Nurse-led clinics

Verbal communication and patient education leaflets provide information for patients. Leaflets may provide information on disease-modifying anti-rheumatic drugs (DMARDs), non-steroidal anti-inflammatory drugs (NSAIDs) (see Chapter 5), coping with a flare or early morning stiffness, for example. Some leaflets may be developed in individual hospital departments or provided by Arthritis Research UK. Patients are given the opportunity to discuss any concerns and ask questions. The aim is to improve their understanding of their condition, awareness of drug therapy effects as well as their side-effects, and to promote self-help of their condition.

Nurses undertake a formal review of disease activity in patients with rheumatoid arthritis (RA), including assessment for tender and swollen joints. The nurse examines the upper limb joints and knees, and records the patient’s erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, and a global health visual analogue score. The Disease Activity Score (DAS 28), based on an assessment of 28 joints, is in widespread use (Table 7.1) and is a reliable, valid and practical assessment tool. Locally agreed protocols based on the severity of the patient’s DAS 28 score are used to determine changes in treatment; the higher the score, the more likely the need to increase or change treatment.

Table 7.1 Common assessments used in patients with rheumatoid arthritis

Assessment of functional status in RA may be undertaken using a standardized, structured, self-completed questionnaire, such as the Health Assessment Questionnaire (HAQ; see Table 7.1), to assess physical activity. It may also be helpful to assess a patient’s mood using the Hospital Anxiety and Depression Scale (HAD; see Table 7.1). If direct interview or the use of these questionnaires reveals significant reduction in physical functioning, changes in medication, further advice and information, and referral to physiotherapy and occupational therapy may be necessary. Patients with decreased mood may benefit from psychological support provided by nurse/therapy specialists and sometimes also require antidepressants.

Physiotherapy assessment

The physical function of the patient, as well as the range of movement and stability of joints, is assessed. Patients’ function can be affected by a flare-up of a rheumatological problem, as a result of a longer-standing problem, such as osteoarthritis of a major joint or in recovering from acute musculoskeletal trauma. Physiotherapists have a valuable role in assessing patients before joint replacement surgery, to advise about the recovery and what the patient may expect after surgery, and to ensure that equipment required as part of their rehabilitation is available for the patient on their return home. Many orthopaedic departments have leaflets that describe major joint replacement, the recovery, and risks and benefits of the procedure.