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Arthritis and musculoskeletal problems: a primary care nursing perspective

Key learning points: 

 - What is arthritis and who is affected?

 - The different types of arthritis

 - Recognising and managing symptoms

Mrs Cooper gets up slowly from the chair at the end of the consultation. She is a 70 year old lady that you have known for quite a few years and is here to see you today for her routine diabetes and hypertension review. As she puts on her scarf and coat she winces with pain and, heading to the door, asks if there's anything you can do about her knees. What would you do?

What is arthritis and who is affected?

Arthritis and musculoskeletal conditions are disorders of the joints, bones and muscles. The term musculoskeletal condition is often used to include a broad range of health conditions, including back pain and osteoarthritis, along with rarer systemic autoimmune diseases such as lupus and rheumatoid arthritis. Together, these conditions affect around ten million people across the UK and account for the fourth largest area of spending in the NHS.1 There are even higher costs to the individual and society as a whole in absence from work, lost income and increased care needs. Joint pain in older people is extremely common, and around a third of people over the age of 50 will consult in primary care about joint pain each year.2

Arthritis and other musculoskeletal conditions are primarily long-term conditions. Common features of these conditions are pain, joint stiffness and limitation in movement which in turn cause impaired function. The symptoms fluctuate in severity over time and often cause depression. Pain is invisible and those around the patient are sometimes not aware how severely musculoskeletal conditions can impact on that person's life. Musculoskeletal conditions account for the largest proportion of years lived with disability in the UK.3

There are over 200 musculoskeletal conditions but broadly they can be considered as belonging to one of three groups, with pain and functional impairment as the common denominator across all of the conditions. 

Group one: inflammatory conditions

The first group is inflammatory conditions such as rheumatoid arthritis, where the immune system attacks and destroys the joints and sometimes the internal organs. These conditions are usually treated in hospitals by specialist rheumatologists and require drug treatments as well as access to allied health professionals such as occupational therapists and physiotherapists. Primary care has an important role to play too, including monitoring of blood tests for shared care prescribing and in management of cardiovascular and fracture risk. 

Rheumatoid arthritis is a progressive condition that can impair people's ability to plan their lives. People living with rheumatoid arthritis often talk about 'flare ups' where the condition is at its most painful. A third of people diagnosed with rheumatoid arthritis will have stopped work within two years of onset.4 The leading cause of death for patients with rheumatoid arthritis is cardiovascular disease (CVD) - the increased CVD risk is equivalent to the increased risk seen in diabetes mellitus. 

Group two: conditions of musculoskeletal pain

The second group includes conditions of musculoskeletal pain such as osteoarthritis, back pain and fibromyalgia. In osteoarthritis there is painful wear and degeneration of joints. These conditions are normally treated in primary care, affect large numbers of people, and management usually involves physical activity and pain management. Severe cases of osteoarthritis can result in the need for joint replacement, which can give people back their mobility.

Over five million people in the UK live with osteoarthritis of the hand. Women are twice as likely to experience this painful condition that limits the ability to perform every day activities.5 

Group three: osteoporosis and fragility fractures

The third group is osteoporosis and fragility fractures. Fragility fractures are breaks that result from mechanical forces that would not ordinarily result in fracture, eg. after a minor trip or fall, even from standing height. Fragility fractures affect large numbers of people and are commonly caused by osteoporosis where bones weaken with age. Identification of those at risk of a fragility fracture takes place mainly in primary care where treatments, including preventative medication, can be prescribed. Long-term pain and loss of independence often follow a fragility fracture, and older people may not survive the trauma of a major fracture.

One in two women and one in five men over the age of 50 will suffer a fragility fractures often as a result of osteoporosis.6

Impact of musculoskeletal conditions on the individual

The impact on the individual and their quality of life can be substantial. More than one third of the population aged over 50 years have arthritis pain that interferes with their normal activities.7 For the most common form of arthritis, osteoarthritis, nearly three-quarters of people with the condition report some form of constant pain with one in eight describing their pain as 'often unbearable.'4 Osteoarthritis of the knee causes pain and disability to one in five people in their 50s, rising to one in three people by age 75 years.8

Impact of musculoskeletal conditions on the health service

Each year 20% of the general population consult their GP about a musculoskeletal problem such as arthritis, the equivalent of over 100,000 consultations a day.2 The majority of these consultations are for osteoarthritis and back pain. This represents a substantial volume of GPs' work, though little is known currently about the numbers of patients with musculoskeletal pain presenting to nurses in primary care. Rising obesity and an ageing population will cause this number to increase, requiring additional primary care capacity to provide high quality care, which is one reason why nurses in primary care are potentially a huge resource to help manage this increasing burden.

