Welcome Back Rheumatology Fans,

Fatigue! The overlooked, underappreciated, oft ignored symptom associated with Arthritis. In this video I go into some detail about why it occurs and why it is so hard to manage, then explain the parameters we can use to actually make improvements!

Ideally watch the video but I have put a summary for you below.

Fatigue: The Most Under-Appreciated Problem In Inflammatory Rheumatology

In this episode, Jack explores what he believes is one of the most under-recognised and poorly managed problems facing people with inflammatory rheumatological conditions: fatigue. While joint pain, stiffness, and function quite rightly receive clinical attention, fatigue is often sidelined—despite being one of the most debilitating symptoms patients report and one of the hardest to treat medically.

Jack focuses specifically on auto-inflammatory rheumatological conditions such as rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, lupus, Sjögren’s syndrome, and polymyalgia rheumatica, rather than osteoarthritis or gout. He argues that fatigue in these conditions sits firmly within the therapist’s remit—not just physiotherapists, but all MSK professionals—because medication alone often fails to meaningfully improve it.

The episode breaks fatigue down into several key contributing factors. First is a literal sleep deficit. Many inflammatory conditions disrupt sleep, often waking patients in the early hours of the morning due to pain and stiffness. Over years, this creates a chronic lack of restorative sleep, often in people who are still working, raising families, and unable to flex their schedules.

Second is immune-driven fatigue. An overactive immune system requires energy and actively promotes tiredness as a protective mechanism—much like the exhaustion felt during flu or infection. In inflammatory disease, this process is switched on constantly, leading to a persistent, unrefreshing fatigue that is largely resistant to disease-modifying drugs.

Finally, Jack highlights muscle loss and deconditioning. Chronic inflammation can reduce muscle bulk, activity levels often fall after diagnosis, and even when disease control improves, muscle mass rarely returns fully to baseline. This means everyday tasks require more effort, accelerating fatigue.

At around the nine-minute mark, Jack emphasises a key clinical reality: fatigue is multifactorial, chronic, and difficult to “fix.” Patients cannot consciously control their immune system, and pacing strategies—while useful for some—are often impractical, particularly for younger patients with busy lives.

Welcome Back Rheumatology Fans,

You have Gout to be joking that I am discussing Gout again! Seriously, fascinating.

Article Link: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2844321

Watch the video → check out the article!

Or below is a summary:

People with gout are at significantly higher risk of cardiovascular disease, and this risk should be central to how we assess and manage them in clinical practice. In this episode, the focus shifts beyond gout as an episodic inflammatory arthritis and instead frames it as a condition with important long-term systemic consequences—particularly for cardiovascular health.

Evidence consistently shows that individuals diagnosed with gout have an elevated five-year risk of major cardiovascular events such as myocardial infarction and stroke. This increased risk is driven by two main factors. First, gout is a chronic inflammatory condition, and systemic inflammation is a well-established contributor to cardiovascular disease. Second, many of the risk factors associated with gout—such as obesity, hypertension, metabolic syndrome, smoking, and alcohol consumption—overlap with those seen in people at high cardiovascular risk. The combination of these mechanisms means that gout should prompt clinicians to think well beyond joint symptoms alone.

A large, robust study involving over 100,000 patients explored whether achieving effective urate control could influence cardiovascular outcomes. Participants with gout were treated with urate-lowering therapy, commonly allopurinol, and outcomes were compared between those who achieved a serum urate level below 6 mg/dL and those who did not. This “treat-to-target” approach resulted in a meaningful reduction in cardiovascular disease risk over five years when compared with usual care.

Importantly, the benefits were not limited to cardiovascular outcomes. Patients who achieved the target serum urate level also experienced fewer gout flares, reinforcing that this biochemical target is clinically meaningful and reflective of effective disease control. In addition, subgroup analysis showed that patients who already had a higher baseline cardiovascular risk—such as those with hypertension or a family history of cardiovascular disease—derived the greatest relative benefit. In other words, the people who stand to lose the most from cardiovascular events may also gain the most from optimal gout management.

For clinicians working in rheumatology and musculoskeletal care, the implications are clear. A diagnosis of gout should act as a trigger for broader cardiovascular risk assessment. This includes monitoring serum urate levels and aiming for a target below 6 mg/dL, but also addressing modifiable lifestyle factors. Reducing alcohol intake, managing body weight (particularly abdominal adiposity), smoking cessation, and supporting physical activity are all key components of comprehensive care. Pharmacological urate-lowering therapy and lifestyle interventions should be viewed as complementary rather than competing strategies.

