Focus on Allied Health Professionals and Devices · Let us consider the case of a 45-year-old...

Summer 2009, Volume 19, Number 2

Allied Health Professionalsand Devices

Focus on

EditorialWhen Pigs Fly

Impression and Opinion:The Benefits of Orthotics for a Patient withMetatarsalgia Russ Horbal

Splinting for Arthritis: A Therapist’s ViewpointDianne Freeman

Northern (High)lights: An Interview with the Inaugural CRA Educator Award Recipient: Dr. Heather McDonald-Blumer

In Memoriam:William John ReynoldsDrs. Robert Inman and Duncan Gordon

Joint Communiqué: Earl Silverman: A TributeDr. Ronald M. Laxer

Committee Reports:• Introduction to Committee Reports Dr. John Thomson• Therapeutics Committee Drs. Vivian Bykerk and Philip Baer• Education Committee Dr. Heather McDonald-Blumer• Pediatric Section Dr. Paivi Miettunen• Access to Care Committee Drs. Michel Zummer and

Dianne Mosher• Arthritis Health Professions Association Karen Gordon and

Marlene Thompson• CRA Website Dr. Andy Thompson• Human Resources Committee Dr. Barry Koehler

Hallway ConsultH1N1: Staying Vigilant During a Pandemic

Joint CountInteresting Times

The CRAJ is online! You can find us at: www.stacommunications.com/craj.html

Mission Statement. The mission of the CRAJ is to encourage discourse among the Canadian rheumatologycommunity for the exchange of opinions and information.

CRA EDITORIAL BOARD

Copyright©2009 STA HealthCare Communications Inc. All rights reserved. THE JOURNAL OF THE CANADIAN RHEUMATOLOGY ASSOCIATION is published by STA Communications Inc. in Pointe Claire, Quebec. None of the contents of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means (electronic, mechanical,photocopying, recording or otherwise) without the prior written permission of the publisher. Published every three months. Publication Mail Registration No. 40063348. Postage paid atSaint-Laurent, Quebec. Date of Publication: April 2009. THE JOURNAL OF THE CANADIAN RHEUMATOLOGY ASSOCIATION selects authors who are knowledgeable in their fields.THE JOURNAL OF THE CANADIAN RHEUMATOLOGY ASSOCIATION does not guarantee the expertise of any author in a particular field, nor is it responsible for any statements by such authors. The opinions expressed herein are those of the authors and do not necessarily reflect the views of STA Communications or the Canadian Rheumatology Association. Physicians should takeinto account the patient’s individual condition and consult officially approved product monographs before making any diagnosis or treatment, or following any procedure based onsuggestions made in this document. Please address requests for subscriptions and correspondence to: THE JOURNAL OF THE CANADIAN RHEUMATOLOGY ASSOCIATION, 955 Boul. St. Jean, Suite 306, Pointe-Claire, Quebec, H9R 5K3.

The editorial board has complete independence in reviewing the articles appearing in this publication and isresponsible for their accuracy. The advertisers exert no influence on the selection or the content of materialpublished.

PUBLISHING STAFF

Paul F. BrandExecutive Editor

Russell KrackovitchEditorial Director, Custom Division

Katherine EllisJunior Editor

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Donna GrahamProduction Manager

Dan OldfieldDesign Director

Jennifer BrennanFinancial Services

Robert E. PassarettiPublisher

EDITOR-IN-CHIEFGlen Thomson, MD, FRCPCFormer President, CanadianRheumatology AssociationRheumatologistWinnipeg, Manitoba

MEMBERS:Ken Blocka, MD, FRCPCBurrard Health BuildingVancouver, British Columbia

Michel Gagné, MD, FRCPCPolyclinique St-EustacheSt-Eustache, Quebec

James Henderson, MD, FRCPCVice President, CanadianRheumatology AssociationChief, Internal Medicine,Dr. Everett Chalmers HospitalTeacher, Dalhousie UniversityFredericton, New Brunswick

Joanne Homik, MD, MSc,FRCPCAssociate Professor ofMedicine,Director, Division ofRheumatologyUniversity of AlbertaEdmonton, Alberta

Sindhu Johnson, MD, FRCPCClinical Associate,Division of Rheumatology University Health Network-Toronto Western Hospital SiteInstructor,University of TorontoToronto, Ontario

Majed M. Khraishi, MD, FRCPCMedical Director,Nexus Clinical ResearchClinical Professor ofRheumatology,Memorial UniversitySt-John’s, Newfoundland

Gunnar R. Kraag, MD, FRCPCPast President, CanadianRheumatologyAssociationProfessor of Medicine,University of OttawaThe Ottawa HospitalOttawa, Ontario

Diane Lacaille, MD, FRCPCAssociate Professor ofRheumatologyDivision of RheumatologyUniversity of British ColumbiaVancouver, British Columbia

Barbara A. E. Walz, MD, FRCPCHead, Division ofRheumatology,Credit Valley HospitalMississauga, Ontario

Janet Markland, MD, FRCPCClinical Professor, Rheumatic Diseases Unit Royal University HospitalVisiting Consultant, Saskatoon City HospitalMedical Staff, St. Paul’s HospitalClinical Professor, University of SaskatchewanSaskatoon, Saskatchewan

Éric Rich, MD, FRCPCAssistant Professor,Director, RheumatologyProgramUniversité de MontréalRheumatologist,Hôpital Notre-Dame du CHUMMontreal, Quebec

John Thomson, MD, FRCPCPresident, CanadianRheumatologyAssociationStaff, The Ottawa Hospital–Civic CampusLecturer, University of OttawaOttawa, Ontario

Lori Tucker, MDClinical Associate Professor inPediatrics,University of British ColumbiaFaculty, Centre for CommunityChild Health ResearchDivision of PediatricRheumatologyBritish Columbia's Children'sHospitalVancouver, British Columbia

Michel Zummer, MD, FRCPCAssociate Professor,Université de MontréalChief, Division ofRheumatology,Hôpital Maisonneuve-RosemontMontreal, Quebec

Correction: Due to an error of translation, the final sentence of the article entitled “An Elective at the General Hospital of

Mexico” by Marie-Paule Morin (in the English edition of the Spring 2009 issue of the CRAJ) was printed as “When I left Mexico,

I had acquired not only knowledge but also a number of real friends, memories of a very fulfilling experience and, above all, the

feeling that countries in southern climates have a great deal to learn about those in the north.” To reflect the author’s intended

meaning, this sentence should have ended with “... the feeling that countries in northern climates have a great deal to learn about

those in the south.” The editor regrets the error, with apologies to Dr. Morin.

Click here to comment on this article CRAJ 2009 • Volume 19, Number 2 3

Many of you opening this issue of The Journal of the

Canadian Rheumatology Association (CRAJ) may be

relaxing by the lake in the company of a cold

beverage—or at least that's what one would expect in our

brilliant, but brief Canadian summers. If you are so fortu-

nate, hopefully this respite will help to put in perspective

some of the unexpected events of the past few months.

This issue’s Joint Count survey reveals that many rheuma-

tologists are further removed from blissful retirement

than they were a year ago due to the economic meltdown

and recession. Some myopic financial sages have resur-

faced with new self-proclaimed telescopic visions of the

future. But at the time of the collapse, no one expected

the consequences of the recovery that has largely been a

work of improv.

“In preparing for battle, I have always found that plans are use-

less, but planning is indispensable.”—Dwight D. Eisenhower

The other great unexpected event this Spring is a pan-

demic originating not from birds in Asia, but rather more

close to home in swine. With the number of H1N1 flu

cases soaring, truly this is the time when pigs fly. At least

during this scare, plans of action from previous pan-

demics are being adapted. In this issue, we have turned

over our Hallway Consult to several experts from the fields

of infectious disease and rheumatology to ask their advice

about what we should be doing for our immunocompro-

mised patients who may be at increased risk.

The annual retreat in April allows the Canadian

Rheumatology Association (CRA) executive to spend

time analyzing and designing for the coming year. This

preparation has the CRA on solid financial ground after

the purchase of The Journal of Rheumatology. Also, the

CRA’s website, annual meeting and many other activi-

ties have taken great strides in the past year. Please

read the Joint Communiqué with reports from the many

subcommittees on current and future activities. The

Educator Awardee lets us know what the Education

Committee is doing, and is celebrated in the Northern

Highlights interview.

The CRAJ salutes and bids farewell to a true gentleman

of rheumatology, Dr. Jack Reynolds. Personally, he taught

me one of the most valuable lessons as a physician—to

always learn something new from each and every patient.

His life and long-term contribution at the Toronto Western

Hospital is celebrated in the In Memoriam department.

Jack’s good humor and decency will be missed.

“Ankles are nearly always neat and good looking, but knees are

nearly always not.”—Dwight D. Eisenhower

The former American president knew something about

planning, but also recognized the importance of the

ankle and, I presume, the lower kinetic chain. Where our

body meets the world is generally under-appreciated but

will not be after the insightful Impression and Opinion

article by Russ Horbal. Another expert allied health pro-

fessional, Dianne Freeman, leads us through the ration-

ale and practice of upper-limb splinting. These articles

will help us to develop better plans for the expected and

unexpected problems that our patients present to us.

