Working Together to Help Children with Juvenile Idiopathic Arthritis MSK Train the Trainer 1 Working Together to Help Children with Juvenile Idiopathic Arthritis Lori B. Tucker, M.D. Clinical Associate Professor in Pediatrics Division of Rheumatology BC Children’s Hospital Vancouver, BC

Faculty/Presenter Disclosure Speaker’s Name: Speaker’s Name Relationships with commercial interests: Grants/Research Support: PharmaCorp ABC Speakers Bureau/Honoraria: XYZ Biopharmaceuticals Ltd Consulting Fees: MedX Group Inc. Other: Employee of XYZ Hospital Group Please fill out all applicable areas (highlighted in red). One slide per speaker.

Disclosure of Commercial Support This program has received financial support from [organization name] in the form of [describe support here – e.g. educational grant]. This program has received in-kind support from [organization name] in the form of [describe the support here – e.g. logistical support]. Potential for conflict(s) of interest: [Speaker/Faculty name] has received [payment/funding, etc.] from [organization supporting this program AND/OR organization whose product(s) are being discussed in this program]. [Supporting organization name] [developed/licenses/distributes/benefits from the sale of, etc.] a product that will be discussed in this program: [enter generic and brand name here]. Please fill out all applicable areas (highlighted in red).

Mitigating Potential Bias [Explain how potential sources of bias identified in slides 1 and 2 have been mitigated]. Refer to “Quick Tips” document Please fill out all applicable areas (highlighted in red).

Certification Up to 21 Mainpro+ Certified credits for GPs awarded upon completion of: All 3 Learning Sessions (NOTE: Credits and payment will be based on the exact number of hours in session) At least 1 Action Period The Post-Activity Reflective Questionnaire (2 months after LS3) Up to 10.5 Section 1 credits for Specialists

Learning Session & Action Period Workflow Pre-Module Visit Opportunity for in-practice visit to introduce applicable EMR-enabled tools & templates prior to LS1 Learning Session 1 Interactive group learning Create Action Plan (using template) Action Period 1 Planning & initial implementation in practice; review of Action Plan & improvements attempted in practice + AP1 requirements Learning Session 2 Interactive group learning Update/revise Action Plan Report of AP1 experiences & successes Payment for: PMV (optional) LS1 Action Period 2 Refine implementation; embed & sustain improvements attempted in practice via Action Plan + AP2 requirements Learning Session 3 Interactive group learning Finalize Action Plan Report of AP2 experiences & successes LS2 LS3 Reflection Reinforce & validate practice improvements - GPs & Specialists complete Post-Activity Reflective Questionnaire (PARQ) 2 months after LS3 & submit to PSP Central

Payment Stream 1 (ideal) Current Rates: GPs Specialists MOAs Hourly Rate $125.73 $148.31 $20.00 Action Period 1 $880.10 $1,038.16 N/A Action Period 2 $660.07 $778.62 Payment made after attending LS2 GPs: PMV = $125.73 LS1 = $440.05 ($125.73 x 3.5hrs max.) AP1 = $880.10 TOTAL $1,445.88 Specialists = $519.08 ($148.31 x 3.5hrs max.) = $1,038.16 $1,557.24 MOAs = $20.00 = $80.00 ($20.00 x 4hrs max.) $100.00 Payment made after attending LS3 GPs: LS2 = $440.05 ($125.73 x 3.5hrs max.) AP2 = $660.08 LS3 TOTAL $1,540.18 Specialists = $519.08 ($148.31 x 3.5hrs max.) = $778.62 $1,816.78 MOAs = $80.00 ($20.00 x 4hrs max.) $160.00

Objectives for This Talk To provide general background about juvenile idiopathic arthritis (JIA). To establish relevance of JIA Module for family physicians. To review key material in the JIA Module.

Goals for the JIA MSK Module Improve the early recognition of juvenile arthritis. Provide clinicians with tools to assist in the diagnosis of MSK complaints in children. Suggest pathways for referral of children with MSK complaints when needed, and increase awareness among GPs of accessibility of care for children and teens with arthritis in BC.

A true story……MC 11 year old girl, living in a rural community in BC Develops gradual stiffness in fingers, wrists and knees, with increasing pain. No swelling is seen. Unable to play the violin, difficulty with writing at school. Seen in local ER and walk in several times. Investigation done….and told everything was normal. Xrays; ANA, RF, ESR done……. 8 months after symptom onset, grandparents take her to their family dr. Urgent referral to pediatric rheumatology is placed. Patient is seen in 3 weeks- dx: polyarticular JIA Active joint count 18; unable to make a fist.

