The majority of rheumatological diseases are long-term chronic conditions, occasionally associated with considerable disability. Even in a stable or slowly progressive disease such as RA, discrete events such as joint surgery may demand sudden physical, mental and occupational adaptation. One of the main principles of rehabilitation is the return, maintenance and protection of a patient’s functionality; a patient’s sense of control – of ‘ownership’ and ability to self-manage can also prove very beneficial psychologically.

Rehabilitation requires a multi-disciplinary team (MDT) approach. Each member of the team has specific but complementary roles; not all patients will require the expertise of all members at any one time.

The main role of the physiotherapist is the maintenance or improvement of physical function through specific focussed exercises. As part of physical rehabilitation, a thorough assessment of the patient’s physical function is mandatory, in combination with identification of contributing factors such as unfavourable biomechanics or poor core stability. The physiotherapist is then able to teach each patient a specific set of stretches and exercises to target problem areas and design a program for escalating either repetitions or resistance as pain/function improves. The most common aims are to rehabilitate post-surgery, to improve muscle strength and balance, relieve tendinopathy and enhance core stability. Hydrotherapy is a crucial component of rehabilitation for inflammatory arthropathy, especially ankylosing spondylitis.

Physical therapy may also include the application of heat, cold and transcutaneous electrical nerve stimulation (TENS) to relieve pain and stiffness.

Occupational therapists (OTs) are invaluable in offering advice and adaptations so that patients are able to realise their full potential both in their home and workplace. Advice and support they offer include:

• Equipment.
  
• Housing adaptations (e.g. bathroom alterations, stair-rails).
  
• Seating and wheelchair assessments.
  
• Splinting (especially upper limb).
  
• Energy conservation, task prioritisation and delegation.

As part of the MDT, they are particularly important in the postoperative period, facilitating a smooth and successful discharge to a safe environment; frequently home visits for ‘on-site’ assessments of a patient’s needs highlight issues that might have been missed while in hospital.

OTs work in close liaison with Social Workers and are very helpful in providing information on workplace-related issues such as worker’s rights and disability allowance.

Foot disease is frequently overlooked in assessment of arthritis. Pain in the heels, forefeet and toes can make life unbearable for many patients and can be a major restriction in activities of daily living or rehabilitation. Podiatrists’ skills rest in managing foot pathology and, in combination with orthotists (see below), provide advice on footwear. Podiatrists offer:

• Callus removal and advice to avoid recurrence.
  
• Skin management to avoid pain and ulceration.
  
• Nail care.

Orthotists design devices to support or modify skeletal structures with adverse biomechanics due to joint or neuromuscular disease. The main aims are to maintain or limit mobility, protect joints or correct malalignment. Orthotics can range in size (e.g. insoles/adaptive footwear up to thoraco-lumbo-sacral orthosis) and are based on a cast of the patient’s limb or trunk for a perfect fit.

Clinical nurse specialists (CNS) are a major source of information, education and support for patients with arthritis. The days and weeks after a new diagnosis of, for example, rheumatoid arthritis can be a bewildering and frightening time for patients. Many are fearful for the future and anxious about potentially life-long treatment with disease modifying agents; a CNS can dedicate time to individualised patient education which not only alleviates fear but improves concordance and outcome. They also play a role in counselling patients before treatments with risks of specific side-effects, such as reduced fertility with cyclophosphamide or transfusion reactions with rituximab. The increasing use of nurse-led clinics for those with stable disease or emergency helplines for patients who are struggling is proving very successful. The main roles of a nurse specialist encompass:

• Patient education regarding diagnosis and treatment.
  
• Emotional support and informal counselling.
  
• Organisation of bloods monitoring.
  
• Teaching subcutaneous injection techniques (e.g. for methotrexate or biologics).
  
• Arranging delivery of subcutaneous drugs, needles and safe disposal systems to patients homes.
  
• Nurse-led clinics.

Patients with musculoskeletal pathology need various forms of support at different stages of their disease; the multidisciplinary approach to patient education, support and rehabilitation is central to successful management.