That is, after we get home from the lake.

Have a happy and healthy summer!

Glen T.D. Thomson, MD, FRCPC

Editor

EDITORIAL

When Pigs FlyBy Glen Thomson, MD, FRCPC

Blowing in the Wind by Shanleigh Thomson

mailto:[email protected]?Subject=Comment on CRAJ Summer 2009

Click here to comment on this article

Orthotics have been compared

to eyeglasses—they are not

designed to cure the problem,

but to assist/solve the functional

problem, and to help the patient’s foot

work better. They can be valuable tools

in the treatment of foot pathology and

are often prescribed appropriately.

However, they are also often misused,

and not well thought out in their appli-

cation. The American Academy of

Orthopaedic Surgeons defines an

orthotic as a device that is used to help a part of the

body to function better.

A foot orthosis is a device placed inside a

shoe and worn underneath the foot that is

used to help the foot and lower kinetic

chain (LKC) function. Foot orthotics can be

classified based on their inherent goals for

treatment. Orthotics can be designed to

synchronize the mechanics of the LKC by

holding the foot as near to its optimal func-

tional position as possible. They can also be

used to reduce shock or impact forces by

absorbing or attenuating them, or to relieve

a specific area of pressure and accommo-

date a tender area. Most often, a patient’s orthotics can

include a blend of all of these design features.

IMPRESSION AND OPINION

The Benefits of Orthotics for a Patientwith MetatarsalgiaBy Russ Horbal, BMR PT, BPE, Ed(cert.), CAT(c), Diploma Sport Physiotherapy

4 CRAJ 2009 • Volume 19, Number 2


CASE STUDYLet us consider the case of a 45-year-old female factory worker who presents with a history of forefoot pain that

has bothered her for the past two years, and whose discomfort has become worse over time. By the end of an

eight-hour shift on concrete floors, she needs to take an analgesic. The patient experiences foot pain while jog-

ging, which has limited her fitness regimen. Furthermore, she cannot wear dress shoes because she experiences

severe pain almost immediately after putting them on. Her pain also worsens when she is barefoot at home. The

patient had surgery for a Morton’s Neuroma between her second and third MTP’s five years ago, and at that

point received custom orthotics, which she now leaves in her work boots. Examination reveals a marked reduc-

tion in height of the longitudinal arch and forefoot pronation. She also has early hallux valgus.

Case DiscussionThis presentation—a loss of medial longitudinal arch

height, excessive pronatory mechanics, hallux valgus,

reduced transverse metatarsal (MT) arch, forefoot discom-

fort that worsens with prolonged weight-bearing and neu-

ralgic-type pain as seen with Morton’s Neuroma—appears

frequently in clinical settings. It is commonly labeled as

metatarsalgia. However, it should be understood that this is

a descriptive term rather than a diagnostic one.1 These

symptoms and signs must be examined carefully untreated,

they lead to impaired function and decreased quality of life.

Metatarsalgia is the most frequent cause of foot pain,

so it is crucial that any clinician dealing with foot dis-

orders thoroughly understands its multivariate etiology

and pathogenesis, even before treatment begins. Thus,

it is imperative that the first step in treatment is ascer-

taining the etiology. The initial medical assessment

must rule out systemic/extraregional diseases including

vascular, metabolic, rheumatic, neurologic or psy-

chogenic diseases.1 These presentations have also been

categorized as secondary metatarsalgia. A complete

medical examination and diagnostic work-up is crucial.

Biomechanical AssessmentAs the secondary component of assessment, the clini-

cian should examine the role biomechanics play in the


patient’s presentation. Biomechanical dysfunction

often leads to alterations in weight distribution and

overload to the forefoot. These are seen as a result of

functional anomalies including excessive or insufficient

pronation of the talocrural (TC) and subtalar (ST)

joints, ligamentous laxity, and insufficient or excessive

loading of the first ray, intermediate rays or fifth ray.1

These presentations have been categorized as primary

metatarsalgia.2 These functional anomalies lead to

altered functional biomechanics in gait leading to pain.

It is crucial that physiotherapists who encounter many

patients with this clinical pattern perform a comprehen-

sive biomechanical examination. This should include the

assessment of active and passive range of motion (ROM),

joint stability, static and dynamic joint positions and

mobility, muscle strength, neural tissue, palpation,

weight-bearing function, and foot and ankle stability.

The practitioner must assess the LKC to evaluate its

contribution to the biomechanical function of the foot.

Poor core stability, and knee, hip and lumbar spine bio-

mechanical dysfunction can play an integral role in

foot and ankle biomechanical alterations. A lumbar

spine scan and gait assessment would be beneficial in

ruling out other factors which could be causing the

patient’s symptoms. In this case, the patient exhibited

an excessive pronatory gait pattern.

The clinician must also examine the patient’s

footwear—in this case work boots and other shoes

she wears at home during activities of daily living

(ADL) and for recreation and fitness activities—to

help determine biomechanics and the role footwear

may play in the pathology. Overall, this patient’s work

and sports footwear were old and showed excessive

wear patterns consistent with excessive pronation and

forefoot loading. Her other footwear consisted of

“fashion-type” footwear and sandals that offered no

support or cushion.

In this patient’s case, she showed slight posterior

muscle tightness (hamstring, glutes, and puriformis)

and slight increased sciatic nerve neural tension. The

patient also exhibited tightness of the calf muscles,

limited ankle dorsiflexion and ankle joint laxity with

talar tilt (from a previous ankle sprain). There was

also slight ST joint hypermobility and marked first

ray instability with hypermobility into dorsiflexion. Her

first MTP joint was slightly limited for dorsi-plantar

flexion mobility. Her hallux was in varus, but mobile

and correctable. She exhibited a rearfoot and fore-

foot varus deformity. Her lesser rays and metatarsal

head were slightly dropped (second < third > fourth >

fifth) with a loss of the transverse MT arch. Resisted

muscle testing exhibited supinatory calf muscle, hip

external rotator and core muscle weakness. There was

marked point tenderness on palpation of the MT

heads with slight distal migration of the MT fat pads.

She described slight dysthesia between her second

and third MT heads and toes consistent with her pre-

vious neuroma resection. In weight bearing, she

exhibited poor single-leg balance with excessive

pronatory mechanics, excess ankle valgus, excess

internal leg rotation and poor trunk, pelvic and hip

stability and control.

The patient’s orthotics must be examined to see if

they are designed and fabricated appropriately to

match her biomechanics and to see how they function

within her footwear. Her orthotics were custom-made

and appeared adequately designed to control her

excessive pronatory mechanics, but time and wear had

degraded their support and function. There were no

accommodations made to address her forefoot patho-

mechanics and excessive loading.

TreatmentOnce these medical and biomechanical assessments are

complete, the clinician can formulate a treatment plan

designed to reduce or eliminate pain and inflammation,

improve biomechanical function of the foot, the ankle

5CRAJ 2009 • Volume 19, Number 2

The clinician must also examine the

patient’s footwear—in this case work

boots and other shoes she wears at

home during activities of daily living

(ADL) and for recreation and fitness

activities—to help determine

biomechanics and the role footwear

may play in the pathology.

CRAJ 2009 • Volume 19, Number 26

and the rest of the LKC, and ultimately enable the

patient to resume a desired level of activity (work, home

and recreation/fitness).

Many therapeutic modalities are designed to

decrease pain and inflammation, such as thermothera-

py (ice or heat); electro-physical modalities (i.e., ultra-

sound, laser therapy, and electro-magnetic stimula-

tion); acupuncture; massage; and manual therapy.

Though these modalities do not prove conclusive or

show a strong evidence-based effectiveness,3 patients

do describe improvement in pain and function with

their use.

In my own practice, I utilize some forms of these

modalities when patients come for in-clinic treatment.

As part of their home-treatment program, I generally

instruct them to warm their feet up prior to activity to

improve blood flow and tissue extensibility. This can be

accomplished through a warm soak during a morning

shower or with the application of a heat pack. I also

advise patients to apply cold (ice) after activity and at

the end of the day to reduce any inflammatory response

created through excessive loading.

Exercise to improve tight muscle groups and stiff

joints can be very beneficial in improving biomechan-

ics. The patient described here exhibited the common-

ly seen pattern of tightness in her gastrocs/soleus com-

plex and posterior-medial leg muscle tightness. Calf

muscle tightness alters TC/ST joint mobility and

mechanics, increases compensatory pronatory mechan-

ics and increases forefoot loading. Therefore, she

should be instructed in a calf and general leg stretch-

ing regimen to be performed at home on a daily basis,

first thing in the morning and at night. I would instruct

her in a muscle-strengthening regimen to address

supinatory calf muscles, hip external rotator and core

muscle weakness. This would incorporate non-weight-

bearing open kinetic chain and weight-bearing closed

kinetic chain exercises.

Due to the patient’s poor weight-bearing stability in this

case, I would also introduce her to an extensive at-home

balance and stability routine to improve her static and

dynamic whole LKC mechanics. Improving core stabili-

ty, pelvic, hip and knee control and foot and ankle sta-

bility will assist controlling excessive pronatory

mechanics. Tailoring a progressive program to match

her daily work, ADLs and sport activity demands will

help her to attain the goal of returning to her desired

level of activity. The home-treatment regimen is inte-

gral in empowering patients to take an active role in

their treatment.

