PT Classroom - Review of Rheumatoid Arthritis ׀ by Amber Devine PA-C & Chai Rasavong, MPT, MBA

Rheumatoid arthritis (RA) is a chronic progressive systemic inflammatory disease that affects joints at the wrist, knee, cervical spine and joints of the fingers, hands or knees (1, 2, 3, 4, 5, 6). It can also affect organs such as the eyes, heart or lungs (1, 2). RA affects 1.3 million U.S. adults (1). It is more common among women than men by a ratio of 5:1 and often begins between the fourth and sixth decades of life (1, 3). RA is a highly disabling disease associated with morbidity (3). Yelin et al (4), reported that despite receiving appropriate drug therapy, up to 7% of patients are disabled to some extent 5 years after the onset of RA and 50% are too disabled to work 10 years after onset.

Signs and Symptoms of Rheumatoid Arthritis
Symptoms of RA usually present insidiously and progress slowly (2). Individuals with RA usually complain of experiencing prolonged stiffness in the morning, joint pain, fatigue, weakness, psychological depression, swelling, palmar erythema, cool moist skin, muscular atrophy, contracture of joints, weight loss, synovial hernias, increased temperature, and the development of firm lumps, called rheumatoid nodules, which grow beneath the skin in places such as the elbow, Achilles tendon and hands (1, 3, 5).

Etiology / Diagnosis
The cause of RA is unknown. However, it is believed that an autoimmune response plays an important role (1, 2). Approximately 80% of individuals with RA are rheumatoid factor-positive (2). Rheumatoid factors are antibodies that react with immunoglobulin antibodies found in the blood, synovial fluid and synovial membrane (2). It is believed that the interaction between the rheumatoid factor and immunoglobulin results in an inflammatory reaction (2). From this reaction destructive lysomal enzymes are released which contribute to articular destruction and synovial hyperplasia (2).

A rheumatologist is able to determine a diagnosis of RA based on history, physical exam and various blood tests (1, 2). Table 1 lists the diagnostic criteria proposed by the American Rheumatism Association (7).

Table 1 - American Rheumatism Association Diagnostic Criteria for RA
RA criteria: (if 5 out of following are present for > 6 weeks);
• morning stiffness
• pain on motion, or tenderness in at least one joint
• swelling (soft tissue thickening or fluid, not bony overgrowth alone) in at least one joint
• swelling of at least one other joint (any interval free of joint symptoms between the two joint)
• poor mucin precipitate from synovial fluid
• characteristic histologic changes in synovium
• characteristic histologic changes in nodules

Physical Therapy and Rheumatoid Arthritis
The treatment goals for a patient with RA are to reduce pain, maintain mobility, minimize stiffness, control edema & inflammation and minimize joint destruction (2). Physical therapy intervention can help with preventing contractures, improving strength & flexibility and promoting aerobic conditioning (2).

A Cochrane Review by Ottawa panel members (3) found good evidence that therapeutic exercises, including functional strengthening and low- or high-intensity exercises, relieve pain and improve overall function in patients with RA. It also recommended further research to determine the efficacy of manual therapy in the management of RA.

A study by Swardh et al. (6) found that when working with patients with RA, it is important to find the proper context and support for each patient’s needs. Furthermore, preparing for exercise maintenance by strengthening the patient’s beliefs in his or her ability to exercise in different settings, by discussing pros and cons of exercise, and by exploiting the patient’s ability to adapt and continue exercise outside of the health care environment might be valuable (6).

Last revised: April 21, 2014
by Amber Devine, PA-C & Chai Rasavong, MPT, MBA