Physical Therapy Intervention for Patients with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a relatively common disease affecting approximately 1% of adults. It is a chronic, systemic autoimmune disease that affects the joints of the hands, wrists, shoulders, elbows, knees, ankles and feet. RA can present with a range of symptoms, including joint swelling, chronic pain, stiffness, restricted or limited joint range of motion and fatigue. Other body systems can also be affected, such as the cardiovascular and respiratory systems. Together, the symptoms can result in the individual being limited in (i) daily activities (including self-care and performing household activities) and (ii) social participation (work and leisure activities) (1*).

The past decades have resulted in advancements in medical treatment, and a variety of effective disease-modifying antirheumatic drugs (DMARDs) are now available. The range of options includes (i) conventional synthetic DMARDs (eg. methotrexate), (ii) targeted synthetic DMARDs (eg. Janus kinase inhibitors), and (iii) biological DMARDs (monoclonal antibodies targeting tumour necrosis factor or other inflammation-causing molecules). Early and aggressive treatment, targeting remission and tight symptom control, appears to provide the best results. However, despite this, many patients still have persisting or recurring disease, with or without joint damage. Additionally, there is increasing evidence showing that patients with

Rheumatoid arthritis (RA) is a relatively common, systemic, autoimmune disease affecting approximately 1% of adults. Symptoms typically occur in joints in the limbs, but RA can also affect the cardiovascular and respiratory systems. Although medication for RA has advanced, education and physical therapy remain crucial in good management of the disease. This article summarises how to assess and categorise patients with RA, which then allows the therapist to provide an appropriate and individually tailored exercise and activity plan for maximum benefit to their patients. Read this article online http://bit.ly/3ZVghZC

By Kathryn Thomas BSc MPhil

inflammatory joint diseases are at an increased risk of cardiovascular disease (2*). According to the latest insights from research and clinical practice, physical therapy is a crucial element in the management of RA (1*,3*), and the cornerstone of this treatment is exercise therapy and education. Therapists need to empower their patients towards self-management, making treatment effective (and also cost-effective) in the long term. This article will highlight the current recommendations for diagnosing and treating patients with RA by physical therapists.

1. Assessment of a Patient with RA

The recommendations for assessment are based on ‘best practice’, ie. expert opinion. The World Health Organization’s International Classification of Functioning,

Disability and Health (ICF) Core

Set for RA provides the basis for a comprehensive assessment (4*). The ICF conceptualises a person’s level of functioning as a dynamic interaction between their health condition, environmental factors and personal factors. It is a biopsychosocial model of disability, based on an integration of the social and medical models of disability. It represents the typical spectrum in the functioning of RA patients with a selection of 96 categories over four components: (a) Body Functions, (b) Body Structures, (c) Activities and Participation, and (d) Environmental Factors (5). The Core Set can be further supplemented with a few factors relevant to physical therapy practice. Patient assessment requires careful history taking, the identification of red and yellow flags, and physical examination.

All references marked with an asterisk are open access and links are provided in the reference list

1.1. History Taking

History taking should include: l an inventory of the patient’s health and impact on daily life; l information on the course of the disease; and l previous and current medical treatment.

Table 1 presents examples of suggested or relevant questions when taking a patient’s history. The questions can be adapted to suit the therapist’s communication style and the patient’s communication level.

Identifying red and/or yellow flags is crucial during history taking. Yellow flags indicate psychosocial risk factors for poorer prognosis and red flags are indicators of severe pathology that may require additional medical evaluation. It is, therefore, vital that before and during treatment red flags (for example, signs of infection and neurological complications) are identified and patients are referred on immediately.

