Rheumatology

The Early Arthritis Service streamlines patients with suspected inflammatory arthritis and provides rapid access to a multidisciplinary clinic which  offers consultant assessment, ultrasound scans, drug counselling, education services and physiotherapy.

Is a clinic in which combined assessments of patients occurs concurrently within dermatology and rheumatology. This clinic is for complex problems in diseases which can affect both skin and joints, such as scleroderma, lupus and psoriatic arthritis.  Referral is usually ‘tertiary’ and usually an opinion/decision is sought, after which the patient is referred back to the original referring physician.

The Paediatric and Adult Rheumatology Teams actively encourages young people with long term health conditions to understand and learn to manage their own health as we know this can lead to better health outcomes.

Our aim is for young people to become confident when meeting doctors and that they are able to put their worries across and take an active part in their healthcare decision making.

We have a dedicated Transition plan for each young person and we will support you through the process using the “Ready Steady Go Programme”. You can view the questionnaire forms below.

We always try to do this in conjunction with the families and carers so young people grow in confidence in the management of their condition.

Transfer to adult services takes place between the ages 16-18 years, and young people generally have the opportunity to meet the Adult Rheumatology Consultant and Nurse Specialist who will be taking over their care before they move on to this team in a dedicated transition clinic.

Useful Links/Forms

• Arthur’s Place
• Ready Steady Go
• Ready Steady Go Transition Programme
• Ready Steady Go Questionnaire (Getting Ready)
• Ready Steady Go Questionnaire (Steady)
• Ready Steady Go Questionnaire (Go)

Is a specialist clinic for patients whom have a rheumatology condition which is also affecting the kidneys. In this clinic patients are reviewed by a Renal and Rheumatology consultant as well as a specialist nurse where a holistic approach can be used to treat and stabilise active disease and preserve renal (kidney) function. These may include conditions such as Lupus and vasculitis that can require close monitoring at the beginning.

We also work in collaboration with fracture liaison and the DEXA scanning department (A DEXA scan is a special type of X-ray that measures bone mineral density (BMD).) To provide DEXA reports to primary and secondary care teams across the region. We also provide specialist assessment for patients with complicated osteoporosis and bone disorders.

Patients can be referred to Physiotherapy and Occupational Therapy at all stages of their diagnosis.

What is physiotherapy?

Physiotherapists help people affected by injury, illness or disability through movement and exercise, manual therapy, education and advice. They maintain health for people of all ages and help patients to manage their condition. The profession helps to encourage development and recovery, enabling people to stay in work while helping them remains independent for as long as possible. (Chartered Society of Physiotherapy, 2018)

Physiotherapists in Rheumatology will carry out detailed patient assessments to:

• Understand how your condition affects you physically and what impacts in your day to day life, plus, how it makes you feel. This may be looking at weakness, loss of movement and difficulties with day to day tasks e.g. walking, cooking, hobbies, work etc.
• Assess your body to get an understanding of how you’re moving and how your muscles are working.
• Look at any special equipment requirements such as walking aids.
• To look at how you manage your condition and coping strategies that you can use day to day.
• Point you in the direction of other health professionals, such as Occupational Therapists whom we work closely with, or services within the trust and wider community that could support you further.

The Physiotherapy team will discuss assessment findings with you and create a plan to help you achieve the things you want to improve. This may be by including range of movement and strengthening exercises, improving mobility and increasing overall fitness whilst finding the right balance between rest and activity. The physiotherapist may help you to understand your condition, plus, guide you on how to best manage your symptoms going forward. We use a variety of treatment approaches to help achieve your physiotherapy goals.

What do we do?

Patients can be referred to Occupational Therapy at all stages of their diagnosis.

Occupation as a term refers to practical and purposeful activities that allow people to live independently and have a sense of identity.

(The Royal College of Occupational Therapists, 2019)

Occupational Therapists, ensure that patients can complete meaningful occupation as independently as possible, for as long as possible.

Leisure: this refers to any hobbies or activities that someone may complete in their spare time. Such as; sports, reading, talking on the telephone.
Productivity: this may include both paid and unpaid work. For example caring for family members, paid jobs, and household preparation such as food preparation and house hold activities.
Self-care: this may include personal tasks such as toileting, showering and grooming. It also includes mobility within activities for example getting on and off the bed, walking around a shop and home.

