Материал: ABC-of-Rheumatology-ABC-Series-

Eugene McCloskey

Reader in Adult Bone Disease

Academic Unit of Bone Metabolism and WHO Collaborating Centre for Metabolic Bone Diseases

University of Sheffield

Sheffield, UK

Caroline Mitchell

Senior Clinical Lecturer General Practitioner

Academic Unit of Primary Medical Care

University of Sheffield

Sheffield, UK

Jacqueline Oliver

Research Associate

Arthritis Research Campaign

Chesterfield, UK

Nicola Peel

Northern General Hospital

Sheffield, UK

Rosalind Ramsey-Goldman

Solovy Arthritis Research Society Research Professor of Medicine Northwestern University Feinberg School of Medicine

Chicago, IL, USA

Sarah Ryan

Nurse Consultant in Rheumatology

Haywood Hospital

Stoke-on-Trent Community Health Service

Stoke-on-Trent, UK

David G I Scott

Consultant Rheumatologist

Norfolk and Norwich University Hospital NHS Trust

Honorary Professor

University of East Anglia

Norwich, UK

Michael Shipley

University College London Hospitals

The Middlesex Hospital

London, UK

Alan Silman

Medical Director

Arthritis Research Campaign

Chesterfield, UK

Taunton R Southwood

Professor of Paediatric Rheumatology

University of Birmingham, Birmingham

Birmingham Children’s Hospital

NHS Foundation Trust

Birmingham, UK

Cathy Speed

Honorary Consultant

Rheumatology and Sports Medicine

Cambridge University Hospital

Cambridge, UK

Ilona S Szer

Director, Pediatric Rheumatology

Rady Children’s Hospital and Health Center

San Diego, CA, USA

Mohammed Tikly

Professor of Rheumatology

Chris Hani Baragwanath Hospital

University of the Witwatersrand

Johannesburg, South Africa

Lori Tucker

Division of Pediatric Rheumatology

British Columbia’s Children’s Hospital

Vancouver, BC, Canada

Martin Underwood

Professor of Primary Care Research

Warwick Medical School

University of Warwick

Coventry, UK

Louise Warburton

Shawbirch Medical Practice

Shawbirch

Telford, UK

Richard A Watts

Consultant Rheumatologist

Clinical Senior Lecturer University of East Anglia, Norwich

Ipswich Hospital NHS Trust

Ipswich, UK

Mark Wilkinson

Clinical Senior Lecturer, Orthopaedics

Academic Unit of Bone Metabolism

University of Sheffield

Northern General Hospital

Sheffield, UK

The fourth edition of the ABC of Rheumatology marks a change in Editor. I would like to thank my predecessor Mike Snaith for his sterling work in producing such excellent previous editions of this book which has led to its worldwide recognition and appeal. The fact that the book is now in its fourth edition is testimony to the great foundation that he laid.

I have kept the tradition as well as enriched the strengths of previous editions to ensure that this book continues to provide a good and up to date foundational knowledge of Rheumatology and Musculoskeletal Medicine for a wide spectrum of those interested in this field. This ranges from family doctors, medical students,

nurse specialists, allied health professionals to doctors in training and others besides.

I would like to thank all those who have contributed to this current edition including my colleagues, not only in Sheffield but also across the United Kingdom and indeed other parts of the world. I am particularly pleased to have so many authors from North America where this book is increasingly being used.

Finally, I wish to thank the publishers for their dedication and professionalism.

Ade Adebajo

OVERVIEW

•The importance of a multidisciplinary care pathway in the management of musculoskeletal patients is now well recognized globally.

•The need to provide a whole-community approach to the management of these patients is also being increasingly recognized globally.

•The shared-care monitoring of rheumatology patients on disease-modifying drugs between primary and secondary care is an example of a successful model using this approach.

•A community-wide approach encompassing the involvement and education of both patient and primary care physician will lead to earlier diagnosis, speedier and more appropriate secondary care referrals, quicker treatment and ultimately improved clinical outcomes.

•A community-wide approach will ensure that psychosocial factors are not overlooked and that “red flags” for regional pain syndromes are not missed.

•This approach will also ensure that evidence-based primary care treatments for musculoskeletal problems are developed and implemented.

The ever-increasing demand upon the acute hospitals to deliver emergency medicine, together with technological (but timeconsuming and expensive) advances means that in the UK and elsewhere follow-up of many chronic conditions has been squeezed out of the acute setting and, by default, delegated to primary care. Unfortunately this shift in activity has not always been mirrored by an appropriate shift in resources and skills. This chapter discusses new ways of working to try to ensure that patients with musculoskeletal conditions receive timely, appropriate treatments within the limitations imposed by restricted resources.

Shared care—how to make it work

With hospital services running at full (or over) capacity, one way

forwards is to develop models of shared care appropriate to local need, responsive to local demands and in the patients’ best interests. Simply transferring the workload from rheumatologists to general practitioners (GPs) will not work—primary care is also bursting at the seams. One way of transferring rheumatological expertise to the community, without increasing the burden on the primary care team, is to develop the roles of health professionals such as nurses, physiotherapists and occupational therapists. Such practitioners, working in an extended role, operate at a high level of clinical practice and cross traditional professional boundaries. Their expertise includes assessment (of the disease and psychosocial factors), follow-up and management of patients with musculoskeletal conditions and inflammatory arthritis. Their roles and responsibilities have recently been defined (Carr, 2001).

What is the role of the specialist nurse?

Specialist nurses are highly skilled and provide holistic care for patients and their significant others by addressing their physical, psychological and social needs. They can play a pivotal role in the management of people with musculoskeletal conditions, acting as effective communicators between the patient, their GP and hospital consultant. Like GPs, they tend to stay in post for many years and become a “constant presence” in the patient’s illness journey, thus ensuring the continuity of care that those with a chronic disease value so highly. The role of the specialist nurse is essentially to provide care management, education and support for patients and their families, and to act as an educator and resource for other health professionals. The role includes those activities shown in Box 1.1. Some nurse specialists also undertake advanced practices such as intra-articular injections (Meadows and Sheehan, 2005). This can be particularly useful to GPs, who may be inexperienced in this procedure. After specialist training these nurses can also prescribe drug therapy (Carr, 2001). Of all these activities, patient education remains one of the priorities of the specialist nurse (Department of Health, 2006).