Proper FootwearProper footwear is also integral to improve the biome-

chanics contributing to forefoot pain. Generally,

footwear should exhibit the appropriate amount of

motion control or motion facilitation needed, provide


Many therapeutic modalities are

designed to decrease pain and

inflammation such as thermotherapy

(ice or heat); electro-physical

modalities (i.e., ultrasound, laser

therapy, and electro-magnetic

stimulation); acupuncture; massage;

and manual therapy.

the appropriate shock attenuation properties and

match the activities the wearer will perform. In patients

with the pathomechanics, signs and symptoms exhibit-

ed by the patient in question, proper footwear should

assist in limiting excessive pronation and excessive

forefoot dorsi-flexion, and should also provide good

shock attenuation in the forefoot and rearfoot.

To control excessive pronation, footwear should have

a rigid heel cup, resist excessive torsion and not flex

excessively in the forefoot and midfoot. This patient’s

work footwear must meet the “safety requirements” of

being steel-toed, which often poses a fit problem. Some

varieties of work footwear come with oversized toe caps

that may fit better. More recently designed work boots

have rubber midsoles and outsoles to provide good

traction and provide better cushioning. In addition to

proper fit, work boots should be made of durable mate-

rials that won’t break down prematurely.

Athletic footwear should exhibit the same character-

istics of motion control and shock absorption, and

match the activity she is going to do (e.g., jogging). I

recommend footwear be of adequate depth and have

removable insoles to accommodate orthotics.

Contoured-bed walking sandals are better than tradi-

tional flip-flops. As for dress shoes, many newer designs

exhibit the aforementioned characteristics while

remaining fashionable.

With my own patients, I suggest time spent in fancy

shoes should be limited to those times when they really

must be dressed up. I also direct all patients with fore-

foot pain to completely avoid walking barefoot, in socks

or in slippers. Footwear must fit properly as to not allow

excessive side-to-side movement or pistoning back and

forth within the shoe. Patients with wide forefoot and

hallux valgus deformities often make the mistake of pur-

chasing too-large shoes to compensate. Most footwear

can be modified (stretched, punched or cut out) to

specifically match the patient’s foot if needed. This can

be done by a shoemaker or certified pedorthist.

As experienced practitioners, we have a good under-

standing of our patients’ specific footwear needs. I will

often write a specific prescription with desired design

components. I also direct patients to footwear stores

that have a better understanding of footwear design

and biomechanics who can fit them appropriately, have

a wide variety of makes, models and sizes of properly

designed footwear, and will communicate with me if

they have any questions or concerns. I remind my

patients to take along their orthotics and wear the

socks that they would normally wear with shoes when

they try on footwear.

OrthoticsAlthough evidence-based literature is limited and

inconclusive regarding the efficacy of custom

orthotics, some research shows they also benefit

patients suffering from metatarsalgia.4-8 The patient in

question would benefit from new, custom-made

orthotics to help control excessive pronatory pathome-

chanics. The orthotic shell should be made of a materi-

al that doesn’t flex excessively, be of adequate width

that matches her foot shape and size, be contoured to

her anatomy, have good rearfoot and midfoot intrinsic

± extrinsic posting and have a deep heel cup. Finally,

the shell should be covered with a full-length shock-

absorbing top cover. Please see Figure 1 for an example

of the components of an orthotic.

The orthotics should incorporate accommodations

such as an anatomically positioned MT pad or specific

relief/cut-out for a painful MT head.4-8 See Figure 2 for

examples of various forefoot modifications for

metatarsalgia.

The practitioner must take care to ensure the

orthotics take into account their fit into footwear. For

this patient, I would recommend two pairs of

CRAJ 2009 • Volume 19, Number 2 7

Figure 1

Example of the Components of anOrthotic

Image courtesy of Paris Orthotics Ltd., Vancouver, B.C.


EDITORIALIMPRESSION AND OPINION

orthotics—one to leave in her work footwear and a sec-

ond pair to utilize in all her other shoes. In patients

who require wearing dress shoes for their work or ADLs,

a smaller, dress-type of orthotic may be indicated to fit

properly into those shoes.

EducationA complete treatment regimen must include educat-

ing the patient on their pathology, the causative fac-

tors and the goals and benefits of their treatment. A

well-informed patient is an empowered patient who

will take an active role in treatment, and is dedicated to

making themselves better.

In summary, patients with forefoot pain present with

multiple etiological factors and their own unique path-

omechanics. A thorough assessment must be done to

direct the appropriate treatment. Treatment must be

multifaceted to address all the causative factors. This

should include passive components such as proper

footwear, orthotics and education and the dynamic com-

ponents of an extensive home exercise and treatment reg-

imen. After all, we don’t make patients better—we help

them make themselves better.

Russ Horbal is a physiotherapist and a Co-Director of

the Sports Physiotherapy Centre—LifeMark at the

Pan Am Clinic in Winnipeg, Manitoba. He is a lecturer

in the Physical Therapy Division, School of Medical

Rehabilitation, Faculty of Medicine at the University

of Manitoba. He also has a teaching appointment in

the Section of Family Practice Faculty of Medicine at

the University of Manitoba. Russ has a post-graduate

Diploma in Sport Physiotherapy and is a Certified

Athletic Therapist.

References: 1. Bardelli M, Turelli L, Scoccianti G. Definition and classification of

metatarsalgia. J Foot and Ankle Surg 2003; 9:79-85.2. Scranton PE. Metatarsalgia: diagnosis and treatment. J Bone Joint Surg Am

1980; 62:723-32.3. Vliet Vlieland TP. Non-drug care for RA – is the era of evidence-based

practice approaching? Rheumatology 2007; 46:1397-1404.4. Postema K, Burm PE, Zande ME, et al. Primary metatarsalgia: the influ-

ence of a custom moulded insole and a rocker on plantar pressure.Prosthet Orthot Int 1998; 22(1):35-44.

5. Chalmers AC, Busby C, Goyert J, et al. Metatarsalgia and rheumatoidarthritis – a randomized, single blind, sequential trial comparing 2 typesof foot orthosis and supportive shoes. J Rheumatol 2000; 27(7):1643-7.

6. Price M, Tasker J, Taylor N, et al. Not just a piece of plastic? A survey oforthotic effectiveness within a podiatry surgery department. BritishJournal of Podiatry 2002; 5(2):36-40.

7. Poon C, Love B. Efficacy of foot orthotics for metatarsalgia. The Foot1997; 7:202-4.

8. Doxey G. Management of metatarsalgia with foot orthotics. JOrthopSports Phsy Ther 1985; 6(6): 324-33.

Figure 2

Various Forefoot Modifications for Metatarsalgia

Image courtesy of Paris Orthotics Ltd., Vancouver, B.C.

Metatarsal Raise Metatarsal Bar Lesion Accomodation

Under 3rd MT Head


Joints of the upper extremity, in particular those of

the hand and wrist, are rarely spared the negative

effects of rheumatoid arthritis (RA). With

increased use of biologic agents, splinting helps RA

patients better manage their condition. Today, splint-

ing is used on a short-term basis to manage symptoms.

Splinting continues to be an effective tool and should

be considered an integral part of a comprehensive

treatment plan for arthritis patients. The fabrication

of a custom-molded splint or the fitting of a prefabri-

cated splint should be accompanied by patient edu-

cation regarding the splint purpose and function,

joint-protection techniques, and active/passive range-

of-motion (ROM) exercises, when indicated. This arti-

cle discusses several splints (custom and prefabricat-

ed) that have been most effective and appreciated by

patients suffering from RA.

Wrist SplintsConsidering the role of the wrist in daily function, it’s fre-

quency of movement and the many articular surfaces

involved, it is easy to appreciate the benefits to be gained

by splinting an inflamed “active” wrist. Approximately

75% of individuals with RA have inflammatory involve-

ment of the wrist joint.1

Splinting For Arthritis: A Therapist’sViewpointBy Dianne Freeman, OT Reg (Ont.)

Figure 1. Prefabricated wrist splint. Figure 2. Custom-molded gauntlet splint.





There are several, good quality, prefabricated wrist

splints available on the market. These are constructed

of fabric with an adjustable metal or plastic bar on

the volar and/or dorsal surface of the wrist (Figure 1).

Proper fit, comfort and esthetics are of utmost

importance in order to achieve splint-wearing com-

pliance. A variety of styles, from different manufac-

turers, should be available for consideration during

the fitting process.

Occasionally, a prefabricated wrist splint will not

meet the needs of the client, and a custom-molded

wrist splint will be fabricated. A custom-molded,

gauntlet-style splint can be very helpful for some

physically active clients with existing wrist-joint

damage, limitation of wrist ROM and pain with move-

ment (Figure 2). The gauntlet splint is worn during

the day and permits clients to continue to function

with very little discomfort. Some have been able to

continue with physically demanding sports such as

downhill skiing, tennis and cycling while wearing a

gauntlet splint. Wearing wrist splints at night is gener-

ally only necessary when the client suffers from carpal

tunnel symptoms, or for pain-management purposes.

