Long-term conditions also known as chronic diseases or non-communicable diseases have been defined by the World Health Organization (WHO, 2005, p.35) as conditions that have origins at young ages take decades to be fully established, with their long duration, requiring a long term and systematic approach to treatment. Plans to transform care for patients with long-term conditions are based on continuing to maintain focus on early intervention and prevention; supporting integrated services shall help the patients and the public have a clear set of rights and patients in turn shall help the health care by undertaking the necessary steps, to take good care of their own health: promoting a preventative, people- centred, and productive care to be delivered (Great Britain. Department of Health, 2009).
Director General of WHO expressed that, “the lives of far too many people in the world are being blighted and cut short by chronic diseases, this is a very serious situation, both for public health and for the societies and economies affected” (WHO, 2005, p. VII), which has raised a need for long term conditions to be managed differently. Goodwin et al (2010, p.61) report that it was recognised, if patients with long-term conditions were managed effectively in the community, they would remain relatively stable and enjoy a quality of life free from frequent crises or observed increases in hospital visits. Chronic diseases have placed a heavy burden on the health care with demand for services and cost for treatment; the economic cost levels incurred; directly by the health care and indirectly by the individuals has also increased, and also increased use of hospital resources, raising need to manage the differently (Canada. Department of Health and Community Services, 2011, p.7).
They are time-consuming and some do not require the expertise and skill of a physician, but rather, may be managed by other members of the health care team (Canada. Ontario Medical Association, 2009, p.1). Chronic conditions have an effect on workplaces as regards productivity losses, where modifications have to be made by employers who attain workers with long-term conditions; so there is a need to manage them differently (Canada. Department of health and Community Services, 2011, p.7).
Great Britain. Department of Health (2012) published a policy to support the management of long term conditions: improving quality of life for patients with long term conditions. Majority of the health care systems of middle-income countries, including Malaysia, are organised around models of healthcare developed in western countries, such systems are clearly at odds when dealing with long-term and continuing illness that require collaboration across health care sectors and where patient behaviour change forms the primary focus (Yasin et al, 2012, p.3). Malaysia is now implementing the Innovative Care for Chronic Conditions Model (ICCC), for it was developed, recognizing the challenges of the under-resourced and non-integrated health systems in low-and-middle income countries; but still holds focus on encouraging behaviour change at an individual level through improving self-management (Yasin et al, 2012, p.4).
Managing long-term conditions requires key principles to be applied for health care to remain focused with the plans to transform care; the Department of Health, Social Services and Public Safety (Great Britain. Department of Health, Social Services and Public Safety, 2012, p.13) identifies six key principles that may be used as guidelines for managing long-term conditions and these include: working in partnership with the patients and their carers, supporting self-management, avail appropriate and timely evidence-based information to service-users and their carers, promote personalised aid for patients to manage their medicines, recognising carers as partners in planning and delivery of services, services should be patient-centred, and flexible and integrated services across all sectors.
In this assignment, a scenario of a patient diagnosed with Rheumatoid Arthritis three months ago, is going to be discuss, regarding examination findings outlined in the pro-forma; her name is Marjory 32 years old, married and a mother of two, works as a secretary. It is her first physiotherapy session, and she is receiving active treatment, and shall be introduced to self-management guidelines that are to help her manage her condition at home.
Rheumatoid arthritis (RA) is an inflammatory, autoimmune disease that causes pain, joint stiffness especially in the morning, and loss of function; it can occur at any age but is more common in persons over the age of 30 years and affects women more often than men (Australia. The Department of Health and Ageing, 2009, p.1). RA is a systematic disease that affects the whole body; joint pain and swelling manifest, leading to structural deformities and disability, causing a reduction in joint movement and muscle use; this happens because the immune system attacks the synovium first, with which the synovial membrane becomes thick and inflamed, resulting in unwanted tissue growth, but the most affected joints are particularly those of the wrists, hands and feet (Australia. The Department of Health and Ageing, 2009, p.3-4). Goal-setting process is required when managing RA patients: a formal process where a physiotherapist together with the patient formulates the rehabilitation goals which need to be specific, measurable, achievable, realistic/relevant and timed, i.e. meeting the criteria for “SMART” principle (Meesters et al, 2013, p.1).
Physiotherapy management of RA uses a comprehensive approach which consists of a combination of education, exercise and pain relief agents, with the emphasis varying depending on clinical needs identified, so the physiotherapist and patient discuss coming to an agreement in regards to setting goals (The National Collaborating Centre for Chronic Condition (NCCCC), 2009, p.77). Physiotherapy aims to reduce pain and stiffness, prevent deformity and maximise function, independence and quality of life, which Marjory equally needs (NCCCC, 2009, p. 77). Kavuncu and Evcik (2004, p.1) assert that successful management involves educating patients and informing them about the planned treatment modalities that are going to be used and their effects to the patient’s identified problems.