Occupational Therapists look at patients lives as whole and consider the impact someone’s diagnosis, both mentally and physically may have on their daily activities.

This may be through joint protection advice, equipment provisions, splinting and hand exercises including hand wax, fatigue and sleep management advice, support with chronic pain this may include mindfulness and emotional support, and onward referrals such as aids and adaptations for difficulties at home.

• Contact Us – Equality Together
• Exercises for healthy joints | Back, neck, knee and foot exercises
• Exercises for the fingers, hands and wrists
• Fitness Studio exercise videos
• Musculoskeletal (MSK) Physiotherapy
• MyWellbeing IAPT Service Bradford
• NRAS | Support for living with RA
• The Sleep Council

How to manage a flare up

A flare can be short lived lasting several hours or more severe lasting several days or weeks. Managing a flare can be frustrating especially if it is affecting your ability to perform basic daily tasks.

A flare can happen at any time especially during periods of stress or infection. Over time patients often become more familiar with recognising a flare and how to manage these. A flare can start with either increased joint pain or stiffness or swelling with heat or redness to a joint.

A flare does not necessarily mean that your medication is not working or your arthritis is becoming worse. It can take up to three months for a new medication to work for arthritis, and you may need a combination of drugs until you find the right one which helps control your arthritis. Everyone is different and what works for one patient may not work for another.

If you have one joint that has become swollen, red and hot to touch and you feel you have fever you may have an infection in that joint-this is a medical emergency, and you should attend A/E as you may need to have fluid drained from the joint along with a course of antibiotics.

Often simple self-management techniques (see below) and a few days rest are enough. It is a good idea to keep a record of your flares, if flares are becoming more frequent or lasting longer then medications may need to be adjusted; this is when you would need to contact our advice line to discuss a review. Assessing your symptoms and taking blood tests does help to determine whether your disease is becoming more active and less well controlled or whether experiencing increased pain is caused by other reasons.

Simple tasks you can do to help yourself during a flare-up:

• Ensure you are taking your medication at the dose and frequency prescribed.
• Take pain relief at regular intervals and as prescribed.
• Get rest and relaxation early on.
• Do gentle exercise; this can help with relieving stiffness.
• Use heat on a joint or take a warm shower or bath to relieve early morning stiffness and pain (see below).
• Use cold items on a joint such as a bowl of cool water or ice packs (see below).
• Wear the correct shoes; often foot wear that gives better support or has thick spongey soles are more comfortable.
• Use aids, such as a stick to support a knee flare or gadgets to open jars.
• Speak to those around you and let them know why you are not coping so they can help and support you. Asking for help only when you feel you need it gives a sense of still being in control.

Learn about your condition the more you know this easier it is to manage, start by viewing these links:

• Managing flares
• Managing your symptoms

You may also find our trust physiotherapy web page useful which has resources on pain to specific parts of the body: Musculoskeletal (MSK) Physiotherapy

Tips on using heat: Using heat therapy either dry or moist can help to relieve pain in a muscle or joint. Dry heat such as a hot water bottle, heat lamps, wheat bag or deep heat creams can be useful but ensure the item is not too hot and you protect your skin with a towel. Check the skin regularly to ensure it is not burning. Wet heat can be things like a warm shower or bath, or a bowl of warm water. Gentle heat will be enough you do not want to burn or scold the skin.

Tips on using cold: Some patients find cold works better at calming an inflamed (red/hot) joint. Use a bowl of cool water with ice cubes for hands and feet or wrap a towel round a bag of frozen peas/beans as a moulded ice pack. A damp towel or flannel kept the fridge or wrap ice cubes in a plastic bag or towel. Always monitor your skin and remove the ice pack if the skin turns bright pink or red, the key is cool not ice cold.

Relaxation: Having a flare can be stressful but do not panic relaxation techniques can help. Ensuring good rest does not mean just taking things easy it means learning how to let go of physical tension and emotional stress, relaxing both the body and mind. Being in pain over long periods of time can mean becoming emotionally and mentally tense without realising it, leading to being “trapped” in a cycle of pain. Relaxation techniques can help to break this cycle and help to reduce pain but it takes practice, once learnt it can be done anywhere. Mediation, deep breathing techniques and guided imagery are some methods along with mindfulness or gentle yoga. No method has shown to be better than the other just find the one or ones that works for you. Apps such as Headspace are useful or ask your local library if they have any books or tapes on relaxation.