A recent study of RA patients wearing prefabricat-

ed wrist splints reported a 32% reduction in visual

analogue scale (VAS) pain scores.2 A well-supported

and more comfortable wrist permits greater function

in the otherwise uncompromised hand. Therefore,

splinting of the wrist can be an effective component

of treatment.

Ulnar Deviation (Drift)Ulnar deviation (UD) is typical in patients with chron-

ic synovitis at the metacarpophalangeal (MCP) joints

due to the resulting expansion of the joint capsule,

stretching of the surrounding ligaments, and attenua-

tion of the extensor tendons. This results in an imbal-

ance of power in the hand. The imbalance, compound-

Figure 5. Prefabricated resting splint.Figure 4. Custom-molded resting splint.

Figure 3. Hand-based splint for UD.


ed by daily external forces typically in the ulnar direc-

tion, leads to an ulnar drift. Splinting can be effective

in the treatment of this problem, while the most effec-

tive treatment is systemic management of the synovitis

causing it.

However, some hand-based splints provide passive

realignment of the affected structures, thereby correct-

ing UD while the splint is being worn (Figure 3).3

Reduction of MCP movement, through splinting, may

have the added benefit of reducing synovitis. In addi-

tion, client education, regarding proper joint position-

ing/alignment during activities of daily living (ADLs),

can be reinforced by use of the UD splint. In my expe-

rience, splints used to correct or to prevent UD should

be considered for short-term use on newly diagnosed

RA patients, whose MCP inflammation has not yet come

under adequate control through systemic management.

Night-time splinting is also an option for treatment

of chronic MCP joint synovitis and/or UD. There is

some indication that custom-molded hand and wrist

resting splints, worn at night, can decrease hand pain,

improving grip and pinch strength, and enhancing

upper limb function (Figure 4).4 Prefabricated resting

splints can also be considered for the inflamed “active”

hand (Figure 5). For RA patients who have a number of

active posterior interphalangeal (PIP) and/or MCP joints,

night-time splinting should be considered early in the

treatment process to assist with pain management.

There is no clear evidence regarding the effectiveness

of this splint in deformity prevention.

PIP SplintingChronic synovitis of the PIP/MCP joints can lead to

characteristic swan neck and boutonniere deformities

of the fingers. Reducible swan neck deformities can be

easily treated with the fitting of plastic or metal oval-

shaped finger orthoses. Orthoses commonly in use are

Oval 8® and Digisplints™ or Silver Ring™ Splints

(Figure 6). These splints are lightweight, easy-to-wear

and very effective in correcting PIP hyperextension and

distal interphalangeal (DIP) flexion. They improve

PIP joint stability and promote finger function.5 The

fitting of these splints should be considered at the

first sign of deformity and are generally very well

accepted by the patient. Boutonniere deformities

should also be splinted early in an attempt to reduce

PIP joint inflammation and prevent further deformity.

The same oval-shaped splints are used to treat this

condition but need to be worn in a manner which

blocks PIP joint flexion. As a result, these splints

impede finger function and are often not considered

practical for long-term wear. It should be noted, oval-

shaped ring splints may not be appropriate for indi-

viduals who have frequent fluctuations in PIP joint

inflammation.

Figure 7. Custom-molded “trigger finger” splint.

Figure 6. Plastic and metal finger orthoses.


Trigger Finger SplintsTenosynovitis involving the flexor digitorum tendons

often leads to a condition commonly referred to as

“trigger finger.” The increased volume of the

inflamed flexor tendon inhibits its smooth excursion

within the tendon sheath, and through the A1 pulley

at the level of the MCP joint in the palm. A tendon

nodule may or may not be present, but it is almost

always tender upon palpation. With cases of advanced

tenosynovitis, active triggering may no longer be

present. However, a profound lack of active move-

ment of the affected digit, with obvious swelling and

a local increase in skin temperature, will likely exist.

Continued use of the affected hand perpetuates the

inflammation due to the friction created within the

tendon sheath with active movement. Static splinting

of the affected digit, with the MCP joint in approxi-

mately 15 degrees of flexion, gives the tendon an

opportunity to rest and promotes a reduction in

inflammation (Figures 7 & 8).6 Patients are instruct-

ed to wear the splint day and night for four to six

weeks, and then gradually taper the wearing of the

splint, as symptoms improve. The patient is also taught

passive ROM exercises and told to ice the affected area.

Trigger finger splints are easily fabricated and are an

effective, non-invasive treatment option.

ConclusionIn summary, splinting RA patients’ hands and wrists

can provide pain relief, support, joint protection, sta-

bility and reduced inflammation. Splints should be

considered early on as part of a comprehensive treat-

ment program, and can be instrumental in enhancing

function for those living with RA.

Dianne Freeman, OT Reg (Ont.)

Occupational Therapist,

Outpatient Hands and Orthopedics,

The Credit Valley Hospital

Mississauga, Ontario

References:1. Flatt AE. The Care of the Rheumatoid Hand. Seventh Edition. C.V.

Mosby, St. Louis, 1968.2. Veehof MM, Taal E, Heijnsdijk-Rouvenhorst LM, et al. Efficacy of wrist

working splints in patients with rheumatoid ar thritis: A randomizedcontrolled study. Ar thritis Rheum 2008; 59:1698-1704.

3. Rennie HJ. Evaluation of the effectiveness of a metacarpophalangealulnar deviation or thosis. J Hand Ther 1996; 9:371-7.

4. Silva AC, Jones A, Silva PG, et al. Effectiveness of a night-time handpositioning splint in rheumatoid ar thritis: A randomized controlledtrial. J Rehabil Med 2008; 40:749-54.

5. Zijlstra TR, Heijnskijk-Rouwenhorst L, Rasker JJ. Silver ring splintsimprove dexterity in patients with rheumatoid ar thritis. Ar thritisRheum 2004; 51:947-51.

6. Colbourn J, Heath N, Manary S, et al. Effectiveness of splinting for thetreatment of trigger finger. J Hand Ther 2008; 21:336-43.


Figure 8. Prefabricated “trigger finger” splint.


1. Congratulations on the receipt of theinaugural Canadian RheumatologyAssociation (CRA) Educator Award. Why haseducation been such a priority in your careeras a rheumatologist? Was your interest in thisfield of rheumatology stimulated by certainindividuals or events?Teaching and education have become priorities in my

career. I believe that without excellence in teaching

and education, rheumatology can’t move forward as a

profession or sustain itself.

When I first began my practice as a rheumatologist,

my emphasis was on patient care. I quickly realized

that much of what I did in the office was educating

patients about their underlying rheumatologic dis-

ease, and its treatment. Developing the knowledge

and skill to present this information in the most

effective manner sparked my interest in the issues

around effective adult education.

While working in my community practice, I was fre-

quently asked to participate in programs to educate

the public and my family practice colleagues, which

highlighted the need to learn more about the teach-

ing and education processes themselves. From there,

I began reading literature on teaching and learning,

and enrolled in a two-year program offered by the

Department of Medicine at the University of Toronto

aimed at improving teaching skills. I was exposed to a

wonderful group of colleagues, teachers and men-

tors—all of whom were excited by our focus on learn-

ing, teaching and education. Between that group and

the old issue that “the more you know, the more you

realize how much there is to know,” I went on to com-

plete my Masters focusing on issues around adult

education and curriculum development. It has been a

long but exciting process.

2. You have long been a proponent of thecreation of such an award. Why is an awardgiven to rheumatologists involved ineducation so important?Actually, it was members of the Education Committee

of the CRA who collectively had the vision to have an

award dedicated to those who focus their career on

teaching and education in the field of rheumatology.

Many members of the CRA are engaged in a variety of

teaching and/or education-related activities. Some of

this is patient directed, some towards providing excel-

lence in Continuing Health Education (CHE) for fami-

ly physicians and allied health practitioners, and some

aimed at teaching trainees—from first-year medical

students to rheumatology fellows. CRA members who

participate in these endeavors not only have substan-

tial expertise in their chosen field of rheumatology,

they have an additional skill set which they have

An Interview with the Inaugural CRA Educator Award Recipient: Dr. Heather McDonald-Blumer

NORTHERN HIGHLIGHTS


acquired to plan and develop curricula and/or imple-

ment educational programs. Just as we recognize our col-

leagues for their work in research or patient advoca-

cy/community involvement, it seemed appropriate to

honor those whose contributions were in the field of

education and teaching as it pertains to rheumatology.

3. Some individuals within our communityhave stated that the development ofeducational programs is the sole purview ofuniversity-based faculty. What is your feelingabout which people in the rheumatologycommunity should be involved in thedevelopment of educational events, and carryout the teaching for undergraduate,postgraduate, and CHE purposes?My quick response to this is: what century are they living

in to have that opinion? University-based and communi-

ty-based rheumatologists are needed in the development

and provision of rheumatology-related education.

Specific roles will depend on the individual’s particular

interest and expertise. Geographic locale of one’s chosen

practice is irrelevant. Having said that, for those in uni-

versity settings, the opportunities to teach or be involved

in education related activities are somewhat easier. The

learners are on the doorstep, the programs are often well

developed, and in many centers there is some remunera-

tion for participation in the education-related activities.

