Rheumatoid Arthritis

Rheumatoid Arthritis Patient Presentation

History

Mrs.TT is a 49 year old single female, who works as a computer programmer. She is unable to commute to work, and is currently working from home. She lives with her 2 children in a three-storey home.
Reason for Referral

Mrs. TT has been referred from her family doctor for multiple arthralgias.

Mrs. TT experienced an insidious (over months) onset of multiple joint pains, involving both her large and small joints. Important aspects on history were her age and gender, 49 year-old female, and learning that the onset and duration of her joint pains were over a year, with gradual worsening over time and an accumulation of multiple joints. She described times in which she would have severe night pain, and difficulties getting out of bed and cooking. These episodes would last for a couple of weeks, and she would then return to her previous condition, in a waxing and waning pattern with slow deterioration/worsening over time. Episodes had recently become more frequent and of concern. She had difficulty quantifying the severity of her pains, but admitted that at times it could be 10/10. She described morning stiffness >1 hour, which was aggravated by rest, but ameliorated by activity, and joints that were red, swollen, warm, and painful. The pattern of joint involvement was initially asymmetrical, involving some of the small joints of her hands (PIPs and MCPs); however, progressed to involve most of the small joints of her hands, metatarsal phalanges, and knees, in a peripheral symmetrical polyarticular pattern. She had also complained of shoulder and neck stiffness in the past, and difficulties in closing her jaw. She had seen a dentist in the past concerning the later, and Valium had been prescribed. Unfortunately, it was only helpful for the first five days. Furthermore, she denied any back pain or spine involvement.

On review of systems, she admitted to profound fatigue, mild weight loss, poor appetite and sleep, but denied any fevers, chills or myalgias, as well as any neurological, cardio-respiratory, GI or GU symptoms. She denied any infections over the past year. Her mood has been fluctuant, and she describes frustration, and frequent episodes of anxiety. However she did not have any other features of a psychiatric disorder, such as Major Depressive Disorder.

Mrs. TT was born in Bangladesh, and has not traveled for over 10 years. She is a very active individual, who enjoys skiing with her daughters. Recently, she has had difficulties participating in many of her favored past-times due to a decrease in her exercise tolerance. She has had fine and gross motor difficulties, which are most prominent in the mornings, with difficulties in dressing, griping, and getting out of bed. On numerous occasions, she is unable to commute to work or carry out duties of her occupation which involve typing. Her functional capacity classification at times is of Class III: marked restriction; can’t perform activities of usual occupation/self-care.

Mrs. TT has a previous history of eczema. Her past history is not significant for any trauma or abuse. She has had a tonsillectomy and left knee arthroscopy secondary to a left knee injury in the past. She denies any alcohol or tobacco use. Her family history was positive for severe rheumatoid arthritis in her maternal grandmother and paternal grandfather. No other diseases were positive in her family history. The patient denies any allergies. She is not on any medications currently; however she has been taking Tylenol, two to six tablets a day with moderate relief of her pain.
Physcial Examination

Mrs. TT is an anxious, thin, middle aged, oriental female that appears her stated age. She was alert and oriented, and was in no apparent distress. There were no stigmata of anemia or liver disease.

Vitals were BP 120/75 (R and L), HR 72, and weight 57 kg (screening for possible signs of a systemic process or internal organ involvement other than the joints). Head and neck examination was normal. There was no alopecia, ocular inflammation (clear fundi), oral or nasal ulcerations/bleeding, malar rash or telangectasia on inspection. There was absent lymphadenopathy and a normal thyroid. Chest was clear, with bilateral and equal air entry (no interstitial disease or effusions). There were no murmurs, rubs or bruits. Examination of the skin and nails did not reveal any psoriasis, rashes, periungual erythema, livedo reticularis, ulcerations, erythema nodosum or telangiectasia. There was a tiny nodule on her left elbow. Examination of her neurological system revealed no signs of any neuropathy or of any CNS abnormalities. The patient had good bulk and strength of her small hand and foot muscles, in addition to her neck, shoulders, hips and knees. She did have difficulty with dorsiflexion of her toes bilaterally. Reflexes were all 2+ and symmetrical and plantar responses were normal bilaterally. Vibration thresholds were 0.2 microns on median and ulnar innervated fingers bilaterally and 0.5 microns on the toes. The patient had normal coordination, and tandem gait.