Physiotherapists and other allied health professionals have an important role to play in recognising cardiovascular risk factors, reinforcing health behaviour change, and ensuring that concerns are escalated appropriately to medical colleagues when needed. Even when cardiovascular management falls outside our direct scope, identifying and flagging risk can make a meaningful difference.

Ultimately, treating gout effectively is not just about preventing flares—it is about improving long-term health outcomes. By adopting a treat-to-target approach and integrating cardiovascular risk reduction into routine care, we can significantly improve both joint health and overall wellbeing for people living with gout.

Further Resources

https://rheumatologyphysio.substack.com/p/investigating-gout

Welcome Back Rheumatology Fans,

Every once in a while, I get really excited. This is one of those once in a whiles…

This Study (please go and download it etc so it counts for the authors stats and such) aimed to develop and initially validate a scoring system to aid us clinicians decision making for referral to Rheumatology in young people with possible Juvenile Idiopathic Arthritis (JIA).

THANK YOU to the authors, I don’t know if I always say that enough.

The Study

Very briefly because the study design is not the crux of this post.

The authors had 342 patients 61 (18%) of which had already been diagnosed with JIA. These were all under 16 and were presenting with joint pains being the primary reason for attendance.

Their exclusion criteria included presence of fever (which is a primary symptom of systemic JIA and is a very important separate factor).

They collected data from the patients at initial assessment, the patients were diagnosed or not with a specialist with JIA and then the authors did some clever statistical calculations to generate the scoring system.

So basically, they gathered information, then the patients were diagnosed and then the authors worked out which were the most useful questions and assigned a scoring system to them based on statistical analysis.

The Scoring Criteria

The important part for MSK Clinicians, GPs, and anyone else seeing under 16s with joint pains.

The authors recommend a score of 3+ providing a sensitivity of 95% bearing in mind this was an initial validation study as they were developing the score.

If you use the score you MUST consider your own clinical reasoning and if you are ensure at all, seek advice. This score is still in relatively early in its validation and should not be relied upon too heavily.

I have replicated this from the article material as I cannot currently find a downloadable/printable version.

Useage Of The Tool

Practically this tool is for use when your presenting patients primary complaint is joint pain WITHOUT fever. Of course we would also have considered other relevant pathology and mechanisms of injury.

A score of 3+ on the tool supports referral to Rheumatology for further consideration the person has developed Juvenile Idiopathic Arthritis.

I cannot stress enough that if you are not sure - get some advice!

Further information on Juvenile Idiopathic Arthritis

Welcome Back Rheumatology Fans,

2026… The year of the GLP-1 Agonist?

Video Summary

In this video, Jack, The Rheumatology Physio, discusses the rapidly growing interest in GLP-1 agonists (such as Ozempic) and their potential role in rheumatology and inflammatory arthritis. I reflect on the increasing public and clinical attention these medications are receiving, particularly as many people report improvements in chronic inflammatory and autoimmune conditions alongside significant weight loss.

GLP-1 agonists mimic the body’s natural GLP-1 hormone, helping regulate blood sugar, suppress appetite, and promote weight loss. The key rheumatology question, however, is why some people with conditions such as rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and osteoarthritis are reporting symptom improvements while taking them.

There are two likely mechanisms. First, excess abdominal fat is immunologically active and raises the body’s baseline level of inflammation, which worsens arthritis symptoms and disease activity. By reducing this fat, GLP-1 drugs may lower systemic inflammation, creating an anti-inflammatory shift. Second, emerging evidence suggests these drugs may also directly interact with inflammatory and immune pathways involved in autoimmune disease — meaning their benefits may go beyond weight loss alone.

However, at present, GLP-1 agonists are not formally prescribed specifically to treat arthritis. They are currently used for weight management, with any improvement in arthritis considered a secondary benefit. His practical advice is for people with inflammatory arthritis and excess body fat to discuss GLP-1 therapy with their GP or rheumatologist as part of a broader medical plan. He predicts that dedicated rheumatology use of GLP-1 drugs is likely to arrive in the near future as evidence grows.