Red flags for RA include: l unwanted weight loss >5kg per month (possible sign of malignancy); l excessive night sweating (possible sign of infection or malignancy); l warm and swollen (red) joints (possible signs of infectious inflammatory process of the joint, bacterial arthritis); l fever or general malaise in the use of biologicals (possible signs of infectious inflammatory process); l neck pain or pain in the back of the head, with or without ‘jumping’ legs, and/or a feeling of sand in the hands (possible signs of myeloma compression due to instability of the cervical spine with (sub)luxation of the first or second cervical vertebra); l motor (paresis or paralysis) and/ or sensory (sensory impairment) symptoms (possible signs of polyneuropathy, mono neuritis or vasculitis); l acute flaring of RA or sudden increase in symptoms (possible signs of active disease); l sudden local motor failure (possible sign of tendon rupture of, for example, the extensor digitorum communis/indices muscle, the

Co-Kinetic.com extensor pollicis longus muscle or the biceps brachii muscle); and l severe pain in the back, whether or not after falling (possibly a vertebral fracture in case of osteoporosis after prolonged corticosteroid use) (1*).

1.2. Physical Examination

The physical examination should involve: l examining and documenting the patient’s current disease activity (extent and severity of joint pain, swelling and limited joint range of motion); l noting structural joint damage and deformities; l assessing general exercise tolerance; and l assessing muscle function.

All the joints (not only the peripheral joints) and peri-articular structures that can be affected by RA must be assessed, including the cervical spine and jaw. Assessments should not be limited to the symptomatic joints alone. Some joints in which symptoms are latent may only have subtle

Rheumatoid

swelling or a limited range of motion – these too should be assessed during the physical examination (6). Detailed assessment points are available in Table 2.

The measurement instruments shown in Figure 1 should be used by physical therapists to support the diagnosis and evaluation when treating patients with RA (1*).

2. Treatment of Patients with RA

The literature emphasises the importance of physical therapy in two main areas of RA management. Firstly, RA patients should have access to

Rheumatoid arthritis (RA) measurement tools

Body structures and functions

Recommended: NRS pain and fatigue, BORG scale 6–20

Optional: 1RM submax test, HHD

Activities

Recommended: HAQ, PSC, 6-minute walk test

Optional: Quick DASH, accelero meter/step counter, MET-method

Participation

Recommended: PSK

Optional: WPAI

External factors

Personal factors

DASH, disability of arm, shoulder and hand questionnaire; HAQ, health assessment questionnaire disability index; HHD, hand-held dynamometer; MET, metabolic equivalent of task; NRS, numerical rating scale; PSC, patient-specific complaint instrument; PSC/PSK, patient-specific functional scale; RM, repetition maximum; WPAI, work productivity and activity impairment.

Figure 1: Measurement tools for RA assessment Reproduced with permission from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline

Table 1: Relevant questions for history taking in patients with RA Reproduced with permission from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline

History-taking items

Relevant questions

General

General

l What is the patient’s need for assistance? (PSC) l What are the expectations regarding physical or exercise therapy? l What are the expectations regarding the progression of the symptoms?

Functions and anatomical characteristics l Is there pain in 1 or more joints? (NPRS) l What is the location of the pain (which joints)? l Is the pain related to exertion? l What is the progression of the pain in the morning, afternoon, evening, or night time? l Is there inexplicable, persistent severe pain and/or inflammatory symptoms in 1 or more joints? (potential red flag) l Is there morning stiffness and/or start-up stiffness? If so, for how long? l Is there swelling of 1 or more joints? If so, which joints? l Is there limited range of motion and/or stiffness in 1 or more joints? If so, which joints? l Is there fatigue? (NRS fatigue) l Is there reduced muscle strength? If so, where and during which activities? l Is there decreased endurance? l Are there skin problems (ulcers) or nail fold infarcts that may be associated with RA? l Are there problems when chewing or swallowing? l Is there dry mouth and/or dry eyes, for example as a result of Sjögren’s syndrome? l Is there high blood pressure? (cardiovascular risk factor) l Is there high cholesterol? (cardiovascular risk factor) l Is there neck pain and/or pain in the back of the head, in combination with paraesthesia and/or dysesthesia, motor deficit, ‘twitching’ legs, and/or a sandy feeling in the hands? (neurological symptoms that could indicate a red flag) l Are there sensory disorders? (potential red flags) l Are there balance problems? (potential red flags) l Are there sleep problems? l Is there a sudden increase of symptoms or an acute RA flare-up? (potential red flag) l Is there severe back pain, possibly after a fall? [potential red flag with osteoporosis and (long-term) corticosteroid use] l Are there signs of infection somewhere other than in the joints, possibly accompanied by fever and/or general malaise? (potential red flag with the use of biologicals)

