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Multidisciplinary disease management in rheumatology

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Susan Oliver, RGN, MSc.

Independent Rheumatology Nurse Specialist, Devon; and Nurse Adviser, National Rheumatoid Arthritis Society

The term arthritis is often used to describe all forms of joint and muscle pain. However, over 200 diseases are considered musculoskeletal disorders, and such a generic term fails to reflect fully the true consequences of many of them. Osteoarthritis (OA) and rheumatoid arthritis (RA) are the two largest disease groups. Although there are similarities between the two, there are significant differences in aetiology, presentation, distribution of joints affected, treatment options and systemic consequences. One of the most significant issues is in the assessment and management of pain (Burckhardt, 2001).


The term arthritis is often used to describe all forms of joint and muscle pain. However, over 200 diseases are considered musculoskeletal disorders, and such a generic term fails to reflect fully the true consequences of many of them. Osteoarthritis (OA) and rheumatoid arthritis (RA) are the two largest disease groups. Although there are similarities between the two, there are significant differences in aetiology, presentation, distribution of joints affected, treatment options and systemic consequences. One of the most significant issues is in the assessment and management of pain (Burckhardt, 2001).



Pre-registration training of health-care professionals in musculoskeletal care is limited (Dequeker et al, 2000; Haq and Giles, 2003). Yet this is a crucial issue, as the growing elderly and chronic disease patient groups require knowledgeable health-care professionals at specific times of their illness pathway.



The professional and patient organisations for all forms of musculoskeletal disease are working together to produce a document setting out standards of care for patients with these conditions. The document is set to be launched in 2004.



This paper explores a template devised by the Standards of Arthritis Relief Group (SOAR) to enhance care for patients with OA and RA in primary care (SOAR, 2003). There are essential aspects of care that all health-care professionals should be able to provide for patients with OA and RA, and the central section of the template (reproduced in Figure 1) sets out a framework for this. However, the guidance should be tailored to the patient’s specific needs and ability to cope with the nature and breadth of information provided.



Aims of the template
SOAR is a multidisciplinary group working to drive optimum standards in the management of arthritis in primary care by encouraging best practice. The template is one of many projects planned by SOAR. The template provides:



- A concise and evidence-based decision-making tool to support all health-care professionals managing patients with arthritis



- An overview of a range of self-management strategies to improve pain control and patients’ perception of control and self-efficacy



- Guidance on the evidence for non-therapeutic options, particularly key aspects of improving functional ability.



The templates aims to:



- Reduce risk and improve management and referral



- Encourage multidisciplinary support for patients with arthritis



- Improve communication between primary and secondary care.



The template identifies the key areas affected by OA (hands, knees and hips) and RA (all joints, but commonly hands, feet, shoulders, elbows, wrists, knees, ankles) and advises on clinical examination (Moder and Hunder, 2000).



Impact of disease
Osteoarthritis - Each year over two million adults consult their doctor with symptoms attributed to OA (McCormick et al, 1995), and it is one of the main causes of joint-replacement surgery (Dieppe, 1999). The growing elderly population means that these figures are set to rise. Doctors and patients often refer to OA as a disease of old age or ‘wear and tear’, which can lead to a sense of inevitability (Brandt, 2000). Although age is the most significant risk factor, over 912 000 people below the age of 64 have OA (Arthritis Research Campaign, 2002).



The dominant sign of OA is that of focal areas of damaged articular cartilage (Dieppe, 1999). Subchondral bone, synovium, ligaments and peri-articular muscle can also be affected (Brandt, 2000). There can be signs of degeneration, regeneration and repair of bony tissue, sometimes with abnormal or inadequate healing (Baird, 2001). Obesity is a potentially modifiable predisposing risk factor to OA, particularly of the knee (Felson, 1998). Clear and effective assessment is vital to identify patients who require referral for complex disease or additional multidisciplinary support.