MSK examination revealed a normal axial skeleton. She had normal posture and alignment, with no muscle spam or bony or soft tissue tenderness. Range of motion (ROM) of her back was normal. Special tests for inflammatory back pain were normal, including occiput-to-wall distance, forward finger-to-floor distance, chest expansion, and a Schobers test. Mechanical back pain tests were also negative, such as straight leg raises, and a femoral stretch test. Examination of the neck, shoulders and hips were also normal. Knee examination revealed some joint line tenderness. The rest of the examination was normal. Examination of peripheral joints revealed erythema, and swelling, with warmth, joint line tenderness, and palpable joint effusions and reduced ROM (both active and passive) in her MCPs and PIPs, MTPs and dorsum of her foot bilaterally. These were much more pronounced on her left side. There was no muscle atrophy, deformities, crepitus or joint laxity found. Furthermore, she did not have any trigger points, 0/14 (eg, fibromyalgia).

Rheumatoid Arthritis Diagnosis

Assessment and Differential Diagnosis

Mrs. TT is suffering from an insidious rheumatic disease, with a waxing and waning, slow progression course over time. The pattern of joint involvement is a small joint, peripheral, symmetrical polyarthropathy, with inflammatory characteristics (eg, morning stiffness > 1 hour). She does not have any axial involvement or extra articular features (EAFs), and denies any past or recent trauma, travel and/or infections. Family history is prominent for severe rheumatoid arthritis. Our initial differential, which was formulated on the above mentioned points (eg, involved joint pattern, distribution, course, etc…), was from most probable to least: early rheumatoid arthritis >>> infectious (eg, viral such as parvovirus) > post-infectious (reactive arthritis) > systemic lupus erythematosus > dermatomyositis > scleroderma > polyartucular gout > vasculitis > sarcoid arthritis.

Investigations that were ordered included general baseline bloodwork, including a complete blood count (CBC), to look for anemia and thrombocytosis as signs of inflammation, and any cytopenias, which can be seen in lupus or viral infections. An erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) to support a systemic inflammatory process and liver function tests (LFTs) to screen for signs of a hepatitis-related process, as well as screening prior to therapy (eg, many rheumatic therapies are hepatotoxic, as well as nephrotoxic). Creatinine, BUN and urinalysis were done to assess the patient’s renal function status (routine screening) prior to therapy and to detect any disease complications, such as glomerularnephritis and lupus nephritis, with an active sediment and proteinuria. Serology, autoantibodies (standard screening tests), were ordered, which included a RF, ANA, C3 and C4, ANCA, and ENA (anti-SM/-Ro/-La/-RNP). Imaging consisted of a chest X-ray and X-rays of the hands, wrists and feet bilaterally.

All laboratory investigations were normal, except for a mildly elevated ESR at 20, and CRP at 14, depicting the presence of inflammation. Imaging revealed changes within her hands, feet and wrists bilaterally consistent with an inflammatory arthropathy. There was periarticular osteopenia, small erosive changes, and a uniform decrease in joint space. These changes are found in early rheumatoid arthritis. There were no diagnostic challenges (even though the RF was negative, it has an overall sensitivity of approximately 80% – therefore, it is not always present) (2).

After completing our investigations, the most probable diagnosis was early rheumatoid arthritis. The order of our differential diagnosis did not change; however the diagnosis of rheumatoid arthritis was much more probable subsequent to the testing (increase in the likelihood ratio/posttest probability that the diagnosis was rheumatoid arthritis).

Rheumatoid Arthritis Treatment

Patient Management Skills

A treatment plan was decided upon by following an evidence-based approach. Once the diagnosis of rheumatoid arthritis was established, the patient was started on therapy immediately following the evidence-based guidelines of the American Rheumatism Association (23,24). Therapy was guided with these principles, and individualized to the goals of the patient. The goals of therapy for rheumatoid arthritis where initially proposed to the patient. These goals consisted of the following: to control inflammation; relieve pain and stiffness; maintain function and lifestyle; prevent joint damage; and early intervention with Disease Modifying Anti-Rheumatic Drugs (DMARDs) to prevent further joint damage. The patient was educated and counseled about rheumatoid arthritis, its diagnosis, prognosis, and course, treatments and management, including drug side-effects, and the role that other disciplines, including occupational therapy OT and physiotherapy PT would play (25,26). The patient did not have any difficulties in accepting the plan, and she was eager to being the process. There was no interaction with any friends or family, as the patient did not have any immediate family or close friends.