Activities (PSC)

Activities (PSC) l Are there limitations to performing activities of daily living and/or functions such as: l changing posture (eg. turning around in bed, getting up from bed, sitting down) l self-care, such as getting dressed and undressed, showering, combing hair (optional measurement instrument for arm and hand function; Quick-DASH) l walking (at home or outside), climbing stairs l picking up items from the ground l writing or other fine motor activities l eating and/or drinking l cycling, driving a car, or using public transportation l sexual activities l Does the patient meet the Physical Activity Guidelines? l If so, with which activities and for how many minutes per week? l If not, what is the most important impeding factor? l Which degree of physical activity is achieved? With which activities and for how many minutes per week? (optional measurement instrument: accelerometer/pedometer or the MET method)

History-taking items

Participation

Relevant questions

l What is the family situation? (to assess the daily exertion compared to the capacity) l Are there limitations resulting from the symptoms in: l relationships and/or social contacts? l paid or volunteer work? (optional measurement instrument: WPAI) l free time, eg. when playing sports or engaging in hobbies? l quality of life (optional measurement instrument: RAQoL)

External factors l Is there a family history of RA? l Is there a family history of cardiovascular disease? l How do the people surrounding the patient (partner, family, friends, co-workers) respond to the symptoms? l What is the patient’s living situation? Are there stairs in the house and how does the patient do climbing these stairs? l Does the patient use medication? If so, which ones? What is the effect of the medication? Are there side effects? If so, which ones? l Has the patient previously undergone physical or exercise therapy for RA? If so, what was the result? l Other than the rheumatologist, is there another medical specialist or other healthcare provider involved with the patient for treating the RA or related co-morbidity? l Does the patient use modifications, aids, or facilities for activities of daily living or household tasks? How about at work or during sport or leisure activities? l Does the patient use a walking aid? If so, what is the effect? l Does the patient use an aid to perform activities? (standing support, stand-up chair, wheeled stool, knee support)? If so, what is the effect? l Has any surgery been performed in the past (for example, joint replacement surgery or tendon surgery)? If so, how long ago did this take place and how did the recovery progress?

Personal factors l What are the patient’s views regarding exercise? l How does the patient handle the complaints in his/her daily life? l What measures has the patient undertaken to influence his/her complaints, such as resting/exercise, and are these helping? l Presence of the following conditions: l Co-morbidity? If so, which ones? Does this influence the patient’s functional movement and/or exercise capacity? l Overweight? (cardiovascular risk factor) l Smoking? If so, how much does the patient smoke? (cardiovascular risk factor) l Facilitating or inhibiting factors towards exercise? If so, which ones? l A need for information about RA and the treatment? l Fear, for example of falling?

DASH, disability of arm, shoulder and hand questionnaire; MET, metabolic equivalent of tasks; NPRS, numeric pain rating scale; NRS fatigue, fatigue numeric rating scale; PSC, patient-specific complaint; RAQoL, rheumatoid arthritis-specific quality of life questionnaire; WPAI, work productivity and activity impairment.

Table 2: Relevant points of attention during the physical examination of patients with RA Reproduced with permission from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline

Where is the pain reported (which joints)? During which movement(s) does the pain occur in the respective joints?

Is there any swelling of the respective joints? If so, which joint(s) and to which degree (slight, moderate, or severe). Is the swelling diffuse or localised?

Are there changes in position or deformities of the joint(s), in particular the hands, wrists, or feet?

Is there any swelling of the joints or surrounding structures (eg. tendons, bursae)?

Is there any temperature increase of the joint(s)?

Is palpation painful?

Are there changes in position or deformities of the joint(s), in particular the hands, wrists, or feet?

Active movement examination: l determination of the range of motion of all joints of the upper and lower extremities and of the cervical spine in all directions; l assessment of the combined shoulder and elbow function by having the patient perform several combined movements (eg. the hair combing movement).