Rheumatoid arthritis (RA) - RA can affect all ages, although peak incidence is in the fourth and fifth decade (Gordon and Hastings, 1995). It affects more women that men (3:1 ratio) although, with increasing age, distribution becomes more equal (Ryan and Oliver, 2002). About a million people have RA in the UK (Hill and Ryan, 2000). Pain, stiffness and fatigue are common and disabling symptoms.



The disease affects synovial tissues and is characterised by an inflammatory systemic disease that causes synovitis, progressive joint damage and disability. RA is an auto-immune disease and has the potential to result in extra-articular features that can be life-threatening. These include blood disorders, pulmonary, cardiac, renal, vascular and ophthalmic disease (Kelly, 2002). The risks of uncontrolled disease include increasing joint destruction, inability to work and premature mortality (Klippel and Dieppe, 1995). These risks have been clearly linked to disease severity rather than side-effects of treatment (Pincus and Callahan, 1993).



About one in four patients with RA may require joint replacement during their lifetime (Hazes, 2003). In addition, the social and psychological aspects of the disease have significant consequences for patients and their families (Ryan, 1999).



The disease may have an insidious or rapid onset (Gordon and Hastings, 1995). Joints are usually affected in a symmetrical distribution; those most commonly involved include the metacarpophalangeal joints, shoulders, elbows, wrists, knees and ankles as well as the metatarsophalangeal joints of the foot.



A growing body of evidence supports the prompt referral and treatment of RA to improve long-term outcomes (Hunder, 2000; Emery et al, 2002). It is therefore essential that signs and symptoms suggestive of RA (as highlighted in the template) should be identified early. The SOAR template provides health-care professionals with advice on the assessment process and referral guidance.



Assessment of needs
OA - The template sets out some of the initial basic aspects required to provide a comprehensive strategy to enhance patient self-management (Newman et al, 2001). The needs assessment must be tailored according to specific factors relevant to that person, their disease, social and psychological needs, as well the provision of care and education available to them.



Much can be achieved to enable individuals with OA to cope with their disease effectively and manage their pain control. This is reflected in the work of Lorig et al (1993), who developed patient education programmes that now form the basis of work to develop expert patient and self-management programmes (DoH, 2001; 2003). Encouraging such principles has significant advantages for both patients and the NHS (Box 1).



RA - Assessment should include disease-specific issues as well as physical function, social and psychological factors. Patients with active RA should be seen regularly by a specialist rheumatology team.



Research examining the views of individuals with RA demonstrate a strong need for continuity of care by knowledgeable practitioners (Ryan et al, 2003). This is partly reflected by the wish for continuity of care in chronic disease but may also highlight the limited amount of knowledgeable support for patients within the primary care setting (Dequeker et al, 2000).



RA is a complex disease with additional risk factors that require skilled management and a sound understanding of the disease and the need to control the disease process using disease-modifying drugs (DMARDs). In addition, the recent emergence of new biologic therapies (etanercept, infliximab and adalimumab) have significantly improved some patients’ quality of life. Further biologic therapies are becoming available. Although two of these therapies - etanercept and infliximab - have been reviewed by the National Institute for Clinical Excellence (2002), the drugs’ safety and efficacy rests with effective communication and management by health-care professionals.



Patient education
Patients with RA face many issues that affect their ability to cope with daily life (Ryan et al, 2003). They are also at increased risk of infection, drug side-effects, blood disorders and other co-morbidities (Weisman et al, 2001).



Educational support should be available in a range of formats and tailored to the individual’s psychological and physical needs. Table 1 lists some of the issues to address. Patient education has more recently been termed ‘self-management’, building on a principle of an informed, enabled person able to manage their disease more effectively (Ramos-Remus et al, 2000). Education or self-management programmes do not simply involve information-giving but also encourage an effective psychological perspective on the disease and enhance individuals’ ability to recognise ways to manage their disease or access appropriate care. This improves self-esteem and prevents ‘learned helplessness’, which can result from chronic disease (Bandura, 1997).



