Rheumatic Conditions

This document has been endorsed by the American Academy of Family Physicians and was developed in cooperation with the American College of Rheumatology, the Association of Departments of Family Medicine, the Association of Family Practice Residency Directors and the Society of Teachers of Family Medicine.

Family physicians encounter a significant number of rheumatologic problems in the course of practice. Millions of work days are lost per year due to osteoarthritis and rheumatoid arthritis. The morbidity of arthropathies results in numerous hospitalizations annually.

Each family practice resident should be aware of the impact of this group of diseases on the patient and the family and be capable of performing a history and physical examination with special attention to the musculoskeletal system. The resident should be able to perform appropriate laboratory tests and basic diagnostic procedures and to initiate a management and therapeutic plan for patients with these diseases.

The following curriculum guidelines provide an outline of attitudes, knowledge and skills that should be included in training programs in family practice.

Attitudes

The resident should:

Understand health care utilization and the disability of rheumatic diseases.
Support patients in reaching their maximal function potential.
Be sensitive to direct and indirect costs of rheumatic diseases.
Recognize the importance of family, psychological and environmental variables on health status.
Understand the importance of a multidisciplinary approach to the enhancement of function.

Knowledge

The normal musculoskeletal system, anatomy and physiology
The role of immunologic mechanisms on the pathogenesis of rheumatic disease
The effect of aging on rheumatic conditions
Evaluation of the patient
1. Joint and soft-tissue evaluation
  1. History
2. Physical examination
  1. Brief screening examination
  2. Complete musculoskeletal examination, when indicated
  3. Functional assessment
3. Laboratory evaluations
  1. Serum
  2. Synovial fluid
4. Imaging techniques
  1. Plain films
  2. Computed Tomographic Scans
  3. Magnetic Resonance Imaging
  4. Ultrasonography
5. Indications for arthroscopy
6. Indications for arthrocentesis
7. Indications for tissue biopsy
Etiology, pathophysiology, epidemiology, clinical presentation, prevention and criteria for diagnosis
1. Osteoarthritis (OA)
  1. Primary
  2. Secondary
2. Rheumatoid arthritis (RA)
  1. Articular
  2. Extra-articular
3. Juvenile arthritis
  1. Pauciarticular
  2. Systemic (Still's disease)
  3. Polyarticular
4. Lupus erythematosus
  1. Systemic
  2. Discoid
  3. Drug-induced
5. Scleroderma
  1. Localized
  2. Systemic
  3. Drug/toxin induced
6. Polymyositis/dermatomyositis
  1. Drug induced myositis
7. Necrotizing vasculitis
  1. Polyarteritis nodosa
  2. Microscopic polyangiitis
  3. Hypersensitivity angiitis
    1. Serum sickness
    2. Henoch-Schönlein purpura
  4. Granulomatous arteritis
    1. Wegener's
    2. Giant Cell (Temporal)
  5. Kawasaki disease
  6. Behset's disease
8. Sjögren's syndrome (Primary and Secondary)
9. Polymyalgia Rheumatica
10. Antiphospholipid Syndrome
11. Spondyloarthritis
  1. Ankylosing
  2. Reiter's Disease
  3. Psoriatic Arthritis
  4. Arthritis associated with inflammatory bowel disease
12. Infectious
  1. Direct
    1. Bacterial
      1. Gonococcal
    2. Viral
      1. Parvovirus B19
    3. Fungal
    4. Spirochetal
      1. Lyme
    5. Rickettsial
      1. Rocky Mountain spotted fever
  2. Reactive
    1. Acute rheumatic fever
    2. Subacute bacterial endocarditis
    3. Post-dysenteric
13. Crystal induced arthropathies
  1. Gout
    1. Inherited
    2. Acquired
  2. Calcium pyrophosphate dihydrate (pseudogout)
  3. Hydroxyapatite deposition
14. Neoplasms that cause arthritis
15. Neurovascular
  1. Compression
    1. Peripheral entrapment, e.g., carpal tunnel
    2. Radiculopathy
    3. Spinal stenosis
  2. Raynaud's
  3. Reflex Sympathetic Dystrophy
16. Bone and cartilage disorders
  1. Osteoporosis
  2. Osteopenia
  3. Osteomalacia
  4. Paget's
  5. Avascular necrosis
  6. Costochondritis
  7. Chondromalacia patella
17. Extra-articular
  1. Bursitis
  2. Tendinitis
  3. Low back pain
18. Fibromyalgia/chronic fatigue syndrome
19. Arthralgia
  1. Drug-induced
20. Other
  1. Relapsing panniculitis (Weber-Christian disease)
  2. Erythema nodosum
  3. Sarcoidosis
  4. Adult Still's Disease
Pharmacology
1. Anti-inflammatory drugs (nonsteroidal anti-inflammatory drugs)
  1. Non-selective (nonsteroidal anti-inflammatory drugs)
  2. COX II selective
2. Slow-acting antirheumatic drugs
  1. Antimalarials
  2. Sulfasalazine
  3. Gold salts (oral and intramuscular)
  4. Minocycline
  5. Penicillamine
  6. Cytotoxic agents (e.g., Methotrexate)
  7. Tumor Necrosis Factor (TNF) inhibitors and other biologic agents
3. Corticosteroids
  1. Systemic
  2. Local
4. Anti-gout drugs
  1. Acute episode
  2. Uric acid lowering
5. Antibiotics
6. Treatment of Osteoporosis
Rehabilitation
Indications for surgical treatment of arthritis
Awareness of commonly used complementary and alternative therapies
Understanding of Rheumatic Disease Classification Criteria