For those whose predominant practice site is in the

community, the participation in education requires more

active planning. While traditionally, the community edu-

cation opportunities have focused on CHE for family

doctors and allied health professionals, and teaching our

patients, this appears to be changing. As the move to dis-

tributed medical education at the undergraduate and

postgraduate levels evolves, a greater role for teaching in

the community realm is guaranteed.

Of far more importance than the location of one’s

practice, is one’s ability to teach well. It is interesting

that as recently as 10 years ago it was assumed by the

medical establishment that all physicians could teach.

However, as recipients of teaching activities, I think that

all of us know that some people teach better than others.

For those who are not innately gifted, a little training can

be very helpful. We now find that some education on how

to teach is part of our rheumatology curriculum, as man-

dated by the Royal College. For those of us who are past

the resident level, there are fabulous courses set up to

assist those with a particular interest—everything from

very practical, succinct courses that focus on the basics

to PhD level programs focusing on a variety of streams in

adult education or education research.

4. What would your advice be to some of ouryounger colleagues who are interested inenhancing their teaching skills asrheumatologists?For any of our younger colleagues who are potentially

interested in teaching or pursuing a career which

includes medical education, I think that you will find

that the opportunities are as broad, varied and exciting

as you (hopefully) find our chosen specialty of rheuma-

tology. I would encourage you to talk with your Program

Directors as they are a wonderful resource.

Additionally, within your Departments of Medicine,

you will find that there will be a group of medical edu-

cators who will be more than delighted to chat with you

about career paths and opportunities. (Even if you are

not still in a residency program, if my experience is a

benchmark, any of these individuals will be more than

happy to talk with you—I had been in practice for more

than 10 years when I started developing this aspect of

my career).

Lastly, there is a growing group of CRA members who

have a depth and breadth of expertise in the field of

medical education who I know would be more than

delighted to help wherever they can. You could start by

contacting any of the members of the Education

Committee and from there, a whole network of opportu-

nities will be on the horizon.

Heather McDonald-Blumer, MD, MSc, FRCPC

Program Director, Rheumatology,

University of Toronto

Toronto, Ontario


NORTHERN HIGHLIGHTS


Still running his practice until a few

weeks before his death, Jack Reynolds

died on March 18, 2009, at 75 years

old. Born in The Pas, Manitoba, and the son

of a Presbyterian minister, Jack graduated in

1958 from the University of Toronto. He then

trained in Internal Medicine and Rheum -

atology in Toronto and the United Kingdom.

With his passing, the rheumatology field

has lost a member of a select group of

rheumatologists who were sponsored by The

Arthritis Society to obtain training at The

Canadian Red Cross Memorial Hospital in Taplow, U.K.

There, Jack came under the influence of Barbara Ansell and

Eric Bywaters, a team whose contributions to rheumatology

in the postwar era had become legendary.

On his return to Canada, with the support of The

Arthritis Society, Jack became the first Director of

Rheumatology at the Toronto Western Hospital with the

establishment of a 20-bed Rheumatic Disease Unit in col-

laboration with physiatrist Dr. Jack Crawford. Jack

Reynolds became a pioneer creating a teaching, research

and clinical practice base at the Western.

The merging of Toronto Western, Toronto General and

Princess Margaret hospitals into a single entity led to the

Western becoming a major center for rheumatology care

and research. Jack’s teaching and clinical skills were recog-

nized, and he was promoted to Associate Professor in 1983.

During these years, and throughout his career, his inter-

ests and publications on chronic pain were stimulated by

colleagues like Harvey Moldofsky and Hugh Smythe. Jack

wrestled with the elusive nature of chronic pain long before

it was fashionable to do so. He formulated a working

biopsychosocial model of chronic pain. He would discuss

the latest insights into parasympathetic overload and gate

theory, while reflecting on the anguish of refugees and tor-

ture victims, who were left with a life of painful memories

and chronic fatigue.

As a medical student, Jack’s degree in music earned him

praise and fees to cover his tuition by playing the organ at

many weddings. Later, as a key member of St. Andrew’s

Presbyterian Church, he contributed enormously to the life

of the congregation. He was also a life long supporter of the

Toronto Symphony and the Canadian Opera Company.

There was something intrinsically appealing

about working with Jack. As a physician, his

distinctive style was characterized by humility

and commitment to his patients. He loved

being a doctor, and frequently expressed his

great admiration for the knowledge and

sophistication of the young residents coming

through the Rheumatology program. After a

journal club presentation, he would often

comment on how exciting the advances in

biomedical science had become.

For all his years of experience, he had a

youthful balanced approach to medicine and to life. His

music gave him an internal cadence, while his balance

came from his family and his faith. He loved to provide

updates on the travels of his children as they grew, and

more recently, his grandchildren. Jack’s career defined the

continuity of our specialty recognized by his wide referral

base and grateful patients from whom he enjoyed a con-

stant flow of presents.

Can physicians, living in the age of molecular genetics and

reductionist scientific methods, keep alive the sense of won-

der at the complexity of the mind-body interaction? Jack did.

Can clinicians, living in an age of tightening budgets

and regulations, keep alive the sense of thankfulness for

the privilege of being a doctor? Jack did.

What we never heard was cynicism, or defeatism, or sar-

casm. What we always heard was warmth, and humor, and

compassion. How fine it would be if that could all be

taught or transmitted to young students of medicine.

What a privilege to have worked and lived with such an

individual. Jack is sorely missed by his colleagues and

patients. We share our great sense of loss with Jack’s wife,

Beverley, and his family.

Robert Inman, MD, FRCPC, FACP, FRCP, Edin

Professor of Medicine and Immunology,

University of Toronto, Toronto Western Hospital

Duncan Gordon, MD, FRCPC, MACR

Professor of Medicine,

University of Toronto, Toronto Western Hospital

Editor, The Journal of Rheumatology

IN MEMORIAM

William John ReynoldsBy Robert Inman, MD, FRCPC, FACP, FRCP, Edin; and Duncan Gordon, MD, FRCPC, MACR

Jack Reynolds, 1933-2009



Click here to comment on this articleCRAJ 2009 • Volume 19, Number 216

JOINT COMMUNIQUÉ

On February 27, 2009, The Hospital for Sick Children

honored Earl Silverman with the inaugural Ho Family

Chair in Autoimmune Diseases. This honor is a won-

derful tribute to Earl and the outstanding contributions he has

made over his stellar 25-year career, and also recognized the

Division of Rheumatology for its scholarship.

Earl’s career in pediatric rheumatology has been marked by

significant contributions in multiple areas of clinical care, edu-

cation and research. In collaboration with members of the

Division of Nephrology, he established the Pediatric Systemic

Lupus Erythematosus (SLE) Clinic in 1985. The clinic has not

only provided a fertile ground for clinical research with studies

in the area of coagulation, renal disease, neuropsychiatric dis-

ease, hematologic disease and clinical outcomes, but has also

been a marvelous teaching resource, providing clinical care in

an interdisciplinary fashion. In 2008, Earl was awarded the

Hope Award from the Ontario Lupus Association for his com-

mitment and dedication to SLE. He also developed a program

in neonatal lupus.

Earl has been the lead author on several therapeutic trials

in juvenile rheumatoid arthritis, including a New England

Journal of Medicine paper comparing leflunomide to methotrex-

ate in 2005. Other areas of interest have included Kawasaki

disease and Macrophage Activation Syndrome. In recognition

of his teaching efforts, he received the Subspecialty Teaching

Award from the University of Toronto Department of

Paediatrics in 2008.

The Rheumatology Program at SickKids is now in its 25th

year. Earl Silverman and Ron Laxer were recruited in 1984.

They joined Len Stein (who relocated to North Carolina in

1987) and became part of a new Division of Immunology and

Rheumatology under Erwin Gelfand. After Erwin’s departure in

1987, Ron and Earl were joined by Abe Shore, and in 1990, they

formed a separate Division of Rheumatology. The Division has

enjoyed great success in all three aspects of the mission of an

Academic Health Science Center. As the patient popula-

tion grew, the Division was able to recruit additional

members—there are currently nine physicians on staff.

When Ron became Vice-Chair, Clinical of the Department of

Paediatrics at SickKids in 1996, Rayfel Schneider became act-

ing and then permanent Division Head in 1998. Recently,

Rayfel became the Vice-Chair for Education in the

Department of Paediatrics and Brian Feldman, a graduate of

the training program, is the current Division Head at SickKids.

Members of the Division have played leading roles in advanc-

ing knowledge in many areas of Pediatric Rheumatology, from

a clinical and a basic-science perspective. The development of

subspecialty clinics for SLE, neonatal lupus erythematosus, sys-

temic juvenile idiopathic arthritis, localized scleroderma,

spondyloarthropathy and juvenile dermatomyositis, has

enabled the development of unique clinical expertise and

training opportunities, fostering research such as health-out-

comes research, forming an important part of the

Rheumatology Program.

To date, 52 people have spent from six months to four years

training in the world-renowned program. Graduates are now

faculty members in Calgary, Edmonton, Toronto, Ottawa,

Montreal and Halifax in Canada, as well as multiple countries

around the world.