There is a wealth of research on patient education in arthritis, showing greater levels of patient satisfaction, concordance and improved self-efficacy (Hill et al, 2001; Reilly and Bird, 2001). Some reviews have questioned whether the overall benefit to health care and the individual are sustained, but the emphasis is on ensuring that outcome measures accurately reflect potential benefits to individuals and overall health economics (Riemsma et al, 2002).



Patient-education programmes are not a static one-stop package. All health-care interactions are potential ‘educational’ opportunities. Most importantly, ‘educated or expert patients’ are more likely to access health-care support in a confident and appropriate manner (DoH, 2001). It is also likely that patient expertise will reduce risk and improve concordance (Carter and Taylor, 2003).



Pain management
Patients with OA and RA experience a significant amount of pain and this affects quality of life (Covic et al, 2003). Pain is a complex mechanism affected by physical and psychological issues. It should be assessed and managed using a holistic approach.



Pain assessment should be structured, looking at therapeutic and non-therapeutic relief strategies. Although pain is a subjective experience a number of tools can help practitioners to understand what a patient is experiencing (Burckhardt, 2001).



Many OA patients with relatively mild disease can achieve satisfactory pain control using simple analgesia and non-pharmacological approaches. Many are likely to require frequent or occasional use of non-steroidal anti-inflammatory drugs (NSAIDs) to relieve inflammatory pain. Some will be at high risk of side-effects from traditional NSAIDs and should be prescribed the more specific cyclo-oxygenase-II (COX II) drugs (NICE, 2001; 2002).



Patients with RA have more complex problems and, generally, more frequent episodes of pain (and stiffness) requiring high doses of anti-inflammatory drugs as well as simple or compound analgesia. Patients should be educated to their optimum ability on pain-management principles using a ‘step-up’ (when experiencing a flare-up of the disease) and ‘step-down’ approach (when this has resolved). This approach has the potential to reduce risk from drug side-effects and improve self-efficacy and concordance, although research in this area on OA and RA patients is limited.



A general increase in pain, stiffness and fatigue can highlight increased disease activity. Pain can also be exacerbated by a number of factors:



- A flare-up, or poorly controlled disease (for instance, inefficacy of current therapies)



- Intercurrent infections that cause a flare-up



- Increased disease activity in one specific joint - for instance, a tender, hot and swollen knee



- Aggravating factors (social/psychological issues).



Access to services
Developing nursing roles - Nurses have an important role in improving health-care delivery, particularly with the advent of primary care trusts, nurse prescribing and extended roles (DoH, 2001; 2003). This is particularly relevant in chronic disease management, where the safety and efficacy of nurses working in extended roles has been demonstrated in a range of settings (Kinnersley et al, 2000). The greatest benefits are achieved if nurses extend their expertise while maintaining the integral aspects of the therapeutic relationship (Castledine, 2002).



It is likely that chronic disease management will be an integral part of extended nursing roles. Nursing assessment models could include patient information and education, helpline support, pain or symptom management, review of medications (including polypharmacy and additional risk, for example osteoporosis or gastrointestinal bleeds) and blood monitoring. Some examples include:



- Patient reviews and support that reduced NSAID use in general practice (Jones et al, 2002)



- Shared-care system of hospital follow-up that reduced pain and use of health-care resources, increasing patient satisfaction (Hewlett et al, 2000)



- Diagnostic triage for early arthritis clinics by GPs or rheumatology nurses (Gormley et al, 2003)



- Specialist nurse outreach clinics in the community (Mooney, 1999)



- Running nurse-led clinics for chronic pain management (Glasgow and Glasgow, 2002).



Nurses have a key role in influencing future care delivery. The SOAR template provides a framework to guide practitioners towards improving care.



This paper aims to inspire nurses to look at proactive and innovative approaches to care. It highlights the benefit that nurses and other members of the team can provide to patients with RA and OA in all care settings. Patient-centred care is rewarding and has the potential to improve a number of key health-related problems for patients with OA and RA.



- The full version of the SOAR template is available from 020 7313 6377, or write to Claire Russell, Shire Health, 3 Olaf Street, London W11 4BE.





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