Filipino Virtual MSK PE Osteoarthritis take off cases

1. Exam rheum 2.0
It’s a joint effort
LISA TRABOCO MD, FPCP, DPRA
UP-MEDICAL INFORMATICS GRAD STUDENT
@rheumarhyme

2. E-C-Q
 Experiences & Explanations
 Challenges : History Taking &
Virtual PE
 Questions : Research to move
forward

3. TELEMEDICINE
 NEJM Catalyst defines telehealth as “The delivery and facilitation of health and
health-related services via telecommunications / digital.”
 World Health Organization defines telemedicine as “The delivery of health-care
services, where distance is a critical factor, by all health-care professionals using
information and communications technologies with the aim of advancing the health
of individuals and communities.”

4. • Indian Medical Council; Telemedicine Practice Guidelines: Enabling Registered Medical Practitioners to provide healthcare using Telemedicine; 25 March 2020

5. Telemedicine
• Telemedicine will NOT be the right model of care for every
patient
• Physicians need to be aware of limitations
• Enhance current processes, not replace them
• Chaet, D et al; Ethical Practice in Telehealth and Telemedicine; J Gen Intern Med 32(10):1136–40; 2017
• Americantelemed.org

6. Najm, A et.al; 2019 Nov 26;7(11):e14730. doi: 10.2196/14730.
Qing, LV; Uhealth. 2019 Jun 3;7(6):e10299. doi: 10.2196/10299.
Telerheumatology
Patient Reported Outcomes
Low to Moderate Quality Mobile Apps
Highly educated patients
Ferruci, ET 2019 Aug 17. Arthritis Care Res (Hoboken)
Chew, LC, Xin, X; Int J Rheum Dis; 2019 Apr;.
Monitoring Stable RA
RA patients with high disease activity

7. https://rheumnow.com/video/virtual-video-joint-exam-updated
INSPECTION
RANGE OF MOTION
CONTRALATERAL COMPARISON

8. Cooke G. (2012). A is for aphorism - is it true that 'a careful history will lead to the diagnosis 80% of the time'?. Australian family physician, 41(7), 534.
 Hampton, 1975
A careful history can
lead to the diagnosis
80% of the time

9. @NatRevImmun
ol

10. Is it Articular
Is it Acute or Chronic
Is Inflammation Present?
How Many or Which Joints are involved?
HPIM16

11. History Taking
 May masakit po pa sa inyong mga buto-buto o kalamnan?
 Kaya po ba natin magbihis ng walang tulong/alalay?
 Kaya po ba natin umakyat o bumaba ng hagdanan mag-isa?
 Discuss the details with How/What/When? (Paano/Saan/Kailan?)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD

12. Challenge
vs
Obstacle

13. Sabi ni
Simon
Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Simon
Says

14. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Sabi ni Simon,
Ibukas ang bibig …at isara
Ngumiti,
iusli ang panga

15. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
TMJ – Range of Motion

16. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Sabi ni Simon
Tingin sa itaas... Tingin sa ibaba
Tingin sa kanan - kaliwa
Ikiling ang ulo at
Subukan idikit sa balikat ang tenga
Gawin pati sa kabila

17. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Cervical Spine –
Rotation & Lateral Flexion

18. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Sabi ni Simon
Maingay! ilagay sa tenga ang kamay
Ipalabas ang siko
Kunwari na parang nagtatali ng buhok
o nagsusuklay

19. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Sabi ni Simon
Ilagay ang kamay sa likod,
(ang siko parin ay nakalabas)
May masakit ba sa pagsuot ng damit,
o yung naka-tikas

20. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Glenohumeral,
sternoclavicular and
acromioclavicular joint
movement

21. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Sabi ni Simon
itaas ang kamay at braso
...Itupi ...at ideretcho ang siko
Iharap ang palad, Ibaba
Sabi ni Simon Magdasal .
..Na parang nagkasala

22. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Flexion and Extension.
Look for swelling,
malalignment, flexion,
extension, supination

23. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Sabi ni Simon
Itupi ang mga daliri
....Hanggang maging kamao
Kunwari isuntok .
...Isa-isa, sa camera ideretcho

24. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Sabi ni Simon
Ang gitna ng kamay at dulo ay idiin
Sabi ni Simon
Patingin nga ng mga singsing

25. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Flexion, extension, fine
precision or dexterity and
tenderness of the MCP

26. Telemedicine consult
• 60 year old female; former secretary
• “Deformed hands”
• Bilateral hand and wrist pain
• Finger joints
• Intermittent  Daily
• Morning stiffness ~15 mins
Example only; Not an actual Teleconsult

27. What can you see via inspection?
 A. Heberden’s Nodes
 B. Bouchard’s Nodes
 C. Carpometacarpal joint squaring
 D. All of the above
Example only; Not an actual Teleconsult

28. Example only; Not an actual Teleconsult

29. Based on your observation,
what can you do next?
 A. Ask the patient if her right hand is painful
 B. Ask the patient to show the hands one by one
 C. Ask the patient to close her fists and open them one by one
 D. All of the above

30. Lower extremities

31. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Sabi ni Simon
iangat mula sa sahig ang binti
igalaw palabas ...ibalik pa-gitna
Sa kaliwa uli

32. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Flexion, Extension,
Adduction, Abduction

33. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Sabi ni Simon
iangat ulit ang kanang binti
ideretcho ang tuhod… itupi
Sabi ni Simon
inagat ang paa… ibaba
iikot sa kanan
ulitin sa kaliwa

34. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Look for knee swelling,
malalignment, flexion,
extension
Look for foot swelling,
dorsiflexion, plantarflexion,
eversion and inversion

35. Telemedicine consult
• 36 year old female, obese
• Former hip-hop dancer until 8 years ago when she had a Right calf muscle tear
• On-off R knee pain for 3 years
• No swelling, redness, warmth
• No fever
• No problems with range of motion at knee
• Father has a history of gout – Colchicine and Febuxostat
Not a real teleconsultation

36. Probable Diagnosis?
 A. Osteoarthritis
 B. Gout
 C. Septic Arthritis
 D. Rheumatoid arthritis

37. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Sabi ni Simon
Tumayo mula sa inyong upuan
Mayroon bang masakit
(Saan humawak, Siya ba ay pumikit)

38. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Sabi ni Simon
Kung may kasama o alalay
Subukan abutin ang paa
Gamit ng dalawang kamay

39. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Checking the patient’s
ability to rise from the
chair: Spine, Hips, Knees
and Ankle are involved in
this action

40. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Sabi ni Simon last na daw
Pwede po mag-yapak ng saglit lang
Para makita ang tindig, pag-lakad
At paano ang pag hakbang

41. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Checking the patient’s
ability to rise from the
chair: Spine, Hips, Knees
and Ankle are involved in
this action

42. Dr Jack Cush; RheumNow; Virtual PE (updated)
Adapted UST – LUISA RETFI Project: Rapid Musculoskeletal Screening translated by Lisa Traboco, MD
Gait
(*Patient must be barefoot.
Make sure someone can assist
the patient. Check for swing,
stance and ability to turn
quickly)

43. Based on your observation,
what can you do next?
 A. Ask the patient to expose both knees so that you can observe for swelling, redness etc
 B. Ask the patient if the right knee is painful
 C. Ask patient to walk across the room
 D. All of the above

44. Telemedicine consult
• 55 year old female with history of rheumatoid arthritis
• Bilateral knee pain with on-off swelling since early quarantine lockdown
• No improvement with self increase of steroids
• Morning stiffness ~10 mins
• Can do ROM of knees but uncomfortable
• Difficulty arising from chair
• Uses cane
• Knees are not warm – according to her
• Not sure if she has fever
Not a real teleconsultation

45. Probable Diagnosis?
 A. Osteoarthritis
 B. Crystal induced arthritis
 C. Infection
 D. Active RA
 E. All of the above