Passive movement examination of the joints with limited range of motion that was determined during the active movement examination.

Assessment: l the muscle weakness and muscle endurance of the upper and lower extremities; l the active and passive stability, muscle length and proprioception; l the static and dynamic balance; l the sensitivity of primarily the upper extremities (potential red flag); l the hand function (movement examination), but also coordination, gripping function, and the functioning of the flexor and extensor tendons in the hand (including tendon gliding); l the physical functioning [(6MWT) is a supporting functional test to estimate the physical functioning and to use as a baseline measurement for the treatment]; l the aerobic capacity [eg. with the help of the Borg scale (6–20) or the heart rate].

Activities

6MWT, six-minute walk test.

Assessment of: l the gait pattern; such as heel strike, ankle function, knee function (is there, for example, a flexion contracture?) and hip function (is there, for example, a Trendelenburg sign?), trunk rotation, and arm function; l the quality of movement during functional activities, such as standing, getting up and sitting down, bending, transfers, getting (un)dressed, walking up/down stairs, reaching and gripping, picking something up from the floor, and writing; l specific activities that are restricted during work, sports, or other leisure activities; l use of aids; l performance of other specific activities where symptoms are reported.

Table 3: Patient profiles for physical therapy in patients with RA Reproduced with permission from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline

Patient profile Description

Criteria l A need for information, advice, instruction and practical tools when exercising and (again) moving and/or; l A need for more insight into the disease, the symptoms and course of RA, and the consequences for physical functioning and social participation and/or; l A need for information about the physical therapists or remedial therapeutic treatment options and the own role in them and/or; l A need for information about the possible health effects of appropriate exercises and an active lifestyle and the own role therein and/or; l A need for information about the practical possibilities of participating independently or with the help of others (eg. informal carers, care providers other than physical therapists or remedial therapists, sports/fitness instructors, etc) in the regular or adapted range of sports and exercise activities to obtain and maintain sufficient physical activity and/or; l A request for help that relates to aspects such as: limitations in self-regulation skills related to physical activity, or the availability of exercise options and social support. l A request for help in the area of RA-related complaints, and related disorders and limitations in daily activities and/or social participation, which cannot be solved by short-term information, advice, and instruction alone and/or; l A need for more and longer guidance to be able to carry out an exercise programme independently and to obtain and maintain sufficient physical activity. l Restriction(s) in basic daily activities and social participation as a result of which the patient is not able to independently obtain or maintain an adequate level of functioning and/or; l A high disease activity based on the clinical picture that cannot be regulated adequately with medication and/or; l Serious joint damage and/or; l Serious joint deformations and/or; l Presence of risk factors for delayed recovery that hinder the implementation of remedial therapy (eg. co-morbidity) and/or; l Presence of psychosocial factors (yellow flags) in combination with inadequate pain coping. evidence-based non-pharmacological treatment, and secondly that people with RA should understand the importance of and benefit of exercise and physical activity in managing their disease. That exercise or activity should be advised appropriately for the individual. Patients may need support regarding their RA-related problems and ensuing limitations in daily activities/sports/social participation. Similarly, if a patient is unable to achieve or maintain an adequate level of exercise or physical activity, physical therapy guidance would be deemed necessary (7*,8).

Depending on the assessment findings and consideration of red flags, physical exercise may be regarded as an absolute contraindication for worsening symptoms. In this case, modification of exercise therapy prescription and physical therapy treatment may be necessary. To assist in this, the literature suggests classifying patients with RA into one of three treatment profiles. These profiles are based on the patient’s needs, requirements for guidance and supervision, the complexity and severity of problems, limited selfmanagement skills and co-morbidities or complications. The profiles are expanded on in Table 3.

2.1. Education

The goal of treating a patient with RA is to achieve effective selfmanagement. Information and advice should be customised to support their needs and to optimise their health and wellbeing. Key points are to (i) emphasise the importance of exercise and a healthy lifestyle (including decreasing stress and fatigue and the way this lifestyle can be achieved and maintained), and (ii) provide treatment options.