Breathing exercises for stress

Importance of Sleep: Having the right amount of good quality sleep has many beneficial qualities for your physical and mental health, evidence shows it is just as important as a healthy diet and regular exercise. Good sleep helps your body to repair itself and improves your body’s natural defences against illness and injuries. Poor sleep can leave you with poor concentration, lacking in motivation and increase your pain levels.

Establishing good sleep habits (sleep hygiene) can help. Try keeping fixed times to go to bed and waking in a morning rather than napping throughout the day. Create a relaxing bedtime routine such as a warm bath, soft music or reading. Avoid caffeine, alcohol, nicotine or eating big meals before bed. Maintain a comfortable sleeping environment that is not too hot, cold, bright or noisy.

Some people find changing their thought process to a more positive mind set helps them to cope better. But this is not for everyone and some find it easier than others. If you want to give it a go try focusing on the things you can do instead of the things you cannot. Diversion and distractions is a methods used to divert your pain by performing activities you enjoy or interest you. To read more around this then follow the links below:

• Why is sleep important?
• Sleep
• Sleep and tiredness

If you have tried the above the next option may be to assess the joint and offer a joint injection if suitable.

Injection of the joint(s) with steroid is sometimes helpful; however, if more than one joint is affected, your medication may need adjusting. Steroid injections are not given as a means of routine treatment but used only when there is a significant amount of inflammation. (Steroids Information Booklet)

You might not be able to start steroids if you have an infection, or if you have any wounds on your body, as steroids might delay these getting better or mask some symptoms.

Steroids can have an adverse effect on some medical conditions, such as diabetes, heart or blood pressure problems, or mental health issues. If you have any of these conditions, the person treating you will need to make sure the steroids will not make these conditions worse.

If you have suffered an injury please see your GP, contact NHS 111 or attend your local A&E department. If you’re GP have ongoing concerns they may refer you for further treatment.

We will discuss the results of any investigations at your next review, or sooner if appropriate. A copy of your results will be available to your GP. We do not routinely contact you with result unless deemed as urgent. The secretaries cannot give results over the telephone but often the consultants will write explaining test results.

Calls to Rheumatology are made by ringing Central Booking on 01274 274274.

This is not an emergency service. It is for you to use if you are worried about any of the following:

• If you have a ‘flare’ of your symptoms that has not responded to your usual self-help treatments and you would like further advice.
• If you have side effects from the medication prescribed for your arthritis.
• If you have been asked by the Rheumatology team to report your progress.
• If you have other questions about your condition or treatment.
• If you have urgent worries or concerns about your Rheumatological condition that cannot wait until your next appointment.

For any general medical enquiries you should contact your GP in the first instance. If out of hours then please try 111.

Some of the drugs used to treat arthritis can harm an unborn baby. We recommend that you let your rheumatologist know if you are planning to become pregnant or planning a family.

Your treatment may need to be changed before you stop using contraception.

If you are pregnant and this is unplanned or not expected, then stop your medication and contact your GP and the Rheumatology Advice Line. Unless this is a steroid medication such as Prednisolone; in which case you should then continue this until you have spoken to our department for further advice.

A guide for employers on how to support employees living with RA:

This booklet has information about rheumatoid arthritis (RA), how it can affect people at work, the kind of difficulties it can cause and how these may be overcome. It also includes up to date information on where employers can go for help and advice on the law relating to disability, on best practice and on making reasonable adjustments for employees at work.

• An employer’s guide to rheumatoid arthritis
• Versus Arthritis: How can I get the right support?

You can request a copy of your last clinic letter which often contains the information needed when making a claim.

We do not do assessments or supporting letters for Blue Badge applications even though the Council has stated this on their letters. The council is responsible for doing these assessments but stopped due to Covid. The correct process should be that the council follow their own guidance and carry out their own assessments with their own medical professionals.

Yes, there are research trials taking place at Bradford supervised by our dedicated research team-your consultant may discuss this with you if they feel you are suitable for a study, or speak to our team to find out more if you are interested in taking part.

Medications in Rheumatology require regular blood tests especially until stable on the drug to ensure you are safe taking the medication and it is working. Also it ensures we are prescribing the medications in a safe manner.