Our initial plan was to get an assessment by PT and OT. A PT referral was done to provide the patient with ROM exercises, improvement in ambulation, pain control, and muscle strengthening, as well as to provide further education of her situation from a different perspective. OT was also involved, in order to provide the patient with education regarding joint protection, energy conservation, and assistive devices. These included splints and devices to help her through her activities of daily living (ADLs), in addition to ergonomic improvements of her workplace (25,26). To provide immediate symptomatic relief, we recommended that she start on a non-steroidal anti-inflammatory drug (NSAID), such as Ibuprofen. This would provide symptomatic relief of her pain rapidly by inhibiting prostaglandin-mediated inflammation and pain. She had been on Celecoxib in the past; however, had to discontinue it due to numerous side-effects. The side-effect profile of Ibuprofen (eg, anorexia, nausea, dyspepsia, abdominal pain, ulcers, GI bleeds, and drug hypersensitivity reactions) was also discussed with the patient and any risk factors for NSAID-induced ulcers were assessed (2).

Rheumatoid arthritis will cause articular damage in almost every patient; however, how much damage will occur is variable and usually can be determined by how early treatment is initiated. Disease Modifying Anti-Rheumatic Drugs are added to NSAIDs as soon as the diagnosis is determined (23). Used early, these drugs are more likely to be effective, as the majority of erosive damage occurs rapidly in the first two years. Slowing the progression of the disease is the main goal of Disease Modifying Anti-Rheumatic Drugs. In a few, there can also be complete remission of their condition. Monitoring the effectiveness of these medications is done through physical examination. The number of swollen and tender joints, length of morning stiffness, disabilities and physician assessments are usually used as measurements (23). Mrs. TT was immediately started on hydroxychloroquine 200mg alternating with 400 mg daily. In addition, methotrexate was added, increasing the dose weekly by 2.5 mg to a maximum of 20 mg weekly. She was counseled on potential side effects, as well as given a handout describing the indications and potential risks associated with methotrexate, such as teratogenicity, nausea and vomiting, mucosal ulceration, lung, liver, and bone marrow toxicity. Folic acid 5 mg everyday, except on her methotrexate day was advised. The side effects of hydroxychloroquine were also discussed (eg, retinopathy, neuromyopathy, GI, skin rash). Mrs. TT had a corporate health benefits plan, so the financial costs of her treatments were completely covered.

A follow-up appointment was booked after one month, in order to ensure continuance of care. Laboratory requisitions were given for weekly CBC, creatinine, and LFTs over 4 weeks, and then monthly for the next 6 months. We will monitor for any changes in her bloodwork over that time and see the patient in the clinic within a month. Subsequent visits would be at 2-3 months intervals, until the patient’s rheumatoid arthritis has become inactive. If she has any adverse effects, she has been instructed to discontinue the medication and call the clinic. Mrs. TT was satisfied and in full agreement of the treatment plan.
References:

Rheumatoid Arthritis Therapy

Health Promotion and Disease Prevention

Mrs. TT had numerous risk factors for severe rheumatoid arthritis, such as the presence of rheumatoid nodules, the fact that she is female, has a family history of severe disabling rheumatoid arthritis and radiographic changes of erosions and periarticular osteopenia, consistent with rheumatoid arthritis. In contrast, she did not have many of the other risk factors for developing severe, disabling rheumatoid arthritis, such as a positive Rheumatoid Factor, involvement of other organ systems, extra articular features (EAFs), low education and unemployment. It was essential however, to prevent progression of her disease and the presence of any comorbidities (28).

The overriding aim of current rheumatoid arthritis interventions is to prevent or retard clinical progression and radiological erosive disease as mentioned previously. We therefore immediately introduced combination therapy with disease modifying agents. Furthermore, we provided the patient with early access to a multidisciplinary team, as numerous sociopsychological factors are known to affect the disease process, such as poor social relations, depression, anxiety, and decrease work capacity. In order to prevent these outcomes, we introduced the patient to the Arthritis Society, which provides a multidisciplinary organized team approach to education, support, and disease prevention and treatment. Many professionals, including rheumatologists, physiotherapy (PT), occupationl therapy (OT), and social work (SW), participate to provide information about diseases and therapies. Numerous preventative services and support groups are offered, as well as educational sessions on diets, coping methods and self-relaxation(1,2).