In addition to training physicians, the Division developed a

unique model of care, which has now been embraced by The

Arthritis Society as the Advanced Clinician Practitioner in

Arthritis Care Program (ACPAC). In 1994, the Division began

a Physiotherapy/Occupational Therapy Practitioner Program,

an advanced practice role fashioned on the model of the

nurse practitioner. Four individuals have graduated from the

Pediatric Program Practitioner Program, precursor of the

ACPAC. Two play integral roles in care delivery at SickKids and

one coordinates the Division’s outreach program in Sudbury.

A celebration of the Division’s achievements is being planned

for 2010.

Ronald M. Laxer, MD, FRCPC

Division of Rheumatology,

The Hospital for Sick Children

Staff, Bloorview Kids Rehab

Professor of Paediatrics & Medicine,


Toronto, Ontario

Earl Silverman: A Tribute By Ronald M. Laxer, MD, FRCPC

In collaboration with members of the

Division of Nephrology, he

established the Pediatric Systemic

Lupus Erythematosus Clinic in 1985.



Iam very pleased to write an introduction to this

issue’s Joint Communiqué. It has been, and continues

to be, my pleasure to serve the Canadian Rheum -

atology Association (CRA) as its President.

The highlight of the job truly is the interaction with

the Executive (comprised of the President, Vice-

President, Secretary-Treasurer and Past-President), the

voting Board members and the committee chairs (who

may or may not be voting Board members).

The committee structure is key to the functioning of

the CRA executive. This structure came into full force

under the reign of our illustrious Canadian Rheumatology

Association Journal (CRAJ) Editor, Glen Thomson, when

he was CRA President in 1998. Most of the issues which

come to the attention of the Executive are dealt with by

the various committees.

Under the guidance and leadership of the chairs, mat-

ters are assessed and studied, and recommendations to

the Executive are put forth. The committee chairs are

chosen by the President and are generally leaders in the

profession with an interest and expertise appropriate to

the committee which they chair. The chairs choose the

members of their committee.

As you will see from the articles that follow, the CRA is

served well by its Board and the committee chairs. These

are very busy people that somehow find the time to do

this important work for our Association.

As President, on behalf of the Association, I thank you.

John Thomson, MD, FRCPC

President, Canadian Rheumatology Association

Staff, The Ottawa Hospital—Civic Campus

Lecturer, University of Ottawa

Ottawa, Ontario

An Introduction to This Year’sCommittee ReportsBy John Thomson, MD, FRCPC

JOINT COMMUNIQUÉ



JOINT COMMUNIQUÉ

The Therapeutics Committee has continued to be

active in multiple spheres over the past 12 months.

There has been major progress by teams formulat-

ing new Canadian guidelines on rheumatoid arthritis

(RA) management, funded by a Canadian Institutes of

Health Research grant. The teams developing guide-

lines in established RA for disease-modifying

antirheumatic drugs, biologics, and safety issues (TB,

pregnancy, vaccination), hope to have these guidelines

ready for presentation at the 2010 Canadian

Rheumatology Association Meeting in Quebec City. A

knowledge translation plan to ensure dissemination

and uptake of these guidelines is also being formulated.

Early RA guidelines are on hold pending a new litera-

ture review on undifferentiated inflammatory arthritis

and anticipated changes in the classification criteria

for early RA.

The Committee is also continuing its collaboration

with the Canadian Pain Society on guidelines for pain

management in arthritis. Other guidelines under

review include the measurement and supplementation

of vitamin D proposed by Osteoporosis Canada, the

guideline development on other rheumatic diseases

such as fibromyalgia, and the use of musculoskeletal

ultrasound by rheumatologists. Given the intensity of

resources required to develop full guidelines, the

Committee may look in the future at issuing more infor-

mal position statements on developing issues in

rheumatology. Submissions of proposed guidelines or

position statements by disease-specific expert groups,

such as SPARCC, CANIOS, the Canadian Scleroderma

Consortium, or other similar groups are welcome.

Reports from any CRA member who has had success

in obtaining reimbursement for off-label use of bio-

logic or other innovative therapies for rare or orphan

diseases to assist their fellow Canadian rheumatolo-

gists are also welcome. This could be done by submit-

ting literature reviews or lists of articles supporting

such therapies to the Therapeutics Committee for

posting on the CRA website.

The Committee would like to extend its welcome to

our newest member, Dr. Mary-Ann Fitzcharles from

Montreal, and welcomes new members and proposals for

future initiatives.

Vivian P. Bykerk, MD, FRCPC

Assistant Professor of Medicine,

University of Toronto,

Department of Rheumatology

Director, Early Arthritis Program

Assistant Director,

Center of Advanced Therapeutics,

Rebecca McDonald Center for Arthritis and

Autoimmunity,

Mount Sinai Hospital

Toronto, Ontario

Philip Baer, MDCM, FRCPC, FACR

Rheumatologist,

Co-Chair, Therapeutics Committee,

Canadian Rheumatology Association (CRA)

Vice-President, Ontario Rheumatology Association (ORA)

Chair, OMA Section of Rheumatology

Toronto, Ontario

CRA Therapeutics Committee Update By Vivian P. Bykerk, MD, FRCPC; and Philip Baer, MDCM, FRCPC, FACR

The CRA made a huge mistake in choosing Quebec City over Sherbrooke for our annual meeting. Next year’s retreat better be in Sherbrooke.



The Education Committee of the CRA had a very pro-

ductive year in 2008. A partnership several years in

the making with Advancing In, a subsidiary of MD

Briefcase, has been established to help bring accredited

medical education programming to CRA members. This

has resulted in the development of a specific web portal

for online rheumatology education, which can be

accessed through the CRA homepage (follow “CRA

Endorsed online CME”) or at www.advancingin.com.

The first education programs available on the website

were three plenary lectures delivered at the 2009 CRA

Annual Scientific Meeting. All who attended the lectures

in person agree that they were excellent, and those who

were unable to attend are encouraged to view them on

the new website. Interactive questions have been provid-

ed to help highlight key features of the meetings. Two

industry symposia were also videotaped and are available

for review online.

It is hoped that over the coming year, new programs

will be added to the website every several months. The

Committee will be involved in choosing the topics that

will be presented, the goals and objectives to be set and

which speakers will be asked to participate. This process

will allow the committee to meet the accreditation crite-

ria set out by the Royal College of Physicians and

Surgeons of Canada, allowing participants in the online

education program to earn Category One Maintenance

of Certification credits.

As with any new endeavor, feedback is essential. It is

important that this project be evaluated carefully to

ensure that it meets the needs of the members, and fits

with the overall philosophy and goals of the CRA. We

invite you to let the Education Committee know if the

online programs meet your educational needs.

The Committee will be doing formal surveys peri-

odically throughout the year, but in the interim, feel

free to address your comments to either myself at

[email protected] or to Christine Charnock

at [email protected].

Heather McDonald-Blumer, MD, MSc, FRCPC

Chair, CRA Education Committee

Program Director, Rheumatology,


Toronto, Ontario

Education Committee ReportBy Heather McDonald-Blumer, MD, MSc, FRCPC

So, what’s a nice girl like you doing in Ottawa? I’m smiling because I made my first correct diagnosis last week. Well, prettyclose anyway.

JOINT COMMUNIQUÉ



The year 2008 was one of the busiest for the Pediatric

Section of the CRA. Since 2006, much effort has

gone into establishing a structure for the various

subcommittees—advocacy, education, human resources

and scientific. Many thanks go to Dr. Bianca Lang, the cur-

rent Chair of the Executive Committee, under whose lead-

ership the Pediatric Section came to fruition. Dr. Lang is

planning to hand over the reins to Dr. Lori Tucker, the

newly elected Vice-Chair, in the year 2010.

The subcommittees have been working in multiple areas

over the past 12 months. Highlights of this year’s activi-

ties are listed below.

The Pediatric Scientific Committee was thrilled to

secure excellent national and international speakers for

the CRA annual meeting in Kananaskis. Dr. Dan Kastner’s

personal tale of periodic fever syndromes, Dr. Rae Young’s

workshop on vasculitis, and Dr. Julie Prendiville’s work-

shop on varied skin manifestations of pediatric rheuma-

tology patients were immensely inspirational.

The Pediatric Advocacy Committee has joined forces

with the Access to Care and Therapeutic Committees to

lobby for improved access to biologic medications for

patients with other diagnoses than rheumatoid arthritis.

The plan is to collect a repository of “best evidence” arti-

cles for management of rare or orphan diseases, adult or

pediatric, with consensus national recommendations that

each center can utilize for case-by-case requests for local

funding for new emerging medications. We hope to see

increased and more uniform access as a result nationwide.

The current chair of the Pediatric Advocacy Committee

was able to participate in The Arthritis Society’s (TAS)

national meeting to establish an arthritis advocacy agen-

da, and we see this as an important way to ensure children

with rheumatic diseases are not forgotten in national

advocacy. Our Section members hope to continue and

increase involvement with TAS and Alliance for the

Canadian Arthritis Program (ACAP) in order to be sure

that children with rheumatic disease are included in

every level of health-service advocacy.

Although the recession may keep many of us working

well past the freedom 55 target, training of future pedi-

atric rheumatologists continues to be one of our key areas

of focus. The current task of the Education Committee is

the refinement of the Royal College exam format for

Pediatric Rheumatology. Our trainees eagerly wait to hear

whether they will be examining actual patients or stan-

dardized patients come fall 2009. We will keep the mem-

bership posted!