Table 4: FITT factors for exercise therapy in patients with RA Reproduced with permission from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline

Factors for exercise therapy

Frequency Intensity Type

Patient goals l Muscle strength training: l Aerobic training:

Aim that the patient preferably performs daily, but at least 2 days/week (for muscle strengthening/functional exercises) to at least 5 days/week at least 30min at a time (for aerobic exercises).

Start with 1 to 2× weekly guided exercise therapy, supplemented with independently performed exercises and complete the guidance during the treatment period.

Aim for the following minimum intensity for muscle strength and aerobic training.

60–80% of 1 repetition maximum (1RM) (≈Borg score 14–17) [or 50–60% of 1RM (≈Borg score 12–13) for people not accustomed to strength training] with 2 to 4 sets of 8 to 15 repetitions with 30–60s rest between sets.

>60% of maximum heart rate (≈Borg score 14–17) [or 40–60% of maximum heart rate (≈Borg score 12–13) for people not used to aerobic training]. Ensure a gradual build-up in intensity during the programme and follow the training principles.

Offer a combination of the following.

Muscle strength training: l Choose exercises primarily aimed at the large muscle groups around the knee and hip joint (especially knee extensors, hip abductors, and knee flexors). l Have these exercises performed on both legs (for hip and knee osteoarthritis, both for unilateral and bilateral arthritis). l Choose both functional exercises with your own body weight and exercises with devices. Exercises with high mechanical knee load (eg. ‘leg extension device’) should preferably be avoided in case of knee osteoarthritis and after joint replacement surgery of the knee.

Aerobic training: l Choose activities with relatively low joint load, such as walking, cycling, swimming, rowing, or cross-trainer.

Functional training: l Choose (parts of) activities that are hindered in the patient’s daily life (eg. walking, climbing stairs, sitting down and getting up from a chair, lifting or packing large or small objects) by exercising (parts of) these activities. l Consider offering specific balance and/or coordination/neuromuscular training in addition to exercise therapy if there are disturbances in balance and/or coordination/neuromuscular control that interfere with the patient’s functioning. l Consider offering (active) range-of-motion or muscle stretching exercises in addition to the exercise therapy if there are muscle shortening and/or reversible mobility limitations of the joint that interfere with the patient’s functioning.

Patient education is proven to provide a small but positive effect on self-reported pain, fatigue, activity limitations, and physical activity. Education should support the patient in disease understanding, in how best to be physically active yet distribute their energy over the day and/or week. RA patients should be able to acknowledge that there may be barriers to exercise and physical activity. A lack of education on this may result in a lack of social support, pain, fatigue or fear that exercise may damage their joints.

Patients therefore need to be educated that individually tailored exercise and/or physical activity has a beneficial effect on muscle strength, aerobic capacity, daily functioning, disease activity and mental health; and that being physically active has protective benefits that are particularly important for RA patients who have an increased risk of cardiovascular disease (7*,8,9*,10*).

Therefore education by the physical therapist should provide:

Table 4

Factors for exercise therapy

Time

Patient goals

l Aim for a treatment period between 3 and 6 months, supplemented by 1 or more follow-up sessions after completion of this treatment period to encourage compliance.

l Encourage the patient to continue practising independently after the treatment period.

General points of attention l Offer exercise therapy in combination with instructions for independently performed exercises or activities to promote physical activity. Observe the Health Council of the Netherlands Movement Guidelines. l In the case of RA, accompany and motivate the patient when moving with specific barriers such as pain, stiffness, fatigue and fear of worsening the disease. l In patients with hand problems, consider a specific exercise programme for the hand. The patient can be referred to a physical therapist or remedial therapist or occupational therapist with specific expertise in the field of the (rheumatic) hand. l Consider water-based exercise therapy in the initial phase of treatment if there are serious pain symptoms during exercise. l Consider using the MET method (see measuring instruments) when estimating exercise capacity. l Consider the use of e-health applications to support the patient in performing or continuing to perform exercises independently and/or to reduce the level of supervision. l Consider offering group exercise therapy if little individual support is required.