Concerning physiotherapy and occupationl therapy , patients are taught how to perform muscle-strengthening exercises and how to protect joints during routine daily life. Moreover, ergonomic training, hand therapy, orthoses, foot care, and advice on other community resources are provided (29). In addition, the need to address other common associations, such as depression, and comorbidities, such as cardiovascular diseases, osteoporosis, and infections is essential (30). A comprehensive approach to Mrs. TT rheumatoid arthritis was therefore essential to promote her health and well-being, and prevent further deterioration of her state and progression of her disease due to additional factors. Education and counseling on the presentation of different comorbidities associated with rheumatoid arthritis (eg, SOB for cardiovascular/respiratory involvement) was done. This was accomplished through regular clinic visits and bloodwork monitoring. Patients like Mrs. X, who have participated in multidisciplinary programs, have revealed significant improvements in disability associated with rheumatoid arthritis, psychosocial interactions, and clinical prognosis, even within a short period of time (30).

Moreover, because of the presence of a history of diabetes in her family, Mrs. TT was encouraged to continue to exercise and maintain a healthy diet. Such modifications have allowed her to continue with her favorite pastimes and at the same time keep fit and active, as rheumatoid arthritis may predispose individuals to living a sedentary lifestyle through physical limitations. PT and adequate pain management, through ibuprofen, were crucial in further preventing these limitations. Furthermore, with great support from her workplace and community, she was able to continue to work.

Numerous screening tests were carried out at her initial visit (mentioned above) to assess for any rheumatoid arthritis comorbidities or EAFs, as well as the presence of other rheumatic and/or connective tissue diseases. Tests were appropriately applied in this situation. Screening tests to assess Mrs. TT glucose tolerance and lipid profile were not done; however, were suggested to her referring family physician, as well as to the patient. She had stated that these had been negative on numerous occasions on previous yearly checkups.
Professional Behaviors

It is crucial to provide early access to a multidisciplinary team, not only for treatment, but for the emotional and psychological aspects of rheumatoid arthritis (31). As mentioned above, rheumatoid arthritis patients need many different health care services and supports, thereby having a complex care demand and making appeals to different care providers. These activities have to be geared to one another and become integrated (32). The composition of the health care team that was involved in the patient’s care included a rheumatologist, a general practitioner, an ophthalmologist, a PT, an OT, and a SW. A pain care specialist was also recommended. Regular communication and understanding between these members, in all aspects of patient care, will involve disclosing each members care plans including treatments and investigations. This will have a positive impact on patient care, as well as decrease the economic costs of rheumatoid arthritis through effective resource management (2).

The rheumatologist was the leader of the team, as the knowledge and experience in rheumatoid arthritis diagnosis, prognosis and treatment, is best appreciated by these specialists. Coordination and allocation of the majority of services is in the hands of the rheumatologist. In addition to having the skills for effective clinical decision-making, the rheumatologist must have exceptional organizational skills in order to benefit both the patient with a positive health impact, as well as the medical community through a cost effective approach. The rheumatologist must have compassion, and a good ability to listen and communicate with the patient and team. Moreover, the rheumatologist is also the one who decides on whether a hospital admission is necessary, which in our case was not needed (31,32).

Evidence-based practice guidelines and consultations from rheumatoid arthritis specialists within the clinic, provided for exceptional care and cost effective management, achieving the highest level of care possible. For example, screening tests, including expensive serology tests (autoantibodies), where included only when indicated, and when there would be an impact/change on patient management and treatment. Laboratory studies, imaging and subsequent clinic visits, were appropriately tailored to prevent redundancy and coordinate resources between team members31. Concerning treatments, the patient was initially treated with first line combination therapy for rheumatoid arthritis (DMARDs), hydroxychloroquine ($0.52/day) and methotrexate ($0.43/day). Movement to expensive biologics, such as Remicade (> $25,000/year) would only occur with failure of the initially proposed treatment plan (following Canadian guidelines) (23,24). Preventative measures were also implemented, to prevent future detrimental and expensive disease associations, such as lung and cardiac disease. Primary and secondary preventative measures were taken, such as routine physical examinations and yearly eye examinations. Overall, this patient was managed in a very cost-effective manner, with an evidence-based approach. No unnecessary tests were done.

However, depending on the particular time in the natural history of the disease, other members of the team will have to take the place of the most important member and become the leader. For example, the general practitioner who initially saw the patient and referred her to our clinic accurately suspected an inflammatory arthropathy and began the patient on a NSAID for effective symptom relief. Furthermore, the practice of a rheumatologist relies on mutual respect, trust and confidence between doctor and team members, as well as patients. Compliance and efficacy can be significantly improved by involving the patient, as well all members of the team in aspects of decision-making with regards to treatment. This can instill confidence in therapy and in the rheumatologist as the leader of patient management (31).