Welcome Back Rheumatology Fans,

I have previously commented that “weight loss for Osteoarthritis is the best bang-for-buck treatment we have currently”:

This slide occasionally gets me in hot water with other Physio’s and MSK Professionals but that doesn’t matter to me really, I stand by it and if anything I am becoming more wedded to this stance.

Anyway… Ben Steele-Turner is an unstoppable force of Osteoarthritis information and dietary advice. I have shameless updated much of my teaching based on his answers to my questions.

NOW HE IS PUBLISHING AS PART OF HIS PhD. His first article is open access HERE.

I have written a short summary below but please click on the link and read the article in full.

Physiotherapist-Led Weight Management for People with Osteoarthritis

This scoping review provides the most comprehensive overview to date of how weight management (WM) is currently understood, implemented, and perceived within physiotherapist-led care for people with osteoarthritis (OA). With 79 records included across 22 countries, the review highlights substantial variability in practice, persistent uncertainty around scope of practice, and a widespread need for improved training and confidence among physiotherapists.

Why Weight Management Matters in OAThe evidence linking excess bodyweight to OA (particularly knee OA) is robust. Weight loss of as little as 7% can reduce pain, while more significant reductions can slow structural progression and reduce joint replacement risk. Despite strong guideline recommendations, weight management remains underprovided in OA care. Physiotherapists, who frequently work with people with OA and often have longer consultation times, may be well placed to address this gap.

Current Practice: Highly Variable and Often MinimalAcross studies, the proportion of physiotherapists who reported including weight management ranged from very high (over 80% in some survey responses) to extremely low when actual practice was audited. For example, only 12% of individuals with knee OA in one prospective study reported receiving any weight management support during physiotherapy, and note audits showed weight management discussions documented in only about 10% of encounters. People with OA also consistently reported that weight management was either not addressed or addressed only superficially.

Scope of PracticePhysiotherapists and people with OA expressed mixed views about whether weight management should fall within physiotherapy’s remit. Many clinicians felt it sat outside traditional physiotherapy roles, often preferring referral to dietitians (admittedly I do this!). However, people with OA who participated in a physiotherapist-led diet-plus-exercise trial reported positive perceptions, especially when physiotherapists had received additional training. This suggests that scope-of-practice concerns may be alleviated when physiotherapists feel more adequately prepared.

Confidence and SkillsA recurring theme across the literature is discomfort discussing weight. Physiotherapists commonly feared damaging rapport, felt unsure how to raise weight sensitively, or believed that effective weight management strategies were outside their expertise. Many reported feeling untrained in nutrition or behavioural counselling, and physiotherapy students also identified weight management as a major skill gap.

These concerns were echoed by people with OA, who sensed that physiotherapists had limited time and limited practical advice to offer. When weight management was addressed, it was often brief, generic, and lacking actionable support.

Education Changes PracticePromisingly, trials of targeted weight management education, such as e-learning modules or structured upskilling programmes, showed clear improvements in physiotherapists’ confidence, knowledge, and attitudes. One physiotherapist-led intervention combining exercise with a structured very low-energy diet yielded clinically significant weight loss and symptom improvements, demonstrating feasibility and safety when clinicians are appropriately trained.

Further Resources

Welcome Back Rheumatology Fans,

I recently spoke at Clockwork Medical’s Event - Power Up To Play | Lower Limb Symposium on Rheumatological Contributors In Lower Limb Tendinopathies. This reminded me of a particular case I worked with successfully a few years back.

I introduce a case focused on managing an insertional Achilles tendon problem in a young rugby player with psoriatic arthritis (PsA).

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Welcome Back Rheumatology Fans,

We are going fully deep dive on a specific topic this week on one of my favourite soap boxes because this suits my bias in a lovely way.

Here is a link to the full article PDF or Site Link

The Johnston County Osteoarthritis Project (JoCoOA) offers a rare, longitudinal look at the burden of hip symptoms, radiographic hip osteoarthritis (rHOA), severe rHOA, and symptomatic radiographic hip OA (sxHOA) over nearly three decades. Across five time points from 1991 to 2018, this large, population-based cohort of adults aged ≥45 revealed a consistent and rising prevalence of structural hip changes. The most striking finding is the substantial increase in rHOA: from 28% at baseline to 53% by 2017–2018. Severe rHOA also rose from 2.5% to 9%, and symptomatic rHOA increased from 10% to 15%. By contrast, hip symptoms alone remained relatively stable over time, hovering around the low-to-mid 30% range.

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