For most children the first health care contact – GP or A and E Second and subsequent health care contacts variable – no set pathway of care – children often get cross referred between specialities before referral to paed rheum – median of 3 health care contacts before paed rheum with consequent impact on time interval from onset to first appt. Few from GP direct to paed rheum Unclear what ultimately prompts referral to paed rheum ? – this is part of our ongoing research

What is Juvenile Idiopathic Arthritis? Most common childhood chronic disease causing disability. About 7/100,00 newly diagnosed children with JIA per year. Prevalence about 1/1,000 children = 1,000 children in BC with JIA. 7 subtypes. Disease begins at any time during childhood or adolescence.

Juvenile Idiopathic Arthritis Child under 16 years old At least one joint with objective signs of arthritis: Swelling, or two of the following: pain with movement, warmth of the joint, restricted movement, or tenderness Duration of more than 6 weeks Other causes have been excluded (ex. Infections, Lupus and other connective tissue diseases, malignancies)

Why do I need to learn about JIA? I will never see a case of this……. Have you seen a case of JIA or other autoimmune disease in a child? Have you seen a child with a limp or MSK pain?

Few know that JIA even exists…. 81% of Canadians say they know almost nothing about JIA. Only 30% had ever seen, read, or heard anything about JIA. Compared with 45-70% for other chronic conditions such as asthma, cancer, diabetes, HIV, CF, cerebral palsy, heart conditions. Ipsos-Reid, 2010

Common Diagnostic Myths About Arthritis in Childhood…… All kids with JIA have fevers. All kids with JIA have rashes. A child with joint pain (but no arthritis) must have JIA. All arthritis is painful. If a child has a positive rheumatoid factor, they must have arthritis. If x-rays are normal, there is no arthritis.

The JIA Module: Helping you with Diagnostic Pathway Child with MSK complaint presents to GP office Medical history Physical examination Red Flags?? Laboratory testing and imaging as indicated

Physical Examination of the Child with an MSK Problem Assess general health status. Child friendly approach. Do a complete physical examination. All joints should be examined, even if complaints are referred to only one. Keep developmental norms in mind.

Watch for Red Flags Child is unwell. Fever, weight loss, weakness Bone pain or night pain. Regression of motor milestones. Significant functional disability. Child not ambulating Child missing school or activities

What is pGALS? Evidence based screening MSK assessment for school aged children based on the adult GALS (Gait, Arms, Legs, Spine) screen Validated with excellent sensitivity and specificity Basic clinical maneuvers completed in an average of 2 minutes http://www.arthritisresearchuk.org/health-professionals-and- students/video-resources/pgals.aspx Foster HE. Arthritis Care Res 2006.55:709-716. Adult GALS missed important abnormalities in 18% of children, mostly at the ankle, foot, and TMJ. pGALS was tested in 65 children (median age 13 years, range 5–17 years) and demonstrated excellent sensitivity (97–100%) and specificity (98–100%) at all joints, with high acceptability scored by child and parent/guardian. The median time to perform pGALS was 2 minutes (range 1.5–3 minutes).

Documentation of pGALS Screen pGALS Screening Questions Any Pain? Right knee Any Difficulty Dressing? No Any Difficulty Walking? Yes Appearance Movement Gait Normal Arms Legs Abnormal Spine

The pGALS Screen Gait Observe the child walking and turning

The pGALS Screen Arms

The pGALS Screen Legs

The pGALS Screen Spine

When to Refer to a Pediatric Rheumatologist…… Child or teen with joint pain, swelling, stiffness, or dysfunction which has lasted more than 2 weeks and is unrelated to trauma. Child with signs and symptoms suggestive of a generalized connective tissue disease or autoimmune condition. Systemic lupus, dermatomyositis, vasculitis, periodic fever syndromes

What if you are not really sure…. General pediatric evaluation is often an excellent interim step.

Where can I refer my patients for help Where can I refer my patients for help? Pediatric Rheumatology Teams in BC Vancouver: David Cabral, Lori Tucker, Jaime Guzman, Kristin Houghton, Kim Morishita, Ross Petty Pediatric physiotherapist, occupational therapist Social worker Pediatric rheumatology nurses Penticton: Katherine Gross, M.D. Nurse and physio/OT Victoria: Roxana Bolaria M.D.

What about when my patient does have JIA? Work together as partners to provide care. Assist in arranging community services. Administer injectable medications i.e. methotrexate Monitor for side effects of medications. Assist parents with school issues if necessary. Provide immunizations, or modify schedule as outlined by pediatric rheumatology team.

Thank you Questions