Rheumatoid Arthritis Community

Community Impact on Patient Care

As mentioned above, there are numerous community resources and community health professionals for rheumatoid arthritis patients, such as PT, OT, The Arthritis Society, patient education groups, vocational rehabilitation groups, workplace programs, and physical exercise group facilities. Patients find considerable comfort and benefit in being introduced to rheumatoid arthritis support groups such as The Arthritis Society (TAS). Such societies allow health management to attend to all aspects of a patient’s needs, and to adopt a holistic approach. It provides a variety of treatments and education programs, such as the Arthritis Self-Management Program, Joints in Motion Training Team and “Ask an Expert” Sessions. Their website is also an exceptional resource to patients (arthritis.ca). Patient education groups, which were provided by the TAS through hospitals are very helpful, and our patient was enthusiastic to attend these. Furthermore, the notion that, increased access to information for rheumatoid arthritis patients must always be beneficial has been challenged recently (31). Easy access and a surfeit of information, such as the Internet, can result in misinformation of patients, which can mislead patients, as well as terrify them. This highlights the need for a close professional relationship between the team and the patient, as well as the role of TAS, which provides a tremendous amount of support and information to the community, as well as online. This information is consistently reviewed and accurate. An Arthritis Bookstore online is also provided. We recommended this to our patient who has utilized the TAS and their website extensively.

Moreover, our patient was encouraged to attend weekly sessions of a physical exercise group, which are organized within the rehabilitation unit of the hospital in order to maintain joint condition and mobility. It is a public-funded rehabilitation program which offers outpatient community-based services. Furthermore, outpatient PT, and a fitness centre and aquatics program were recommended. Individual treatment services provided by PT were crucial and involved job coaching, work conditioning, wellness programs and psychological consultation. As our patient lived alone in a private household, PT and OT assessments were essential. Functional abilities evaluation, job site assessment, physical demands analysis, and home site assessments were done.

Although there were monthly waiting lists for these multidisciplinary programs and services, the patient had tremendous financial supports and an extensive employee benefits program. As such, her employment benefits from Nortel, in addition to substantial private funds, provided her access to numerous services immediately, without any time limitations or restrictions. Funds were also available for non-medically supported services and resources, such as Acupuncture and Naturopathic medicine which the patient found helpful. In contrast to patients with a lower socioeconomic status (SES), resource availability was not a problem for our patient. The availability of numerous services, such as PT, was very accessible through private funds and a strong benefits program. Not only were waitlists avoided, but the time of therapy was much more extensive and beneficial. This patient could take advantage of all the resources available in the community, and has significantly benefited.

Considering her work, the patient works for Nortel and has been unable to resume work for numerous months. She is trying to follow a vocational rehabilitation program; however, she is aware that her work, as well as getting to work, which is a one hour commute on the public transit system, has become physically too heavy. The patient has described that her workplace, Nortel, has a flexible work program that allows ill patients to have flexible work hours, as well as work at home. This will be of great benefit to her.

It is well documented, that before the industrial revolution, there have been limited, if any cases of rheumatoid arthritis. An examination, which occurred in the United Kingdom (UK), of over 800 medieval skeletons, failed to show any evidence of rheumatoid arthritis 33,34. In contrast, the present day UK population has a 1.16% prevalence of rheumatoid arthritis in females and 0.44% in males33. Moreover, in African populations, there is a higher prevalence of rheumatoid arthritis in people from an urban rather than a rural environment, and that these people suffer more severe disease (35). These studies suggest that environmental factors are important in rheumatoid arthritis.

Our patient has had numerous environmental factors in her local community impact on the severity of her disease and its progression, as well as possibly contributing to its cause. These same factors also impend her ability to cope with rheumatoid arthritis and overcome its difficulties. These include psychosocial factors, such as living alone, with no supports in a low socioeconomic status community with an increased crime rate and poor public transportation/transit. Poor mechanical/ergonomic factors within the community, often pose difficulties for independent arthritic patients to commute within buses and walk the distances to bus stops. Urban noise contributes to the patients’ poor sleep, and urban pollution predisposes an immunosuppressed patient to toxins and infection. Furthermore, hygiene becomes an issue, as the patient is independent but does not have the capabilities of cleaning and maintaining a two-storey home. Mechanical/ergonomic factors will be crucial to assess and improve within the patient’s house and workplace environment.  Infection, moisture and dust may become common problems and will predispose her to numerous future co-morbidities that are commonly associated with rheumatoid arthritis, such as recurrent infections. Moreover, nutrition and diet may become a problem, as cooking and shopping may pose difficulties to the patient.

