Being diagnosed with arthritis is often overwhelming. Arthritis is much more than joint pain, as it affects every part of your life. An integrative care team recognizes that no single clinician can handle all aspects of daily living. It takes a small ecosystem of expertise to help patients navigate the complexities of living with arthritis.
Alicia B, an Arthritis Patient Advisory Board (APAB) member who lives with rheumatoid arthritis, describes a care team that includes her rheumatologist, family doctor, registered massage therapist, naturopath, dietitian, and pharmacist.
“My pharmacist case manager has walked me through the world of biologics,” she says. “I met with my dietitian weekly for a year to discuss things I could alter to assist with my wellness. “
Integrative Care Team Members
Care is usually led by a rheumatologist, who diagnoses inflammatory arthritis, manages treatment, and monitors disease activity. A family doctor supports overall health, manages prevention care such as vaccines, screening for cancer and risk factors for cardiovascular disease and other chronic conditions more common in people with arthritis, and coordinates referrals.
Dr. Claire Barber, a rheumatologist and Arthritis Research Canada scientist whose work focuses on improving health systems, notes, “Arthritis is best managed when care is coordinated across multiple disciplines, because no single provider can address all aspects of the disease on their own.”
Arthritis rarely exists in isolation. Your care team may expand to include the following experts, depending on your disease and symptoms:
- Medical Specialists: These specialists may include dermatologists, ophthalmologists, nephrologists, gastroenterologists, endocrinologists, and pulmonologists, who manage organ- and system-specific complications involving the skin, eyes, kidneys, gut, hormones, lungs, and related conditions.
Other specialists include internal medicine specialists, who oversee chronic diseases like hypertension and vascular disease, pain specialists for chronic pain management, and dentists.
- Pharmacists: Your pharmacist is a medication expert who manages medication interactions and side effects.
- Movement and Lifestyle Specialists: Physiotherapists, occupational therapists, vocational rehabilitation specialists who support return to work, registered dietitians, and sleep specialists all help support daily life with arthritis.
- Mental Health Support: Social workers, psychologists, and behavioural therapists offer mental health tools and strategies to support the mental load of dealing with chronic illness.
- Joint Support Specialists: Podiatrists/foot specialists, orthopedic surgeons, and hand specialists offer prevention strategies for long-term joint damage, or surgical intervention and treatments for the joints when necessary.
- Nurses: Nurse practitioners, rheumatology nurses, and infusion nurses provide ongoing care for your arthritis.
- Other Providers: Acupuncturists, massage therapists, mind-body therapists, and naturopaths also support system management and your overall well-being.
How to Manage Multiple Appointments
While having a great team in place is important, it can be overwhelming to organize. Juggling appointments, repeating your story to multiple health professionals, tracking medications, chasing referrals, and trying to function at the same time is exhausting.
“If an appointment can be done virtually, I opt for that so I can attend comfortably from home and not aggravate my symptoms,” says APAB member Anna Samson.
Dr. Diane Lacaille, Arthritis Research Canada’s Scientific Director, adds, “Virtual care offers convenience when an in-person physical exam is not necessary for treatment decisions.”
“My husband and I use a shared calendar, along with a kitchen calendar, so all appointments are immediately written down in both places,” says Alicia.
Fellow APAB member Kari Wutzke advocates for personalized scheduling. “Because I struggle going out, I try to schedule appointments on the same day if they’re close by,” she says.
Addressing Gaps in Arthritis Care
If you ask people living with arthritis who should be included in their care, but currently aren’t, the answer is consistent: the system is still too narrow and focused on pain.
Mental health professionals should be a standard part of care. Chronic pain, fatigue, and loss of function affect far more than the body. They shape identity, relationships, work, and everyday life. Occupational therapists are also essential, as they help patients with everyday tasks such as getting dressed, cooking, and working.
Alicia shares, “The focus is so strong on physical pain and minimizing long-term joint damage that no one on my arthritis care team has ever asked about my mental health.”
“Fatigue has a huge impact on my life, and it feels like no doctors are able to help with it,” adds Anna. “It’s one of the main symptoms I deal with, and it goes unaddressed.”
These experiences highlight gaps in how arthritis care is designed and delivered. Along with Dr. Lacaille, Dr. Barber’s research underscores the need for more coordinated, patient-centered systems of care. Her team developed a patient-centered scorecard to identify opportunities for improvement in rheumatoid arthritis care.
“Improving arthritis outcomes depends on how care is delivered,” explains Dr. Barber, “It takes coordinated teams to ensure patients can access the right care at the right time.”
