Pathway to Independence: Physical Therapy for Patients With Rheumatoid Arthritis

Arthritis is one of the leading causes of disability in the United States, and it affects millions of people worldwide. There are many types of arthritis that, in combination, result in high medical costs, lost work productivity, and millions of physician visits each year.[1] Rheumatoid arthritis (RA) is a serious, systemic, autoimmune disease that results in the inflammation of joints and joint lining and may also affect internal organs and vascular systems. Typically, RA affects the bilateral joints of the wrists, fingers, knees, ankles, or feet. Rheumatoid arthritis is not only linked to joint and organ inflammation, but it is also associated with profound fatigue. Approximately three quarters of patients are women, with the onset of disease typically occurring between 20 and 45 years of age.[2] Regardless of epidemiology, this debilitating disease may significantly interfere with quality of life if early diagnosis and treatment are not implemented. Physical therapists and other rehabilitation specialists are important members of the treatment team that help patients cope with the chronic pain and disability of joint inflammation.

Since there is no cure for RA, disease management is the key. In Medscape General Medicine's new review article “Physiotherapy in Rheumatoid Arthritis,”[3] authors Kavuncu and Evcik elegantly describe the methodology by which physical therapists may help patients with RA understand and explore the available treatment options. This presentation of treatment modalities and rehabilitative strategies is supported by the scientific rationale of both current and classic literature. In general, treatment goals for patients with RA focus on early detection and intervention to minimize joint damage as early in the disease course as possible to help limit the need for surgical joint replacement. Management goals include controlling disease activity, alleviating pain, maintaining physical function, and maximizing quality of life.[4] Physicians coordinating the medical treatment of RA may utilize nonsteroidal anti-inflammatory medications, corticosteroids, disease-modifying antirheumatic drugs, and biologic disease response modifiers to help suppress inflammation and target physiologic factors that can lead to joint damage. Pharmacologic intervention may include oral, injected, or local medications.

Physicians help patients manage RA nonpharmacologically by working closely with an interdisciplinary team of healthcare professionals to provide patients with strategies to control pain, minimize fatigue, and maximize functional mobility. The goals of managing any disease must include the sustained effort of all healthcare professionals, with each team member keeping their focus on the patient intact — the patient is the one who must define what is meaningful activity. The treatment team uses a multidisciplinary approach and includes the primary care physician, rheumatologist, nurse specialist, physical therapist, occupational therapist, psychologist, dietician, and social worker. A successful treatment outcome requires the coordinated efforts of the team to inform the patient about the disease process and to encourage patient involvement in decision-making.

Individualized rehabilitation programs focus on educating patients about how exercise, weight control, pacing of activities, and lifestyle changes can improve function and independence. The emphasis is on patient empowerment to participate in self-care tasks and on personal responsibility in managing the disease. Rehabilitation specialists such as physical therapists help patients with RA understand and manage the daily tasks essential to maintaining quality of life. Although every healthcare professional contributes essential information to patients regarding each individual case, the physical therapist is critical in providing patient education and activity guidance. Therapists and patients work together to mutually establish goals that are meaningful, achievable, and based on the patient's own priorities. Treatment program goals must include consideration of health history, medications, joint stability or laxity, posture, coordination, balance, muscular atrophy, strength, joint swelling, and the impact of joint deformity or possible subluxation/dislocation. Plans of care must be modified according to the patient's tolerance and disease response. Patients are instructed in energy conservation techniques, work simplification, and independent problem solving. When patients understand that they have some control over their disease, they are more able to participate successfully in and comply with treatment regimens. Long-term compliance with a home exercise program is enhanced when patients are instructed about how to modify their activities according their physical limitations and stage of disease. Ability, not disability, is always the primary focus of treatment.

Physical therapists, also known as physiotherapists, comprehensively assess RA patients in an ongoing manner. The evaluation of each patient includes an examination of affected joint flexibility, bony alignment/joint deformity, muscle strength, endurance, mobility, ambulatory status, and the ability to perform activities of daily living. It can be a delicate balance to enhance mobility and strength without fatiguing the patient or creating an acute arthritis flare-up. Physical therapists are able to progressively tailor treatment plans to the individual by incorporating periods of activity and rest. Exercises that gently improve flexibility, strength, and endurance help to improve the patient's mood, outlook, mobility, and the ability to participate in important life events. Strength training is a key component of rehabilitation, as most people with RA suffer from muscular weakness even in the early stages of the disease. Häkkinen's recent study, “Effectiveness and Safety of Strength Training in Rheumatoid Arthritis,” shows that muscle strength can be maintained or improved in patients with RA through moderate or high-intensity strength training.[5] Despite their disease, patients with RA are able to demonstrate gains in muscle mass, strength, and endurance in response to physical exercise.[6] These positive changes in muscle function are significant in allowing patients to maintain independence and perform daily activities without negative effects on disease process or pain levels. Other benefits of exercise are improvement in bone density, coordination, and balance, which can minimize the risk of falls.[7]

People who receive rehabilitative treatment for RA are more likely to be able to be lead an active life and are enabled to participate in work, social, and self-care activities. Physical therapists act as mentors, friends, coaches, and drill instructors. They must be skilled, experienced, patient, and good listeners in order to help each patient achieve the highest level of function possible and limit disability. When a diagnosis of RA has been reached, it is critical to involve the patient in every aspect of self-management to support maximal functioning. Each patient's personal goals are always the first consideration when planning therapeutic intervention, and the health professional team members must work closely together to help educate and guide the patient. It is essential to find a balance between protecting the joints and gently exercising to enhance flexibility, mobility, and strength. The input of skilled physical therapists is critical to educate patients how to safely exercise, pace activities, protect joints, improve flexibility, and use assistive devices and adaptive equipment when appropriate. After discharge of patients from formal physical therapy programs, physical therapists coordinate goal-oriented home programs and provide resources for additional education in the community.

Physical therapists are trained to help each patient maximize his or her functional independence, and they are important members of every healthcare team in the management of RA. Physical therapists inform patients about rehabilitative treatment options and recommend appropriate treatment modalities for each stage of the disease process. Although there is no known cure for RA, the therapeutic intervention of physical therapists empowers patients in self-management of symptoms, preservation of functional mobility, and conservation of independence.