Training principles for people with RA l Precede the workout with a warm-up and finish with a cooling-down. l Determine the starting intensity of the strength training and monitor the intensity during the treatment using the 1RM submaximal test. l Determine the starting intensity of the aerobic training and monitor the intensity during treatment using heart rate and/or Borg score. l Gradually increase the intensity of training to the maximum level possible for the patient. l Reduce the intensity of the next workout if joint pain increases after the workout and persists for more than 2h. l Start with a short period of 10min (or less if necessary) in aerobic exercises, in patients who are untrained and/or limited by joint pain and mobility. l Offer alternative exercises using the same muscle groups and energy systems if the exercise leads to an increase in joint pain. l When adjusting training intensity, use variation in sets and repetitions (in strength), intensity, duration of session or exercise, type of exercise, and rest rests and determine the adjustment in consultation with the patient. l information about the condition and strategies to reduce disability; l instruction and advice regarding specific activities, for example, distributing load over multiple joints when lifting or carrying or using assistive devices; l instruction and advice on patientspecific exercises and promoting an active lifestyle; l support for the patient to choose the best physical activities to distribute their energy over the day/week (teach patients about pacing); l understanding of the barriers for some exercise; and l education regarding behavioural change – this is essential to ensure an ongoing commitment to an active lifestyle, and a sustained integration of exercise into their daily lives (Box 1) (8).

FITT, frequency, intensity, type, and time frame; MET, metabolic equivalent of tasks; 1RM, 1 repetition maximum.

2.2. Exercise Therapy Recommendations for exercise therapy

in patients with RA are taken from guidelines on physical activity and arthritis as well as from systematic reviews of randomised controlled trials (RCTs) (Table 4) (4*,7*,8).

Exercise therapy should be offered with instruction to ultimately perform activities independently. Motivation and support are necessary when moving RA patients through activities that carry specific barriers such as pain, fatigue, stiffness and fear of worsening the disease. In patients with hand problems, a specific hand exercise programme as well as referral to a remedial therapist or occupational therapist with specific expertise may be necessary. Waterbased exercise therapy in the initial phase of treatment or in those whose symptoms flare during exercise may be beneficial. Estimating exercise capacity can be challenging, thus considering the use of the metabolic equivalent of task (MET) method may help. In order to progressively reduce supervision, ultimately having the patient perform their exercises independently, e-health/ telehealth or a group therapy class could be suggested.

According to the guidelines of the American College of Sports Medicine for patients with arthritis (7*), the intensity of muscle-strengthening exercises should be built up from 50–60% of the 1-repetition maximum to 60–80% of the 1-repetition maximum. The intensity of aerobic exercise should be built up from 40–60% of the maximum heart rate to more than 60% of the maximum heart rate (7*). This will clearly vary depending on the starting capacity of the patient and must be

Box 1: Principles of behavioural interventions based on theories of behavioural change Reproduced with permission from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline adjusted regularly. It is important that the frequency of exercising does not decrease as the emphasis shifts from supervised to non-supervised exercise. Table 5 shows the exercise recommendations specific to the three patient groups.

✓ Take into account the phase of behavioural change in which the patient finds himself/herself.

✓ Formulate achievable goals in consultation with the patient.

✓ Provide good instructions that allow the patient to know and understand what he or she should or can do.

✓ Ensure that there is sufficient variation during the exercise sessions.

✓ Integrate individual exercises and physical activities into daily life and teach the patient to integrate individual exercises and physical activities into daily life to increase effectiveness.

✓ Make sure the patient becomes independent of the therapeutic support.

✓ Help the patient to prevent relapse into the old (inactive) movement behaviour.

✓ Inform the patient about progress and teach the patient to monitor this himself/herself.

✓ Involve the patient’s environment (partner, children, friends, etc.) to support the change in movement behaviour.

✓ Encourage confidence in the patient’s own abilities.

✓ Evaluate with the patient what is effective and what is not.

✓ Help the patient to continue to pursue their own goals.

✓ Teach the patient to deal with negative emotions and stress that can hinder the achievement of set goals.