It has been previously described that stress from life events may contribute to the onset and worsening of rheumatoid arthritis (36). “Matrimonial quarrels, problems at work and/or economic problems” during the 5-year period preceding the rheumatoid arthritis symptoms and diagnosis, were significantly associated with the onset of rheumatoid arthritis compared to controls (37). Moreover, poor social environmental factors and medical status have been associated with the onset of other autoimmune disorders, such as psoriasis. The impact of psychological influences on hormonal and immunological changes within the human body has been postulated to be the mechanism possibly underlying the cause of rheumatoid arthritis (36). It is therefore crucial to prevent any further stressors from worsening a patients rheumatoid arthritis through appropriate allocation of health resources and supports, and advocating for appropriate workplace environments and economic supports.

The association between low socioeconomic status and poorer health outcomes in arthritis is also well established. Interestingly, recent reports suggest that community social determinants (eg, the socioeconomic environment of an individual’s community) may be also associated to health outcomes in arthritis. The association of community social determinants with health outcomes however, appears to be independent of an individual’s socioeconomic status (38). The socioeconomic context of communities may affect the environment to which all residents are exposed, irrespective of their own individual socioeconomic status. This can occur two ways; indirectly through shaping an individuals’ educational attainment, job prospects, and income level, or directly, by affecting the social, service and physical environments. These upstream determinants related to the community, include place of residence, work environment, and the wider social and economic policies of society. Indicators associated with a worse clinical outcome in rheumatoid arthritis in poorer neighborhoods included unemployment, poor education, overcrowding and no access to a vehicle (38). In our patient, no access to a vehicle, and a poor social, service and physical environment in her neighborhood, place her at a disadvantaged situation to access support. Economic support and an improved social infrastructure could greatly benefit this community through physician advocacy.

There are numerous actions that the physician along with the community, allied health care workers and/or through a broader public health initiative can accomplish, to make contributions to environmental issues within this community. Physicians can advocate for their patients during the development of public policy. Lobbying all levels of government through physician-based associations, such as the Canadian and Ontario Medical Associations to develop policies for improved community and work environments, such as making public transit more accessible to patients with arthritis who are not candidates for wheeltrans, can be very effective. Our patient had difficulties with transportation within her community. Greater access to transportation, and user-friendly buses, trains and sidewalks for patients with arthritis would be beneficial. In addition, physicians can advocate for more community supports for patients with arthritis, as well as making the government more aware of the prevalence and complexities of arthritis and their patients’ needs. Participation in societies, such as Doctors for the Environment39, can create large, influential societies that can create the needed voice for the environment from physicians. These societies can effectively educate other physicians on environmental issues, and prepare spokespersons to comment on the health implications of their own community issues. National interventions could possibly include legislation against the use of pesticides and ozone depleting chemicals, and the preservation of parks and recreational areas.

Primary prevention efforts have the potential to reach large and diverse groups of people, especially when used early in life (eg, talks at schools to prevent air pollution and increase awareness on pesticide use). Different factors and strategies can be used to address and implement issues in different settings, such as in the community, schools, or clinical setting, in order to improve and benefit a community and its environment. Primary prevention can take place at numerous different levels (40).

Physicians should advocate for easily accessible educational and treatment programs, and support for patients with arthritis. Greater access to treatment programs will facilitate the identification and treatment of RA individuals, in addition to patients with other rheumatic diseases. In many cases, newly immigrated families or individuals who come to Canada, usually speak little English, except for their children, and are unknowledgeable about the health care system and what it has to offer. The provision of information regarding available community supports, and health care programs in primary care offices and community clinics which offer support, advice, and direction to access other regional and health care services and supports is crucial in a physician. Information can be provided in different forms, such as multilingual pamphlets and posters, or through direct one-to-one discussions at routine visits with patients or parents. Furthermore, a discussion of environmental issues within the community would be beneficial with these opportunities. A knowledgeable physician that can direct his or her patients to these community and health care services can be an asset to patients.

Finally, community-level programs, which can be integrated with the school system, clinics, local media and religious, youth, and parenting organizations, can be the most influential mode of support and change, and can provide the opportunity to create a synergistic effect among the many different levels and agents of change in the community and its’ environment (14). In addition, greater access to education and treatment programs for patients and families, will facilitate the identification and treatment of rheumatoid arthritis early, and also prevent relapses and life-threatening consequences.

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