46. Class I
(Non-
inflammatory)
Class II
(Inflammatory)
Class III
(Septic)
Class IV
(Hemorrhagic )
Color Clear/ yellow Yellow/White Yellow/
White
Red
Clarity Transparent Translucent/
Opaque
Opaque Opaque
Viscosity High Variable Low NA
Kelley’s ; HPIM ; Uptodate
Zahar A, Lausmann C, Cavalheiro C, Dhamangaonkar AC, Bonanzinga T, Gehrke T, Citak M. How Reliable Is the Cell Count Analysis in the Diagnosis of
Prosthetic Joint Infection? J Arthroplasty. 2018 Oct;33(10):3257-3262.
McCabe, P. S., Parkes, M. J., Maricar, N., Hutchinson, C. E., Freemont, A., O'Neill, T. W., & Felson, D. T. (2017). Brief Report: Synovial Fluid White Blood Cell
Count in Knee Osteoarthritis: Association With Structural Findings and Treatment Response. Arthritis & rheumatology (Hoboken, N.J.), 69(1), 103–107.
https://doi.org/10.1002/art.39829
WCC in
osteoarthritis is
typically
designated as a
non-inflammatory
fluid (defined by
count as <1000
cells/mm3)

47. Telemedicine
• Telemedicine will NOT be the right model of care for every
patient
• Physicians must be aware of limitations
• Enhance current processes, not replace them
• Chaet, D et al; Ethical Practice in Telehealth and Telemedicine; J Gen Intern Med 32(10):1136–40; 2017
• Americantelemed.org

48. CHALLENGES in TELE-HISTORY TAKING
AND VIRTUAL PE
https://www.rheumatology.org
RheumNow.com
Initial Visit?
Follow up Visit?
New/Old  Urgent Visit

49. Kulcsar Z, Albert D, Ercolano E, Mecchella J. Telerheumatology: A Technology Not Appropriate for All [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). https://acrabstracts.org/abstract/telerheumatology-
a-technology-not-appropriate-for-all/. Accessed July 15, 2020.

50. Working Telemedicine Guidance, PRA 2020
Telerheumatology
appropriate?
Patient State Disease State
YES • Stable • Diagnosis is well-established
• Screening prior to (first) in-person
visit
NO • In Flare
• Needs procedure
(i.e arthrocentesis)
• Needs early treatment / medicine
• Hard of hearing or poor
engagement
• Diagnosis is well-established
• Complex or unconfirmed
diagnosis
• Failed prior teleconsultation

51. E-C-Q
 Experiences & Explanations
 Challenges : History Taking &
Virtual PE
 Questions : Research to move
forward

52. Questions & research to move forward
 Diagnosis Concordance?
 Telecollaboration
 Telepharmacy
Dr Alvin Wells, RheumNow
McDougall; 2017 DOI 10.1002/acr.23153
Grainger; 2017 /doi.org/10.2196/mhealth.6956

53. Dr Alvin Wells, RheumNow
McDougall; 2017 DOI 10.1002/acr.23153
Grainger; 2017 /doi.org/10.2196/mhealth.6956
Lay Education,
Online
Advocacies
Future Tech,
Mobile
Health –
Patient
reported
outcomes

54. Teixeira, V et a; y; Acta Reumatol Port. 2018 Oct-Dec
Wood, PR et al; J Clin Rheumatology; 2019 Jan
Strickler AS; Rev Chil Pediatr; 2018 Feb
.
Reduce hazardous travel costs
Reduce work/school absenteeism
Early diagnosis and treatment
Avoid unnecessary treatment
?

55. McDougall JA, Arthritis Care Res (Hoboken). 2017
Oct
No TM Standard
Training of proxy examiner?
?

56. Dr Bryan Vartabedian
@Doctor_V
33chart.com
“Telemedicine is a moving target.
What works or doesn’t work today may have a very different
solution or experience a year from now.
Flexibility and rapid reiteration of our processes will be
critical to successful adjustment and growth.”

57. Thank you! ありがとうございます！감사합니다!
Does it hurt when I press
here?