It may be challenging to determine which exercise and physical activity plans should best be tailored to the individual patient when co-morbidities are present, as in ‘patient profile 3’. Co-morbidity occurs relatively frequently in patients with RA because of (complications of) the disease and/or medication use and/or independently of RA. Modified exercise therapy for such patients also requires specific knowledge and skills relating to the individual patient’s co-morbidities (11,12). The general rule of ‘unskilled is unauthorised’ would apply here. If the treating therapist has insufficient knowledge and skills regarding the patient’s co-morbidity, then the patient should be referred to another therapist.

2.3. Other Therapeutic Interventions and Passive Mobilisations

In patients with RA, evidence suggests you should not offer interventions including low-level laser therapy, electrostimulation (including transcutaneous electrical nerve stimulation), ultrasound, massage, thermotherapy, medical taping or dry needling. In addition to this, passive mobilisation of joints and muscles should preferably not be offered to patients with RA. This is based on a lack/absence of evidence or low-/poor-quality evidence.

Short-term passive mobilisation of an affected joint may be considered only as an exception to support exercise therapy to increase joint mobility in patients without active inflammation. Current evidence for this neither supports nor opposes the intervention. However, it is strongly

Table 5: Specific Recommendations per patient profile Sourced from Peter WF, Swart NM, Meerhoff GA, Fliet Vlieland TPM. Clinical practice guideline for physical therapist management of people with rheumatoid arthritis. Physical Therapy 2021;101(8):pzab127 (1*), revision of the 2008 Royal Dutch Society of Physical Therapy guideline

Patient profile

General Profile 1 l Primary focus is education, advice and instruction l Based on moderate effect of unsupervised exercise therapy on quality of life (QoL), physical functioning and a large effect on pain in patients with RA l Small effect size on muscle strength, disease activity and positive effect on radiological damage

Exercise recommendations l Ensure that exercises are aligned with the patient’s request for help l Individually tailored exercise and physical activity plan should be developed, with limited supervision to monitor the appropriate performance l Appropriate advice and instruction for patients to perform exercises on their own l Maximum of 3–6 sessions over period of 3–6 months l Treatments consecutively or spread over the time l Re-evaluate every 8 weeks

Profile 2 l Primary focus is intermittent or short-term supervised exercise therapy l Based on patients with RA receiving supervised exercise therapy having large effect size on QoL, muscle strength and mobility l Moderate effect on physical functioning, aerobic capacity and pain l Small positive effect on disease activity and radiological damage

Profile 3 l Patients have serious/progressive functional disability due to severe co-morbidities or complications l Primary focus is intensified supervised exercise therapy l No RCT on this patient group. Advice should be based on expert opinion l Instructions for exercises to be done primarily independently and a concise period of supervision l Individualised exercise and physical activity plan l Independently performed home exercise programme l Supplemented with supervised exercise therapy 2× week in initial phase l Longstanding, supervised therapy l Frequency, intensity, and duration of the exercise therapy will depend on patient’s health status l i3-S model (11): a 3-step inventory of: o relevant comorbid diseases o contraindications and restrictions to exercise o potential adaptations to exercise therapy l Maintaining and possibly improving daily functioning and social participation is treatment goal l Given the varying nature and severity of the problem, treatment goals are regularly adjusted or new treatment goals set suggested that passive mobilisations of cervical problems should not be offered. These recommendations align with the use of treatment modalities in the Choose Wisely campaign of the American Physical Therapy Association (13*).

Final Words

The evidence discussed in this article comes from the latest physical therapy guidelines for the assessment and treatment of patients with RA (1*). These are based on scientific evidence and expert consensus, which show that the best outcomes from physical therapy treatment for RA patients include both active exercise therapy along with education, so that the patients understand why activity is important for managing their disease and that it can be done safely and without causing further damage.