It was identified that Marjory had residual swelling around her hands, but no heat on palpation and the range of motion (ROM) had also reduced; paraffin wax therapy and hand exercises are the interventions chosen. Kacunvu and Evcik (2004, p.2) recommend using heat therapy before exercise for maximum benefit and applications are recommended for 10–20 minutes once or twice a day. Paraffin wax therapy has a short term symptomatic relief of pain and stiffness at the hands; the use of moist heat is intended to increase blood flow to the area, reduce pain and improve ROM (Welch et al, 2011, p.2).
Recent evidence shows positive results for paraffin wax baths combined with hand exercises for arthritic hands on objective measures of ROM, pinch function, grip strength, pain on non-resisted motion, stiffness compared to control after four consecutive weeks of treatment (Welch et al, 2011, p.2). Despite paraffin wax therapy having benefits, its heat effects may increase inflammation, thus increasing swelling of the synovial membrane, so both joint and skin temperature elevate following superficial heating, which is a disadvantage to using heat therapy as an intervention, because RA patients often have unstable vascular reactions following exposure to heat (Hayes, pg.255, 2006).
Another identified problem on Marjory was the swelling on the knees with heat on palpation, cold therapy is preferred for active joints where intra-articular heat increase is undesired; the physiological effects of cold therapy include an abrupt drop in skin temperature, and a slow decline in temperatures within the muscles and joints: the recommended application time is 20 minutes to decrease synovial blood flow in patients with arthritis (Demoulin and Vanderthommen, 2011, p.117). Cold therapy is advocated to be applied intermittently rather than continuous, for the optimal parameters; each session should last 25 to 30 minutes, which is the time thought to be needed to substantially decrease temperature, blood flow, and metabolism (Demoulin and Vanderthommen, 2011, p.118).
After cold therapy application, then TENS will be applied on Marjory’s knees, for it decreases pain and inflammation, and also reduces stiffness; its physiological effect of stimulation of the large sensory fibres prevents impulses from the smaller pain fibres from being transmitted in the ascending tracks in the spinal cord; decreased inflammation and joint volume will give an analgesic effect (Hayes, 2006, p.257). The burst-mode is recommended for it has both the high (70–100 Hz), and low (3–4 bursts per second) frequency modes; the advantage of burst-mode TENS is the greater comfort of the current, recommended treatment time is 30 minutes, only once per day for several weeks (Hayes, 2006, p. 257). The disadvantage of TENS, is the discomfort that arises from skin irritation through the electrode couplant from the electricity, and a study reported that an RA patient developed paresthesias which increased pain following heat and TENS, these effects were delayed, so RA patients should be monitored closely (Hayes, 2006, p. 257).
In early disease of RA, patient education is a foundation of all rehabilitation interventions; however, using cognitive behavioural approach delivered at the appropriate time which is after active treatment, in order to promote long-term adherence to management strategies rather than an education-only approach (Luqmani et al, 2006, p.5). Research suggests that changing of illness perceptions and the use of coping strategies have a significant influence on psychological well- being, health-seeking behaviours, adherence and treatment outcome on rheumatoid arthritis patients (Dures and Hewlett, 2012, p.553).
Rehabilitation is targets managing the consequences of disease, so there are other strategies that are to be applied for long-term remission for everyone with RA (Hammond A, pg.135, 2004); for which Marjory shall be empowered to manage her condition.
Self-management training does plays a role with patient knowledge gain, aiming to give patients the strategies and tools necessary to make daily decisions to cope with the disease; patients’ involvement in the management of their care helps to improve self-confidence, desirable behaviour and improved functional status (Vliet Vlieland, 2007, p.1400). Self-efficacy is a component that may influence Marjory to have a positive change towards her health behaviour, become motivated to succeed and have perseverance once she has decided on a plan of action; and she gain the ability to recover from setbacks, and the likelihood of maintaining the change over time (Dures and Hewlett, 2012, p.553)
Joint Protection and energy conservation strategies through resting and using splinting, compressive gloves, assistive devices, and adaptive equipment have beneficial effects in managing RA symptoms and deformities, which help to stabilise Marjory’s symptoms; splints may be used to give desired position at rest and functional positioning to the involved active joints; indirectly diminishing pain and inflammation, preventing development of deformities, preventing joint stress, supporting joints, and reducing joint stiffness (Kanvucu and Evcik, 2004, p.4). Compression gloves give a gentle compression which is an advantage on controlling joint swelling leading to decrease of pain (Kanvucu and Evcik, 2004, p.4).
Exercise therapy has physiological advantages of improving cardiovascular health, increasing muscular hypertrophy and increasing bone mineral density; also as a therapy, it enhances physical function and psychosocial advantages of the patients (Law et al, 2012, p. 332). Despite the positive reports about exercise, there are barriers to this management approach: psychosocial aspects cause barriers, concerns relating to joint health and limitations in exercise prescription, musculoskeletal pain and fatigue (Law et al, 2012, p. 334).
