Summary of Condition
Rheumatoid arthritis (RA) is defined as a chronic, autoimmune, inflammatory disease that affects multiple joints in the body that are lined with synovial fluid. Combating rheumatoid arthritis normally consists of medicinal interventions, lifestyle changes, and conservative treatments to manage symptoms and provide pain relief for patients. In more severe cases of rheumatoid arthritis, surgery is indicated. This section will focus on the physical therapy management of rheumatoid arthritis without surgical intervention.
Physical therapy interventions can benefit rheumatoid arthritis patients who suffer from the major problems of the condition. They are as follows:
- Symmetrical joint presentation
- Severe pain
- Redness over the joints affected
- Impaired range of motion
- Impaired functional mobility
- Joint destruction and possible joint deformities
Guide to Physical Therapy Practice — Practice Pattern and Suggested Management (1)
Rheumatoid arthritis is relative to the following practice pattern:
Pattern 4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Connective Tissue Dysfunction
ICD-9 Code: 714.0 - Rheumatoid arthritis
Expected Range of Number of Visits Per Episode of Care: 3 to 36
Interventions/treatment for rheumatoid arthritis include:
- 1. Therapeutic Exercise: aerobic capacity/endurance conditioning, gait training, aquatic programs, range of motion techniques, stretching, strength, power and endurance training
- 2. Functional Training: ADLs, task adaptation, injury prevention
- 3. Manual Therapy: manual traction, passive range of motion, soft tissue mobilization
- 4. Electrotherapeutic Modalities: biofeedback, electrical muscle stimulation (EMS), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS)
- 5. Physical Agents and Mechanical Modalities: cryotherapy, hydrotherapy, thermotherapy, taping, continuous passive motion (CPM), traction devices
- 6. Prescription, Application, and Fabrication of Devices and Equipment: assistive devices, protective devices, orthotics, and other supportive devices
** Note: The interventions below are suggested by The Guide for patients presenting under this practical pattern. All interventions may not be appropriate for Rheumatoid arthritis or all patients.
Anticipated goals and expected outcomes:
- Pain is decreased
- Joint swelling, inflammation, or restriction is reduced
- Improved joint integrity
- Improved range of motion
- Ability to perform physical actions or tasks related to self, home, work and community is improved
- Functional mobility is improved
- Overall increase in quality of life
Evidence Based Treatment of Rheumatoid Arthritis (2) (3) (4) (5) (6) (7) (8) (9) (10) (11)
Exercising a patient with Rheumatoid Arthritis
With rheumatoid arthritis described as a chronic autoimmune disorder, the consequences to joint surfaces and increased morbidity make patients susceptible to loss of muscle mass, range of motion and diminished aerobic endurance. An exercise program is essential to prevent joint destruction and combat the symptoms associated with the disease, but comes with a multitude of challenges. Those who are diagnosed with RA may be unsure of beginning an exercise regimen due a lack of confidence in abilities and the pain it may cause. In a review article on the benefits of exercise in this patient population, it is shown that assistance from instructors and social interaction boost motivation for involvement in regular exercise routines. This is where physical therapists play a very important role!
Since the marker of this disease is joint destruction, the most important benefit to note is the impact exercise has on improving joint health. During the course of the disease, tendon sheaths, ligaments and cartilage can be affected and exercise can maintain their integrity. Range of motion and flexibility deficits that hinder a patients productivity can be improved with regular exercise, and combat RA-related fatigue.
Apart from the above benefits of incorporating exercise into an individual's lifestyle, the benefits for patients with rheumatoid are listed below:
-Reduce risk of cardiovascular disease
-Progressive resistance training has been shown to improve skeletal muscle size and strength, and is safe for patients with RA.
-In combination with progressive resistance training, weight-bearing exercises can improve bone mineral density.
-Improve overall function and increase quality of life
ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities summarizes exercise prescription for patients with rheumatoid arthritis: (11)
|Benefit||Type of Exercise||How to achieve|
|Improve CV health||Cycling, walking, swimming, dance||60-80% HR Max, 30-60 min/session, 3-5 days a week; Increase duration, then intensity over time|
|Increase muscle mass & strength||Free weights, weight machines, therabands||60-80% 1RPM, 8-10 exercises (large muscle groups), 8-12 repetitions, 2-3 sets, increase intensity over time|
|Increase ROM & flexibility for enhanced joint health||Stretching, Tai Chi, Yoga/Pilates||10-15 minutes, 2 days a week|
|Improve balance||One leg stance, stability ball, strengthening core muscles||regular basis|
The RA Hand - exercises:
Image Source: http://www.drfoot.co.uk/pictures/wristexe.jpg
In terms of finding strategies that offer a patient with rheumatoid arthritis relief, a lot of "evidence" regarding the benefit is individual-specific. The most commonly used physical agents in combating rheumatoid arthritis are thermotherapy and cryotherapy. Thermotherapy modalities can increase blood flow and elasticity of tissues and can be applied as hot packs, paraffin wax, or hydrotherapy. During a flare up of rheumatoid arthritis, a patient may prefer cryotherapy over thermotherapy to cool the joint down, attempt to numb the pain and control inflammation. A cold-pack, ice chips, ice massage or nitrogen spray can be applied to areas where calming inflammation and pain are desired. According to a Cochrane Review of these physical agents, in treating rheumatoid arthritis, there was no significance for hot and cold packs in objective measures of disease activity (pain, ROM, grip strength, etc) but paraffin wax paths showed positive results in reducing pain and objective measures of range of motion in the arthritic hand. It is recommended that these methods be used in conjunction with medical management and exercise programs for patients with rheumatoid arthritis.
