Lynn suggests asking if the patient is sexually active, and if not, whether it has anything to do with the RA. If it does, she suggests asking whether this change has occurred since diagnosis and whether relationship issues have arisen as a result.
If the patient is having problems with sexuality, Schwartzman-Morris advises determining first whether the problem is physical or psychological. It is important to bear in mind that some physical issues, such as skin problems, may have psychological sequelae, she says.
Referring Patients to Other Providers
The distinction between physical and psychological problems is important when determining who to refer the patient to, should a referral be necessary. Both physical therapists and therapists who address patients’ emotional and psychological states can be critical to a rheumatology patient’s sexual well-being.
Quality-of-life scores are good indicators of the need for physical therapy. Particularly if the patient lacks strength or range of motion, “we can help them achieve a better sex life,” says Watkins. “We can improve range of motion, especially in the large joints, hips and knees, so that patients can move easier and maintain sexual positions more easily.”
She says physical therapists can also help patients find ways to work around fatigue.
“Encourage your patients to maintain, if not improve, current levels of function, through endurance exercises, strength training and stretching,” says Sarah Smith, a physical therapist in Loyola University Medical Center’s acute inpatient rehabilitation unit. “If you see a decline in any of those areas, therapy services would be beneficial to help enhance all aspects of your patients’ lives.”
Physical therapists can also teach patients to know their limits and to work within them, which is particularly difficult because the limits are always changing, says Smith. “We help them find their limits, and know where to push them and where to back off.”
All this is critical “to maintaining the function you have,” says Smith. “If you don’t use it, you lose it—whether it’s functional endurance or range of motion.”
Lynn recommends that rheumatologists identify local sex therapists to whom they can refer patients, noting that her institution has a sex wellness clinic with a six-week program for helping patients with arthritis and other conditions. Leach emphasizes the need for sex therapists who deal with disabilities and expresses her frustration that a sex therapist she found in her area wasn’t taking new patients.
As for when to make referrals, Nortin M. Hadler, MD, MACP, MACR, FACOEM, a professor of medicine and microbiology/immunology, and attending rheumatologist, University of North Carolina Hospitals, says he refers patients “when the patient and I feel pretty certain that [the patient’s problem] is beyond us.” Knowing that, he says, is helped by knowing the patient well.