We hope to include all pediatric rheumatologists

across Canada as members of our Section, which

improves our ability to advocate for our patients and

pediatric rheumatology needs. Members of the Section

can be contacted through Christine Charnock, the

Executive Coordinator of the CRA, and potential new

members are invited to contact one of the members of

the Pediatric Section Executive Committee. At this time,

a call is going out to adult and pediatric rheumatolo-

gists for a list of excellent articles on management of

rare pediatric diseases. Please feel free to contact one of

the members of the Pediatric Section Advocacy

Committee with your recommendations!

Paivi Miettunen, MD, FRCPC, FAAP

Chief, Pediatric Rheumatology

Assistant Professor, University of Calgary

Calgary, Alberta

The CRA Pediatric Section By Paivi Miettunen, MD, FRCPC, FAAP

Three smart and good-looking guys. [Note: Caption editor Gunnar Kraag wishesto clarify that the correct number of smart and good-looking guys in this photo isthree, and not four, as was indicated in the print version of this article.]

JOINT COMMUNIQUÉ




The CRA has concentrated most of the access to

care issues through the efforts of The Alliance for

the Canadian Arthritis Program (ACAP). The coali-

tion of stakeholders in arthritis care has embarked on

an important process to bring arthritis care and

research to the forefront in Canadian healthcare. I have

asked Dianne Mosher, co-chair of ACAP, to provide the

CRAJ with a report.

Over the past year, much of the work at ACAP has been

devoted to developing a business case for arthritis.

Several years ago, Dr. Gillian Hawker asked one of the

senior policy advisors at Health Canada: “What does

arthritis need to do to get where cancer is?” The answer

was work collectively as a community, identify arthritis

champions and develop a business case.

ACAP has since hired Riskanalytica, the company that

created the business case for cancer, which became a

necessary step to achieve support for a cancer strategy

from the federal government. They have also worked on

other projects such as smoking cessation, spinal cord

injury and planning for a pandemic.

The business case in arthritis will look first at the base

case. What are the costs associated with status quo if we

continue to practice as we are now, and change nothing?

Two diseases have been chosen as models for the case:

osteoarthritis (OA) and rheumatoid arthritis (RA). Due to

the generous contribution of data from CRA members

Drs. Diane Lacaille, Gillian Hawker, and Claire

Bombardier, all the data for the base case has been

entered and run using the Riskanalytica model.

The next step in the process was deciding what should

be the business case? What should we model for change

that would improve the care, outcome and costs associ-

ated with arthritis? In December 2008, a group of sub-

ject matter experts (many CRA members) met and decid-

ed to model joint replacement surgery, obesity, pain con-

trol and early access and treatment of RA. The difference

between the base case and the cost savings of the inter-

ventions is the business case.

Today, we have created a base case and have provided

Riskanalytica with the data necessary to do the scenar-

ios. This project has been interesting and challenging.

Unlike some other conditions, our business case is

measured primarily around disability and loss of work

using presenteeism and absenteeism. The input and

data from Drs. Claire Bombardier, Diane Lacaille,

Monique Gignac, Gillian Hawker and Jacek Kopec has

been invaluable.

With the results of the base case alone, we have infor-

mation on the effects of the aging population, obesity

and smoking on the incidence and prevalence of OA and

RA independently. The business case will be completed

in June with a report available later this year.

The Public Health Agency is due to release Arthritis in

Canada in the near future, and we believe the reports will

be complementary to each other. We anticipate the

reports will allow our community, government and the

public to better understand and plan for arthritis.

Michel Zummer, MD, FRCPC

Chair, Access to Care Committee

Chief, Division of Rheumatology,

Hôpital Maisonneuve-Rosemont

Dianne Mosher, MD, FRCPC

Associate Professor, Dalhousie University

Access to Care Committee UpdateBy Michel Zummer, MD, FRCPC; and Dianne Mosher, MD, FRCPC

Pensive. Attentive. The weight of the CRA on his shoulders! Or is he just daydreaming?


JOINT COMMUNIQUÉ



For our inaugural submission to the CRAJ, the

Arthritis Health Professions Association (AHPA)

is pleased to report the Association has had a

very productive year and has successfully accom-

plished the goals set in 2008.

The first goal was to build a strong foundation for

the AHPA organization. The AHPA board has since

created procedure documents and steering docu-

ments outlining responsibilities, goals and direction

for the board members and committees. AHPA also

launched a new interactive and easy to use website,

www.ahpa.ca. In 2009, the finances and membership

administration was transferred to the CRA, which will

help facilitate accessibility and administration as we

align educational initiatives more closely with the CRA.

The organization also met its second goal to

increase educational resources and opportunities. In

addition to three well-attended AHPA workshops at

the 2009 CRA conference, the new one-day Advanced

Skills pre-course at Kananaskis was “sold out.”

Thanks to pharmaceutical sponsorship, the AHPA was

able to offer funding to members attending the pre-

course. In 2009, we are also offering a series of six

audio conferences at no cost to our members. A

monthly e-mail news brief continues to keep mem-

bers up to date with AHPA news, upcoming courses,

conference announcements and interesting recent

journal abstracts.

Finally, the Association achieved its third goal,

increasing its membership by 37% this year. Members

include nurses, occupational therapists, physiothera-

pists, social workers, researchers and pharmacists.

Karen Gordon, PT

Communications Chair, AHPA

Physical Therapist, The Arthritis Society

Ottawa, Ontario

Marlene Thompson, BSc, BScPT

President, AHPA

Physical Therapist, St. Joseph's Hospital/UWO

Associate Clinical Professor Physical Therapy, FHS,

University of Western Ontario

London, Ontario

Arthritis Health ProfessionsAssociation: It’s Our First! By Karen Gordon, PT; and Marlene Thompson, BSc, BScPT

I didn’t know that there was stuff like that on the Internet!


JOINT COMMUNIQUÉ



We would like to thank members for their contin-

ued support of the website. We have seen our vis-

its increase by 77%, with more than 22,500 new

visitors in 2008!

The last year has been a busy time redesigning the web-

site. Members will now see a grey bar on the right hand side

of the home page with a link titled “Sponsored Programs.”

Sponsors of the CRA website are allowed to upload educa-

tional content beneficial to CRA members such as accred-

ited programs, key articles and slide collections. I would like

to thank our current sponsors, Amgen Canada, Abbott

Canada, AstraZeneca, Roche Canada, and Bristol-Myers

Squibb, for their support.

The CRA Educational Committee, under the guidance of

Dr. Heather McDonald-Blumer, has been working diligent-

ly to create CRA-developed educational content. Through a

relationship with AdvancingIn Rheumatology, the

Education Committee has now posted four programs: The

Journey to Remission in RA, Germs & Blood Vessels, From

Bench to Bedside, and Vitamin D: The Silent Epidemic. We

encourage members to view these exceptional programs by

logging into the website and clicking on the link in the top

right corner of the page. The CRA’s home page has also

been modified with a new prominent area for website high-

lights, and an obvious link to the CRAJ.

There will be more exciting developments in 2009. Our

webmaster, Elisia Teixeira, has been working on a monthly

CRA website newsletter. The first edition was sent out in

April 2009, and stay tuned for the May 2009 issue. A career

centre, where members can post rheumatology jobs in their

local area, is also under development. Finally, a special cen-

tre for rheumatology program directors is being developed

as a repository for useful material.

Once again, thanks for your continued support of the

CRA website!

Andy Thompson, MD, FRCPC

Chair, CRA Website Committee

Staff, St Joseph's Health Care

London, Ontario

News about the CRA Website By Andy Thompson, MD, FRCPC

I need more than juice to get through this meeting... Editor at work or is he asleep?


JOINT COMMUNIQUÉ



The members of the Human Resources Committee

agree that there are not enough rheumatologists in

Canada to meet population and patient demands.

An effort was made to “guesstimate” a desirable ratio of

rheumatologists to the Canadian population.

In areas where the average population age is elevated, or

where certain ethnic/racial groupings have higher disease

prevalence, it was suggested that a ratio of one full-time

equivalent rheumatologist to 50,000 to 75,000 population

might be a reasonable figure. This assumes that the

rheumatologist is seeing new patients for 45 minutes,

and follow-ups for 15 to 20 minutes. It was noted that

this patient timing made for a very busy day.

During the meeting, it was proposed that some demo-

graphic data collection at the time of the payment of the

annual dues might help in obtaining a better idea of

where rheumatology need is most severe.

A discussion of the arthritis health professional’s

(AHP) role in a rheumatology clinic revealed varying

experiences. Some had a very positive experience even

though funding was provided entirely by the rheumatol-

ogist involved. Others found that the AHP’s presence cre-

ated more work for the rheumatologist. There was cer-

tainly a need for various models to be explored.

Governments need to be told that such models need to

be evaluated on the basis of care effectiveness, not

whether the model is cost neutral or cost saving.

Barry Koehler, MD, FRCPC

Clinical Professor Emeritus, Department of Medicine,

University of British Columbia

Richmond, British Columbia

I wear it because I like red, and besides, it matches my underwear.