Transcutaneous electrical nerve stimulation (TENS) is a therapeutic intervention indicated for pain control and muscle stimulation. While the literature on the use of TENS in patients with rheumatoid arthritis is rather conflicting, it can be supported using the modality for this patient population as TENS does not cause any adverse side effects. Brosseau, Yonge et al. provide literature on TENS for the treatment of rheumatoid arthritis in the hand and include the methods of administering TENS and can be found in the chart below:
|Type of TENS||Frequency||Intensity|
|Conventional TENS||HIGH (40-150Hz)||LOW|
|Burst TENS||HIGH (40-150Hz)||LOW (1-2Hz)|
The ambiguity of the effectiveness of TENS can be related to the type of intensity and frequency administered. Research suggests that TENS for patients with this condition, mainly in treating RA of the hand, provides pain relief when the method is administered, but upon its completion, shows little to no residual benefit. It is safe to say at this time TENS is a short-acting therapy and the beneficial frequency to deliver is 70Hz.
Image Source: http://chirocity.com/ProductImages/ccs/tens/tens7000.jpg
A Cochrane Review in 2010 evaluated the effectiveness of continuous ultrasound in the treatment of RA. This review showed that ultrasound applied to the dorsal and palmar surfaces of hand increased grip strength and to a lesser extent improve wrist flexion and reduce swelling in joints.
Joint Protecting Strategies
Patients with rheumatoid arthritis often have joint deformity and severe pain manifesting in the great toe, heel, and lesser toe. This can impact gait and functional mobility. Patients with RA can be prescribed foot orthoses or specialist footwear to combat these issues, and receive education for care of skin and nails.
Image Source: http://www.kellythechiro.com
The use of splints may be able to provide relief for a rheumatoid patient in acute stage of the disease. Splints may allow functional position to give rest to involved joints. Splinting can provide pain relief, reduce inflammation, increase range of motion, and prevent deformities.
Physical therapists can employ the use of assistive devices for patients with RA to improve functional ability and independence in daily activities. Appropriate assistive devices that benefit patients range from work chairs, rolling walkers, canes, and reachers. Research suggests reasons for using assistive devices also reduce amount of load placed on the joint, reduce pain, fatigue and inflammation.
Sources such as the Mayo Clinic and the Cleveland Clinic discuss that there are other ways to promote joint health in RA patients. Proper diet is an essential part of maintenance of the disease, as well as adequate rest. Tai Chi, Yoga, and Pilates are also effective disciplines that can increase range of motion, flexibility, strength, and cardiovascular endurance without putting a large amount of force on joint surfaces.
Image Source: http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_images/articles/health_tools/RA_exercises_slideshow/getty_rr_photo_of_group_doing_tai_chi.jpg
Image Source: http://yogainbocaraton.com/wp-content/uploads/2011/12/pilates1.jpg
Other available resources:
1. American Physical Therapy Association. Guide to physical therapist practice, 2nd ed. Phys Ther. 2001;81(1): 9-746
2. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Questions about Rheumatoid Arthritis. 2012. http://www.niams.nih.gov/Health_Info/Arthritis/arthritis_rheumatic_qa.asp
3. Welch V, Brosseau L, Casimiro L, Judd M, Shea B, Tugwell P, Wells GA. Thermotherapy (heat treatment) for treating rheumatoid arthritis. Cochrane Database for Systematic Reviews. 2011.
4. Davies S, Williams A, Graham A, Dagg a, Longrigg K, Lyons C, Bowen C. Guidelines for the management of foot health for people with rheumatoid arthritis. North West Podiatry Services Clinical Effectiveness Group - Rheumatology. 2010.
5. Kavuncu V, Evcik D. Physiotherapy in rheumatoid arthritis. Med Gen Med. 2004;6(2).
6. Vlieland V TPM. Non-drug care for RA — is the era of evidence-based practice approaching? Rheumatology. 2007;46:1397-1404.
7. Brosseau L, Yonge KA, Robinson V, Marchand S, Judd M, Wells G, Tugwell P. Transcutaneous electrical nerve stimulation (TENS) for the treatment of rheumatoid arthritis in the hand. Cochrane Database for Systematic Reviews. 2003.
8. Casimiro L, Brosseau L, Welch V, Milne S, Judd M, Wells GA, Tugwell P, Shea B. Continuous ultrasound to the hand benefits grip strength in people with rheumatoid arthritis. Cochrane Database for Systematic Reviews. 2010.
9. de Boer IG, Peeters AJ, Ronday HK, Mertens BJA, Huizinga TWJ, Vlieland V TPM. Assistive devices: usage in patients with rheumatoid arthritis. Clin Rheumatol. 2008;28:119-128.
10. Cooney JK, Law R, Matschke V, Lemmey AB, Moore JP, Ahmad Y, Jones JG, Maddison P, Thom JM. Benefits of exercise in rheumatoid arthritis. Journal of Aging Research. 2011.
11. Durstine JL, Moore GE, Painter PL, Roberts SO. ACSM’s Exercise Managment for Persons with Chronic Diseases and Disabilities. 2003.