Skills

Diagnostic
1. Perform target history
2. Perform complete musculoskeletal examination, including functional assessment
3. Interpret laboratory results
4. Aspirate and analyze joint and bursal fluids and order appropriate testing
5. Interpret radiographs
6. Evaluate psychosocial aspects
7. Evaluate disability
Management/therapeutic
1. Appropriately prescribe and monitor common medications
2. Manage the "red hot" joint
3. Perform intra-articular and soft tissue injections
4. Appropriately prescribe physical therapy, splinting and assistive devices
5. Educate family and patient about disease, community resources
6. Perform common measurements to follow disease progression
7. Provide patient and family psychosocial support and counseling as indicated
8. Demonstrate an understanding of the specific indications for consultation and referral to each of the health professionals having different expertise: orthopedic surgeons, rheumatologists, physiatrists, and physical and occupational therapists

Implementation

The implementation of these curriculum guidelines should be longitudinal throughout the resident's experience or may include block experiences in specialty offices focusing on these conditions. The residency library should have reference material available that amplifies topics in these educational guidelines. The curriculum guidelines should be integrated into the schedule of conferences and other teaching modalities, such as monographs, films and consultations. The resident should gain hands-on experience by being involved in the management of this group of diseases in the family practice center or a similar environment.

Resources

Schumacher HR, Klippel JH, Koopman WJ, eds. Primer on the rheumatic diseases. 12th ed. Atlanta: Arthritis Foundation, 2001.

Guides to the evaluation of permanent impairment. 5th ed. Chicago: American Medical Association, 2002.

Ruddy S, Harris, ED, Sledge CB, Sergents JS Budd RC. Eds. Textbook of Rheumatology. 6th ed. Vols 1 and 2. Philadelphia: Saunders, 2001

Klippel JH, Dieppe PA. Rheumatology. 2nd ed. St. Louis, MO: Mosby, 1998

Guidelines for the Management of Rheumatoid Arthritis: Arthritis and Rheumatism. 2002, 46:328.46

Web sites

http://www.rheumatology.org - American Collge of Rheumatology Home Page

http://www.rheumatology.org/publications/primarycare/index.html
(contains "Rheumatology and Musculoskeletal Medicine for Primary Care" - by mail or online)

http://www.arthritis.org - National Arthritis Foundation Home Page - can order the Primer on Rheumatic Diseases from this site. Can also order "Arthritis Today 2001 Supplement - Guide to Herbs, Vitamins and Other Remedies" free from this site.

http://www.niams.nih.gov - National Institute of Arthritis and Musculoskeletal and Skin Disease site.

Published 10/90
Revised and Retitled 07/96
Revised 6/02