Pain Management strategies are needed because pain is the main cause for the lack of activity and losses of functional ability in RA patients, successful rehabilitation cannot be achieved if the patient is in pain, so the control of the disease with classic therapeutic forms to control the pain and to improve the activities is needed (Giavasopoulos.E.K., 2008, p.65). Thermotherapies should be recommended for Marjory to use at home; even if hot and cold stimuli, in inflammatory arthritis do not alter the articular inflammation, but improve the secondary answer in the pain and the behaviour (Giavasopoulos.E.K. pg.66, 2008). Pain in the soles is common presentation among RA patients, recommendations on using insoles from high density polypropylene, that are to produce satisfactory treatment of the pain (Giavasopoulos.E.K., 2008, p.67).
Work rehabilitation strategies are needed; Hammond (2004, p.143) points out key strategies to maintain people in work and these include: rapid communication with employers, job modification, re-organizing work schedules; short periods of rest should be allowed because rest decreases the inflammation and the pain and promotes the physiologic place of articulation. Good evidence indicates that introducing a simple work problem-screening tool assists early identification of work problems, and early work assessment reduces work problems, maintain people in work and results in high levels of satisfaction from workers with RA (Hammond, 2004, p.143).
This assignment has justified the purpose of promoting the plans to transform care for patients with long term conditions, particularly RA for this case, by showing how the policy of improving quality of care for people with long term should be implemented in the healthcare system. The key principle priorities that were applied to Marjory, were: provision of patient education, facilitation of self-management, delivery of patient-centred care, giving evidence-based interventions and improvising early proactive intervention: these principles display patient involvement to improve the quality of care with the aim of producing good management outcomes and preventing secondary complications on the patient, so as to improve the patient’s quality of life despite her having rheumatoid arthritis.
Proposed Management Approach Pro-forma
Student Number: w12035846Scenario Number: #1
Current problems identified in order of priority:
•Pain, swelling and stiffness at the knees
•Stiffness in her hands – MCP and PIP joints
•Slight swelling at the hands
•Reduced grip strength
Short Term Goals:
•Increase grip strength
•Increase range of motion in reference to the extension lack at the knees •Increase muscle strength of quadriceps
•Counsel patient to correct emotional status
Long Term Goals:
•To stabilize symptoms
•To improve quality of life
Does the patient require any active treatment at the moment? If so, what? If not, why? •Yes, in reference the swelling and stiffness around the hands •Active treatments: Paraffin wax therapy combined with hand exercises, Ice therapy for the knees, TENS, and Patient Education What strategies do you think it would be appropriate for you to use in assisting the patient to self-manage their condition at this stage? •Joint protection (energy conservation, assistive devices, splints) strategies, •Pain management strategies heat therapy
•Work rehabilitation strategies
• Evaluation and monitoring strategies using outcome measures How do you think your role will change / evolve in the long-term management of his patient?
Physiotherapy plays as a role in rehabilitating Rheumatoid Arthritis (RA) with the goal to optimize function in patients. As a physiotherapist, role playing is recognised through providing patient education with reliable and appropriate information, and availing evidence based treatment programmes to the patient; by identifying factors that will positively or negatively affect maintenance of the management of RA condition. Also encourage the patient to have a positive mind set towards exercise prescriptions and physical activity tasks. Another role is to improve patients’ perception towards the management approach of RA.
Australia. The Department of Health and Ageing (2009) A picture of rheumatoid arthritis in Australia. Canberra: Australian Institute of Health and Welfare (9) (pp.1,3,4) [Online]. Available at: http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=6442459857 (Accessed: 14 May 2014) Canada. Ontario Medical Association (2009) Policy on Chronic Disease Management, Ontario: Health Policy Department [Online] Available at: https://www.oma.org/Resources/Documents/2009ChronicDiseaseManagement.pdf (Accessed: 7 May 2014) Canada. Department of Health and Community Services (2011) Improving Health Together: a policy framework for Chronic Disease Prevention and Management in Newfoundland Labrador. Newfoundland Labrador: The Department of Health and Community Services. (p.7) [Online] Available at: http://www.health.gov.nl.ca/health/chronicdisease/Improving_Health_Together.pdf (Accessed: 14 May 2014) Demoulin, C and Vanderthommen, M. (2011) ‘Cryotherapy in rheumatic diseases’, Joint Bone Spine, 79, pp. 117-118. ScienceDirect [Online] Available at: (Accessed: 20 May 2014) Dures, E. and Hewlett, S. (2012) ‘Cognitive–behavioural approaches to self-management in rheumatic disease’, Perspectives, 8(10), p.553. [Online] Available at: (Accessed: 27 May 2014) Giavasopoulos, E.K. (2008) ‘Rehabilitation in Patients with Rheumatoid Arthrits’, Health Science Journal, 2 (2), pp.