References

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9. Zangi HA, Ndosi M, Adams J et al. EULAR recommendations for patient education for people with inflammatory arthritis. Annals of the Rheumatic Diseases 2015;74:954–962 Open access https://bit.ly/3YgxxXU

10. Gwinnutt JM, Wieczorek M, Balanescu A et al. 2021 EULAR recommendations regarding lifestyle behaviours and work participation to prevent progression of rheumatic and musculoskeletal diseases. Annals of the Rheumatic Diseases 2023;82:48–56 Open access https://bit.ly/3ERu633

11. Dekker J, de Rooij M, van der Leeden M. Exercise and comorbidity: the i3-S l What are the key ‘comments’ during history taking, or findings on physical examination, that might indicate a sensitive patient susceptible to symptom flare-up with exercise therapy? l Do you find the three patient profiles helpful in guiding treatment plans? l How often do you encounter patients willing to work towards selfmanagement through exercise therapy versus those with a desire for greater support and passive interventions? How do you manage that from a psychosocial perspective?

Key Points

l Despite recent advancements in pharmaceutical management, there is a substantial proportion of rheumatoid arthritis (RA) patients with persisting or recurring disease activity, with or without joint damage.

l Many individuals are limited in their daily activities, including self-care and performing household activities as well as social participation, work and leisure activities.

l The cornerstone of non-pharmacological treatment is exercise therapy and education.

l Patients need to be empowered towards self-management, making treatment effective but also cost-effective in the long term.

l A thorough history and examination, tailored towards physical therapy, is required to fully understand the biopsychosocial complexity of the disability and pain.

l RA patients should be classified into three treatment profiles based on their assessment.

l The profiles are based on patients’ needs, requirements for guidance and supervision, the complexity and severity of problems, limited selfmanagement skills and co-morbidities or complications.

l Patient education is proven to provide a small but positive effect on selfreported pain, fatigue, disease understanding, activity limitations and physical activity.

l Exercise therapy should follow the FITT (frequency, intensity, type, time) principles and progressively increase depending on the capacity of the patients and the irritability of their arthritis.

l Co-morbidity occurs frequently in patients with RA, thus modifications to exercise therapy may be required.

l Passive treatment interventions should play a subordinate role in managing patients with RA.

strategy for developing comorbidityrelated adaptations to exercise therapy. Disability and Rehabilitation 2016;38:905–909

12. van der Leeden M, Huijsmans RJ, Geleijn E, de Rooij M, Konings IR, Buffart LM, et al. Tailoring exercise interventions to comorbidities and treatment-induced adverse effects in patients with early stage breast cancer undergoing chemotherapy: a framework to support clinical decisions. Disability and Rehabilitation 2018;40:486–496

13. ‘Choosing Wisely’ app now available [website]. American Physical Therapy Association 2017 http://bit.ly/3YkjWPj

Related Content

l Low Back Pain: Moving Back To Basics [Article] https://bit.ly/3Wv7mwj l Pain Does Not Always Indicate Injury [Article] https://bit.ly/3pweyZI l Rehabilitation adherence: is it time to prioritise? https://bit.ly/3KULrfo l Gait retraining in medial osteoarthritis of the knee [Article] https://bit.ly/3y8NyV7

THE AUTHOR

Kathryn Thomas BSc Physio, MPhil Sports Physiotherapy is a physiotherapist with a Master’s degree in Sports Physiotherapy from the Institute of Sports Science and University of Cape Town, South Africa. She graduated both her honours and Master’s degrees Cum Laude, and with Deans awards. After graduating in 2000 Kathryn worked in sports practices focusing on musculoskeletal injuries and rehabilitation. She was contracted to work with the Dolphins Cricket team (county/provincial team) and The Sharks rugby teams (Super rugby). Kathryn has also worked and supervised physios at the annual Comrades Marathon and Amashova cycle races for many years. She has worked with elite athletes from different sporting disciplines such as hockey, athletics, swimming and tennis. She was a competitive athlete holding national and provincial colours for swimming, biathlon, athletics, and surf lifesaving, and has a passion for sports and exercise physiology. She has presented research at the annual American College of Sports Medicine congress in Baltimore, and at South African Sports Medicine Association in 2000 and 2011. She is Co-Kinetic’s technical editor and has taken on responsibility for writing our new clinical review updates for practitioners.

Email: kittyjoythomas@gmail.com