It is important to note that all blood values will fluctuate slightly and usually no further action is needed-if there are any abnormalities that require further assessment we would contact you to discuss the results.

We do spend a considerable amount of time checking results and it would be very helpful if you can ensure you attend for blood tests when asked/directed by our team.

Adult Phlebotomy / Blood Test – Appointment Booking

Due to Covid-19, Bradford Teaching Hospitals NHS Foundation Trust is currently operating a booked appointment service instead of the usual drop-in clinics. The appointment service is running from our St. Luke’s site.

Please ring 01274–365056 or 01274-365170 to make an appointment to have your blood test done. Alternatively, you can book your own blood test appointment by using this link: https://my.drdoctor.co.uk/clinic/bth-bloodtest

Phone lines are open Monday to Friday between 8.30am and 4.00pm. The lines do get busy so please leave a message if they are engaged.  Calls will be answered within 24 hours.

PLEASE REMEMBER TO BRING YOUR BLOOD FORM WITH YOU IF YOU HAVE ONE.

Please do NOT attend for your appointment if you are showing symptoms of Covid-19. Call the number above or log in using the link provided to cancel your appointment until you have recovered fully.

Some GP’s are still happy to book patients in at the local surgery for blood tests but due to Covid many have had to reduce the service dramatically. If you would like to attend your GP  then please contact them.

The majority of medications can take on average 12 weeks to be effective, particularly if they require a gradual dose increase. Some people notice an improvement earlier than this.

This will have been discussed at your clinic appointment but if you are unsure then it is safer to ring our Rheumatology Advice Line for clarification.

This would depend on the type of medication you are taking, the reason for your admission and the type of surgery.

If it is an acute admission the admitting team may stop your medications as it is deemed necessary to treat you, but they often contact the on call Rheumatologist for advice. On discharge from hospital if you are unclear if you can restart your rheumatology medications then please contact us via the Advice Line by ringing 01274 274274

Some treatments may need to be stopped before surgery, and can usually restart after surgery, once the wound is healed and you are free of infections. Surgical teams often ask that you contact us to check this before stopping or restarting treatments.

No, we recommend that you continue on your medication, unless you are prescribed antibiotics then stop until you complete the course.

There are a group of medications called Bisphosphonates which can interfere with dental healing; please check with your dentist if you are on this medication and need dental work.

Most patients stay on their medications for a number of years. The aim of treatment is to get the condition into remission, which means a significant reduction in the symptoms of inflammation, but it doesn’t necessarily mean that the condition has gone.

Not everyone will be able to stop their medications, but most should be able to reduce the dose and number of medications they take once their disease is under control. We will aim to ultimately get you on the minimum amount of medication to keep you well.

With any chronic inflammatory condition flares may occur and should not be seen as a sign of treatment failure, though if your flares increase in frequency or severity we will need to adjust or increase your treatment.

Some patients can stop their medication altogether once their disease is controlled and is in remission but in some instances your consultant may recommend you continue your medication lifelong.

Some medicines used to treat your arthritis are processed by your liver, and when taken with alcohol can increase the risk of liver side-effects.

We recommend that you have no more than 14 units of alcohol a week. (Calculating Alcohol Units)

Some of the medication can cause side effects, often these are mild and wear off once the body gets used to the medication. The most common are feeling bloated (like you have eaten a big meal), mild nausea (feeling sick) and loose stools (very soft poo). Anything listed below which you feel is severe and failing to settle then please stop your medication and book an advice line call.

• nausea
• diarrhoea
• vomiting
• headache
• dizziness
• mouth ulcers
• sore throats
• rashes

Rarely, patients can develop shortness of breath and/or a dry cough, which may require further investigation.

It is important to report any side-effects, even if not listed above, and seek advice from your GP and the Rheumatology team about continuing treatment. It is safer to stop the medication and wait for advice then continue unless you are taking a steroid such as Prednisolone.

Please read all information provided by our team about your treatment carefully so that you are familiar with any potential side effects.

Injection site reactions include redness, itching, pain or swelling at the injection site. They mostly occur one to two days after an injection and go away within three to five days. They are most common during the first few months of treatment.

