Table 16.

Key Elements of Recurrent Counseling (Courtesy of LA Saketkoo, rights reserved)

Category	Sub-Category	Item	Advisements for Patients
VASCULAR	Raynaud	Prevention is key	- Related complications include DUs, calcinosis, osteolysis and core temperature loss - Initiate protective measure in anticipation of and upon noticing a cold atmosphere, before allowing oneself to ‘feel’ cold - Immediate action can result in decreased recovery time, pain and the sequela associated with loss of core warmth (fatigue, headache, incapacity etc.) - Avoid extreme temperature changes, e.g. from cold to warmth - Anticipate cold environments, e.g. air conditioning in summer, grocery store freezer aisle, hospitals etc.
		Core Temperature	- Exercise / movement increases circulation and body heat - Clothes layering and use of insulated vests
		Peripheral	- Gloves / socks always at hand - Should allow for a thin space to trap a warming layer of air - Pocket hand warmers, can be placed in pockets, gloves, socks, undergarments - Heated gloves / insoles/shoes
	Digital Ulcers / Calcinosis	Protection	Cushioned bandages for high friction areas Waterproof gloves for washing or handling wet items Bandage and gloves for handling dry household items potentially snagging healing ulcers and to protect from bacteria and chemical irritants Exercise gloves for use of gym equipment
		Pain management	- Protection as above - Topical lidocaine - Cleansing routine
		Signs of infection	- Increased pain/tenderness - Redness - Purulence
		Prevention	As much as possible avoid: - Cold exposure - Trauma Topical antibiotics with signs of infection
	Additional calcinosis	Advisement	- Avoid digging to prevent infection - If intolerable can try repeated soaking in warm Epsom salt water - Topical antibiotics
	Erectile dysfunction		- Increased physical activity may help protect circulatory and neuronal function - Preventive measures as for RP might have a protective effect
NUTRITION	Calorie intake	Nutritious	- Avocado - Nuts, nut butters - Cheeses, butter - Potatoes, rice - Olive and other oils
	Food Tolerance	Nutritious	- Pureed foods (soups, dips, stews) - Smaller amounts of a food - Foods softened (marinated) with small amounts of citrus or vinegar - Mobility after eating to increase motility
HEENT	Oro-facial		Facial Exercises and Massage for skin tightness, mobility and circulation
	Oral		High risk for dental complications: - Essential follow-up with a dental clinician sensitive to SSc care or perhaps pediatric dentist - Proactive dental care - Keeping mouth moist - Adapted and powered devices for teeth and oral care
	SICCA		Wetting and pro-salivation products Possibly singing, humming, chanting and exercise
CARDIOPULMONARY			Graded exercise essential to health
			Control of GERD and PND to avoid lung injury from micro-aspiration
			Vaccination for prevention of infection
	PH and Cardiac	Monitor for symptoms of heart failure	Daily weights as needed; recording of post-void morning weight Alert MD of new onset lower extremity edema
GASTROINTESTINAL
	GERD	Esophageal Injury & Lung Risks	Reflux in SSc is a serious issue of which related injury can lead to multiple complications that impact mortality. - Often exists without pain - Pain not equate severity - Esophagitis - Esophageal cancer - Dysphagia and potential loss of swallow function - Strictures & Webbing - Need for esophageal stretching - Acid aggravates lung disease
		Medications	- PPI daily or twice daily, especially with esophagitis or esophageal ulcer - Adding PRN or OTC agents (e.g. sucralfate, H2 blockade) -- it is perceived that in SSc the benefits of PPIs greatly outweigh associated risks
		Sleep Essentials	- Head of Bed Elevation (wedge pillow, leveraging mattress, bricks/books under bed legs) - Avoid right side lying
		Reflux hygiene	- Smaller, more frequent meals - Avoid meals 2–3 hours before lying - Avoid sphincter relaxants at end of day e.g. alcohol, chocolate, caffeine, mint etc.
	Gastroparesis		- Sleep and hygiene as for GERD - Exercise / walking may help - Gravity strategies for passive digestion  - upright position  - attention to food consistency e.g. thinner foods - Gastroparesis dietary suggestions for food tolerance
	Bloating		- Exercise for motility - Small frequent meals
	Nausea	SSc or Medication related	- Mobility / exercise to decrease nausea - Ginger sweets, drink - Sucking candies - Cold pops - Instruction on PRN anti-emetics
	Diarrhea	SSc or Medication related	Logistics until controlled: change of clothes, time planning Medication use: risks / benefits / when
MEDICATION	See Appendix of Medications
VACCINES	See Table 17		Pneumococcal immunizations per CDC guidelines Influenza annually Herpes zoster (killed only i.e. Shingrix) COVID-19
EXERCISE			Improves: - Circulation and vascular responsiveness - Body warmth - Sleep - Self-Esteem - Breathlessness - Joint mobility stiffness and lubrication - Skin function - GI function - Possibly erectile function - Nausea - Salivation - Respiratory performance - Cognitive clarity Decreases: - inflammation - Pain (anywhere) - Joint stiffness - Possibly contractures - Possibly skin tightness - Depression - Stress - Fatigue
WOMEN OF CHILD-BEARING AGE	Medication toxicity		- Use of contraception essential with specific IS and PAH medications - Discontinuation of specific IS or PAH medications prior to conception
	Conception		- Must be a planned - Medication washout pre-conception - Discuss assessing extent of ILD, PH, cardiac or renal involvement in light of safe pregnancy
	Care of children		-Adaptations for child care - Strategies to manage fatigue
PSYCHOLOGICAL			Advocacy / Education Groups Local support groups
			Online self-management program (see resources)