthritis (update of previous guidelines of April 2001). Rheumatology 44:157–63.[Free Full Text] - Leeb BF, Andel I, Sautner J, Nothnagl T, Rintelen B. (2004) The DAS 28 in rheumatoid arthritis and fibromyalgia patients. Rheumatology 43:1504–7.
[Abstract/Free Full Text] - Wolfe F and Michaud K. (2004) Severe rheumatoid arthritis (RA), worse outcomes, comorbid illness and sociodemographic disadvantage characterise RA patients with Fibromyalgia. J Rheumatol 31:695–700.
[Abstract/Free Full Text] - Escalante A and Inmaculada DR. (2002) The disablement process in rheumatoid arthritis. Arthritis Care and Research 47:333–42.[CrossRef]
- Camilleri-Brennan J, Ruta DA, Steele RJC. (2002) Patient generated index; new instrument for measuring quality of life in patients with rectal cancer. World J Surg 26:1354–9.[CrossRef][Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||