• It may help to apply a cold compress to the site
• Anti-histamine tablets or creams available from your chemist can help
• Check your injection technique – we may need to check the way you are doing the injection
• Remember to change the injection site each time you give the injection

If you have pain, redness, or swelling around the injection site that doesn’t go away or spreads then stop and ring the advice line.

If your arthritis is particularly active, we may consider giving you a steroid injection to settle your symptoms, especially if you are waiting for new treatments to start working.

However, regular use of steroids can be harmful, so we do not routinely offer this before holidays or other special occasions.

There is no rule about the number of steroid injections a person can have, but long-term continued steroid use is associated with significant side-effects, so repeated injections are best avoided and should only be used if your condition has flared. This is the reason many doctors limit the number of injections they offer to patients. If a steroid injection wears off quickly, or does not improve things, then repeating it may not help either.

If you need steroid injections often, it may be a sign that your disease is not well-controlled, and we may need to think about making changes to your medication.

We would not recommend having more than 3 steroid injections in 1 year in order to reduce the amount of long term side effects steroids could potentially cause.

You may want to take your medication/injections with you, when you go on holiday depending on the length of your trip.

• Please ensure your blood monitoring is up to date before travelling. It would delay ordering medications if your blood tests are due.
• If you get your prescription from your GP, please get in touch with them in good time to request extra medication for when you are on holiday
• If we supply your medication, make sure you have sufficient supplies of your medication and ‘sharps’ bins for disposal of used syringes
• A travel letter can be requested via the advice line or the company who deliver your injections.
• Keep your medication in your hand luggage if you are flying.
• If your medication is a fridge item please ensure you have a suitable fridge to store your medication before you arrive at your destination.
• Some destinations may not have a good electricity supply. We have had some situations were medications had to be disposed as the fridge could not maintain a good temperature due to poor electricity supply.
• If you are abroad we cannot make arrangements for any extra medications to ship or prescribe. You would have to wait until you were back in the UK.

Ideally your medication schedule should not be interrupted as this increases the risk of your condition flaring. But if your disease is stable and you are only travelling for a short period then the decision to withhold for a week should not cause any great detriment, unless you have a more serious condition such as vasculitis or lupus, in which case you should always continue your medication unless told otherwise.

If you have weekly Methotrexate injections, it may be possible to have a small supply of tablets prescribed for you to use instead during your holiday, but this is not an option if you have previously been intolerant of these.

Please seek advice from the rheumatology team first prior to travelling.

Where possible, schedule tests for a week or so before your departure and as soon as possible after your return. We cannot prescribe medications if your blood tests are overdue as it would not be safe.

If you are planning an extended trip please discuss this with your Rheumatology team, as alternative arrangements may need to be made.

Always check over-the-counter medications for possible interactions with prescribed drugs. Speak to the pharmacist and inform them of all medications currently taken so they can advise.

Simple painkillers such as Paracetamol are usually safe, providing you do not exceed the maximum recommended dose and ensure that none of your prescribed drugs also contain Paracetamol, since this could result in accidental overdose.

Do not take over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs) such as Nurofen if you are already taking prescribed NSAIDs. Avoid NSAIDs if you have previously suffered any adverse effects or have a history of gastritis or stomach ulcers. Also avoid NSAIDs if you are asthmatic, have high blood pressure or take anti-coagulation medications, unless your GP or Rheumatology team advises you to take them.

Bring a list of all your medications with you to every appointment: we take all your medications into account when making prescribing decisions.

Complementary or herbal medicines may interact with prescribed drugs. If you wish to use these therapies, please discuss this with us at your appointment. For more information please visit Versus Arthritis https://www.versusarthritis.org/about-arthritis/managing-symptoms/diet/.

Your doctor will receive a letter regarding any changes to your treatment made in clinic and will renew your prescription. However, within the first twelve weeks of commencing a DMARD, you will receive your supplies form the hospital team until we know these are tolerated. This is known as a Shared Care agreement within the Yorkshire region.

Biologic drugs are the exception and are only prescribed via the rheumatology department. You will need to attend your clinic appointments and have blood tests as requested, for us to be able to do this. The prescription is then managed with the appropriate homecare delivery company.

Your prescription is managed by the rheumatology nurses in conjunction with the delivery companies. Usually the appropriate delivery company asks the nurses for your repeat prescription to be renewed well before it is going to expire but occasionally this does not happen in time.

