1. 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

2. 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.

3. 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].
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4. 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).

5. 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

6. 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

7. 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
= $ ($ x 3.5hrs max.)
AP1
= $880.10
TOTAL
$1,445.88
Specialists
= $ ($ 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
= $ ($ x 3.5hrs max.)
AP2
= $660.08
LS3
TOTAL
$1,540.18
Specialists
= $ ($ x 3.5hrs max.)
= $778.62
$1,816.78
MOAs
= $80.00 ($20.00 x 4hrs max.)
$160.00

8. 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.

9. 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.

10. 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.

11. 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

12. 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.

13. 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)

14. 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?

15. 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

16. 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.

17. 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

18. 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.

19. 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

20. 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
students/video-resources/pgals.aspx Foster HE. Arthritis Care Res :
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).

21. 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

22. The pGALS Screen
Gait
Observe the child walking and turning

23. The pGALS Screen
Arms

24. The pGALS Screen
Legs

25. The pGALS Screen
Spine

26. 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

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

28. 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.

29. 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.

30. Thank you
Questions