Not Enough Rheumatologists: HR CommitteeBy Barry Koehler, MD, FRCPC

They just found out that neither one will receive the DistinguishedRheumatologist award. They are half way there—they are Rheumatologists!


JOINT COMMUNIQUÉ



EDITORIALHALLWAY CONSULT

H1N1: Staying Vigilant During aPandemic Interviews with Drs. Donald Low, Anthony Russell, Paul Haraoui, Janet Pope and Ted Ralph.

The World Health Organization (WHO) declared the

H1N1 flu virus, or Swine Flu, a pandemic on June 11

leading rheumatologists to face a difficult decision.

Will they continue to prescribe immunosuppressive ther-

apies even if these therapies leave their patients immuno-

compromised?

Dr. Anthony Russell, Dr. Paul Haraoui and Dr. Janet

Pope, with a few comments from Dr. Ted Ralph, an infec-

tious disease expert, tackle this question in this issue’s

Hallway Consult to determine how or if their patient

care/procedures would alter during a Swine Flu pandem-

ic. As well, Dr. Donald Low, the microbiologist-in-chief at

Mount Sinai Hospital in Toronto, lists possible treatment

and preventive care options for immunosuppressed

patients during an H1N1 outbreak.

Swine Flu Around the WorldThe H1N1 flu virus, or the Swine Flu, has caused havoc in

the spring and summer months for people worldwide. The

virus presents with symptoms such as fever, fatigue, lack of

appetite, coughing, vomiting and diarrhea. There had

been more than 3,500 laboratory-confirmed cases of

H1N1 as of June 12 in Canada, with the average age of the

infected being 22 years. From those cases, 182 individuals

had been hospitalized and four Canadians had died

according to Health Canada. As of June 15, the WHO

reported the H1N1 flu was found in 74 countries, with

nearly 36,000 laboratory-confirmed cases, and 163 deaths

worldwide.

However, the H1N1 mortality rates appear, thus far, to

be equivalent to seasonal influenza if the virus’ death toll

were to continue at its current rate, says Dr. Low. In

Canada, nearly 20,000 Canadians are hospitalized during

the November to April flu season, with nearly 4,000 to

6,000 deaths depending on the severity of the illness that

year. The WHO states there are reports of three to five mil-

lion severe cases, and 250,000 to 500,000 deaths per

year. People older than 65 years and children younger

than two years are the most at risk.

Unknown VirusUnlike influenza or seasonal flu, there is still much that is

unknown about the Swine Flu, which could lead to prob-

lems during a pandemic. “If you had, for example, a pan-

demic that followed the classic pattern of about six to

eight weeks, then [a patient taking immunosuppressive

therapies] could go on prophylactic antibiotics or antivi-

ral drugs for that time period,” says Dr. Low. “However,

with this virus, as with all these things, each one has its

own story. So, it might not be as simple as six to eight

weeks. This [pandemic] might last from 12 to 16 weeks,

and then it might become rational [for the patient] to stop

taking their medication.”

Yet all the rheumatologists interviewed agreed that they

would not stop the administration of immunosuppressive

therapies to their patients during a pandemic. “At this

point, we frankly don’t know how much more severe it is

[than influenza]... But I would regard this as any other flu,

accordingly and appropriately,” says Dr. Russell, a rheuma-

tologist from Edmonton.

Preventive MedicineDr. Haraoui, a rheumatologist in Montreal, lists four key

steps to help prevent or to help limit exposure to the

Swine Flu:

1.Tell patients to consider H1N1 as any other infection,

and reiterate the message that patients receiving

immunosuppressive agents, including biologics, should

seek medical attention at the first sign of an infection.

This message should be especially conveyed to patients

Not all clinically significant questions have been definitively answered by randomized double-blind placebo-controlledtrials. The Hallway Consult department in the Journal of the Canadian Rheumatology Association will seek a consensusanswer from rheumatologic experts for your difficult questions. Please forward questions for future issues to:[email protected].



with other comorbid conditions (chronic obstructive

pulmonary disease, diabetes), and those treated with

prednisone. These risk factors have demonstrated an

increased incidence of serious infections in patients

receiving biologic agents. Patients should not stop their

biologic medication by fear of contracting an infection,

but only should stop if they become sick.

2.Patients should follow the recommendations of Public

Health authorities, which would include the avoid-

ance of travel to any endemic area or to areas with

large outbreaks.

3.In case the pandemic reaches Canada, patients should

avoid contact with people that are infected, and apply

basic hygiene recommendations (e.g., frequent hand

washing) after being in contact with the public.

4.Encourage all patients to get their influenza vaccine

and if there is an H1N1 vaccine available, in the fall. I

recommend the pneumococcal vaccinations as well for

all those who have not been immunized in the past few

years.

Dr. Russell also agrees that patients taking immuno sup-

pressive therapies should be vaccinated before beginning

the therapies. “I don’t think a [pandemic] will affect my [clin-

ic] management,” he says. “But I will certainly encourage my

patients to receive a vaccination if there is one available, and

to use whatever precautions deemed appropriate.”

Rheumatology Patients At RiskDr. Pope, a rheumatologist from London, says rheumatol-

ogy patients have an increased risk to develop infections

from common bacteria, viruses and other infections to

which most people are immune (e.g., tuberculosis reacti-

vation, histoplasmosis, fungal and PCP infections.) “There

is also debate about the vaccination against pneumococ-

cus in our population,” she says. “And whether those with

malfunctioning spleens, such as Felty's syndrome and SLE

with ITP, should be vaccinated.”

Dr. Pope also contacted Dr. Ralph, an infectious disease

expert. “Common sense prevails,” says Dr. Ralph. “Your

rheumatology patients with the new biological response

modifiers and other immunosuppressives are at increased

risk for all infections, epidemic or otherwise. These

patients are similar to our HIV and transplant patients,

and there are no universal guidelines.”

Dr. Low states that rheumatologists should tell their

patients that the virus is in the community and is pre-

dominantly found in children. If someone in the house-

hold is unwell with an influenza-like illness, patients

should distance themselves from them. “Just taking the

extra step of really trying to minimize your contact with

[an infected] individual is an important message for

[rheumatology patients],” says Dr. Low. “People have to

realize that they are at risk. They should try to minimize

contact with people who are sick, and if they become ill

themselves, they should seek medical care sooner rather

than later.”

ConclusionRheumatologists and their patients must remain vigilant,

keeping an eye out for possible infection, and continue

following standard preventive techniques (i.e., washing

hands, covering mouth with hand or arm while cough-

ing/sneezing). Though there is still much that is unknown

about the H1N1 virus, patients and their rheumatologists

should not panic, and should continue to pay attention to

news regarding the Swine Flu pandemic.

Sponsored by an unrestricted educational grant from Pfizer Canada.

Working together for a healthier worldTM

Publication of The Journal of the Canadian Rheumatology Association is madepossible through an unrestricted educational grant from Pfizer Canada.

Working together for a healthier worldTM

Not only has this year’s unstable economy affected

retirement plans of many Canadians, fear of an

H1N1 flu virus, or Swine Flu, pandemic has affected

the economy and travel plans of people around the world.

In this issue’s Joint Count survey, rheumatologists across

the country gave their feedback as to whether the recent

economic and health uncertainties have affected the way

they practice and care for their patients.

Even in these interesting times, 82.5% stated they have

not altered their plans to travel for professional or personal

reasons. Yet, 37.6% agreed that the current economic prob-

lems have had a significant impact on how they will save for

their retirement.

And retirement may be coming much sooner for some

than others, as nearly half of this survey’s respondents are

50 years of age or older. Thirty-two percent of those who

qualified to answer the question expressed concerns about

their savings in this economy, and reported having since

delayed plans to retire, while 19.8% strongly agreed and

have done the same.

The economy appears to slightly affect how rheumatolo-

gists run their practice or prescribe medication to patients

who may or may not be able to afford them. Thirty-one per-

cent of respondents disagreed that the economy has affect-

ed their prescriptions, whereas 21.9% agreed that the times

have affected their prescription choices.

Still, only 6.1% of all respondents strongly disagreed that

the economic and epidemic concerns of 2009 will be

resolved by this time next year. Perhaps these interesting

times will be over sooner than we think.

Congratulations to this issue’s Joint Count survey winnerDr. Anna Oswaldfrom Edmonton, AB

Strongly DisagreeDisagreeNeutralAgreeStrongly Agree

A. The current economic recessionhas caused me to choose differentmedicines for some of my patientsbecause of their inability to affordcertain drugs.

B. The current economic problemshave had a significant impact on how I will save in the future for myretirement.

C. (ONLY For Rheumatologists 50years of age or older) I havedelayed plans to retire (or slowdown the practice) because ofconcerns about my retirementsavings and the economy.

D. I am optimistic that these currentproblems (economic and epidemic)will be well on their way to a resolution by this time next year.

17.7%31.1%

24.4%

4.9%21.9%

6.7%13.9%

25.4%

16.4%37.6%

11.1%25.9%

19.8%32.1%

6.1%25.6%

33.0%

4.2%31.1%

11.1%

Interesting Times

JOINT COUNTJOINT COUNT

2. On a scale from 1 (strongly disagree) through 5 (strongly agree), please rate the following statements:



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