The rheumatology nurses will renew your repeat prescription if you have attended your scheduled clinic appointments and had any relevant bloods or tests that have been asked for.

Please contact the company that delivers your medications to reorganise the delivery and ensure you are available on the given delivery slot.

If you have unresolved delivery problems and cannot solve these yourself with the company, please contact the rheumatology nurses and leave a message on the prescription line: 01274 365779.

Due to Covid there are staffing problems within pharmacy and with the delivery companies which is contributing to delays. The delivery company should supply you with their contact details on how to organise a delivery.

Please stop your DMARD medication whilst you have an infection requiring antibiotics. You should not stop taking steroids (Prednisolone) during an infection. Only restart once the infection is clear and any antibiotics are completed.

If you are on more than one medication such as methotrexate and sulfasalazine or methotrexate and a biologic (injections) then please stop both until the infection has cleared.

If you think you may have Covid then book a test if the result is positive stop your medication for 10 days. Do no restart if you have continued breathing difficulties or fevers, seek advice.  If you are taking steroids such as Prednisolone then do not stop continue this medication. Hydroxychloroquine can be continued but you may want to stop this is you are feeling unwell.

If you have not previously had chicken pox yourself and if you are on a drug that suppresses your immune system and you come in close contact with anyone who has chicken pox or shingles, you should contact your GP for advice as treatment may be required.

Close contact means being in the same room as someone who has shingles for more than 15 minutes or having immediate contact with someone who has shingles on many parts of their body or where it is exposed, e.g. on the face.

Where possible you should keep away from anyone you know who has chicken pox or shingles, if you have not previously had chicken pox yourself.

If your immune system is suppressed due to medication, it is particularly important that you are adequately protected. If you are receiving treatment with immunosuppressive drugs such as methotrexate, leflunomide, azathioprine, biologic therapies or high dose steroids you should avoid ‘live’ vaccinations as they are contra-indicated: these include oral polio vaccine, yellow fever vaccine and german measles (Rubella).

There may be inactivated vaccines available as an alternative-please check with your GP or your rheumatology team if you are planning to have vaccines for any reason.

If you are on immunosuppressive medications vaccinations are an important method of reducing complications and hospital admission from virus’s and infections. We recommend the Covid vaccine & boosters to all our patients as well as the yearly flu vaccination.

Some treatments may reduce the efficacy of the Covid vaccine-the team will discuss this with you when planning your treatment if appropriate. We would still recommend you have the vaccine so you can have some protection.

Likewise, the pneumonia (pneumococcal) vaccine is recommended for all patients with rheumatological conditions on immunosuppressive drugs. This should be repeated after 5 years, with a maximum of two injections per lifetime.

Regular exercise can boost strength and flexibility in everybody, including people who have arthritis and pain conditions. Stronger muscles can better support your joints and prepare you for your normal daily activities, while improved flexibility can help our joints feel less stiff.

Exercise can reduce fatigue and improve overall fitness. This can help manage stress, improve sleep, maintain a healthy weight and reduce the likelihood of developing preventable diseases such as heart disease, stroke and Type II diabetes.

Arthritis and pain conditions can also cause the muscles to become weaker that typically occurs as people get older. That’s why it’s important to do exercises that will build muscle, in addition to aerobic exercises, which strengthen your heart and lungs.

Weight-bearing exercises, such as walking, are important for bone health, which is important with arthritis and as we all get older.

Many people worry that exercising with arthritis could affect our joints and cause us to be in more pain. In physiotherapy, we are here to guide you and are able to show you exercises that are suitable for you and your condition and hopefully find something that is fun. Exercise comes in lots of different ways!

Its important to pace your activities, use our pacing leaflet to help with this. Also use of warm water or cool water can help regularly throughout the day particularly on a morning and during the night. Gentle exercises as found on our versus arthritis website link can be helpful to complete daily to improve lost strength.

You can attend equality together in Bradford who can help with signposting to more specific aids that may make things more helpful. You can ask for a referral to Occupational Therapy to help with signposting and problem solving.

The Sleep Council website have some handy tips for helping with sleep. Ensure you are comfortable, using techniques you find helpful such as warm water, pillows for support and avoiding increase use of light 90minutes before bed and over night. Use our sleep leaflet to help with some more helpful tips. You can be referred through to occupational therapy to help manage difficulties if they remain consistent.