Experience from the front line

Andrew Finney, Lecturer of Nursing and doctoral research fellow at the Arthritis Research UK Primary Care Centre at Keele University, has undertaken research with primary care nurses into the management of osteoarthritis in consultations. He states that “from talking to patients with joint pains the main thing that struck me was how patients described that this was the first time they had been heard. I would start off a consultation by asking 'tell me how your joint pains are affecting you?' and you could sense a huge weight of anxiety starting to lift. They benefitted greatly from telling you their story, being heard and sharing how the pain was affecting their lives.”

“People with joint pains often feel that their pain is an inevitable part of the ageing process and that nothing can be done to help, which is absolutely not the case. The pain of osteoarthritis often fluctuates and is likely to affect different joints, typically knees, hips, hands, and the spine, at different times. Nurses in primary care can make a huge difference to their patients with joint pain by asking about their pain and offering simple advice about analgesia (especially dosage and timing), signposting to information about their condition such as that produced by Arthritis Research UK and giving simple advice around weight management, physical activity and exercise.”

The role of nurses in primary care

A recent report by Arthritis Research UK identified nurses in primary care as a key group of health professionals whose skills could be developed to improve health and wellbeing for people affected by musculoskeletal conditions.10 Broadly the core areas that needed developing could be summarised as the 'three Es':

 1. Education.

 2. Easing pain.

 3. Exercise.

Education

People want access to information about their condition to maintain physical, psychological and social function so that they can engage in self-management and maximise independence. See the resources section for links to information. 

Easing pain 

Pain is the main symptom experienced by people with musculoskeletal problems. The report identified a lack of service provision to help people manage their pain and often a lack of understanding from health professionals about how debilitating the pain could be. People with musculoskeletal conditions want to know how to manage their pain and to have someone to talk to when the pain has a negative effect on their mood. 

Exercise

Exercise is a core treatment in the National Institute for Health and Care Excellence (NICE) guidelines for low back pain, rheumatoid arthritis and osteoarthritis. Health professionals should be able to give simple structured advice or signposting around the benefits of, and access to, exercise and physical activity. See resources section for information on exercises to relieve pain.

Back to Mrs Cooper

Practice nurses will often hear about patients' musculoskeletal pain during consultations for other problems, as was the case with Mrs Cooper. The reality with long-term conditions is that they co-exist. Around 20-35% of people with conditions such as diabetes, hypertension and cardiovascular disease will also have problems with long-term musculoskeletal pain.10 It can be this pain that acts as the main barrier to patients achieving goals in their long-term conditions management, for example, getting more physically active or losing weight. 

Nurses in primary care can make a huge difference to patients with musculoskeletal pain by asking about pain and function and applying the principle of the three Es. For those wishing to find out more, Arthritis Research UK have a wealth of resources for healthcare professionals, students and people affected by musculoskeletal problems and have recently collaborated with Education for Health to develop a course on the assessment and management of joint pains in primary care. See resources section for information and details of training bursaries for nurses. 

 

Resources

Arthritis Research UK primary care resources

Exercise and arthritis

Links to NICE and other national guidelines including low back pain, rheumatoid arthritis and osteoarthritis:

www.arthritisresearchuk.org/health-professionals-and-students/impact-too...

Education for Health

Nurse Training bursaries

 

References 

1. Department of Health. England level programme budgeting data 2010-11.

2. Arthritis Research UK, National Primary Care Centre, Keele University. Musculoskeletal Matters, bulletin 1. What do General Practitioners see? October 2009. 

3. Murray CJL, et al. UK health performance: findings of the Global Burden of Disease Study. The Lancet 2013;381(9871):997-1020. 

4. Arthritis Care. OA Nation. 2012.

5. Arthritis Research UK. Data and statistics on osteoarthritis of the hand.

6. van Staa TP, et al. Epidemiology of fractures in England and Wales. Bone 2001;(29)517-22.

7. Thomas E, et al. The prevalence of pain and pain interference in a general population of older adults: crosssectional findings from the North Staffordshire Osteoarthritis Project (NorStOP). Pain 2004;110(1-2):361-8.

8. Arthritis Research UK. Data and statistics on osteoarthritis of the knee.  

9. Arthritis Research UK. Osteoarthritis in general practice. 2013. 

10. Ryan S, Lillie K, Adams J. The absent health professional: The educational needs of nurses, allied health professionals and associate practitioners working with people with osteoarthritis or rheumatoid arthritis. Arthritis Research UK. 2013.  

11. Guthrie P, Payne K, Alderson P, et al. Adapting clinical guidelines to take account of multimorbidity. BMJ 2012;345