Why is rheumatoid arthritis a significant health problem?

  • Rheumatoid arthritis is a National Health Priority Area in Australia
  • Rheumatoid arthritis is the most common autoimmune disease in Australia
  • Rheumatoid arthritis is the second most common arthritis after osteoarthritis (OA) and the most common inflammatory arthritis condition
  • The incidence of rheumatoid arthritis increases with age with the greatest onset being between 25 and 50 years; that is during the peak income-earning years
  • There is a gender bias towards females of ~2.5:1
  • Rheumatoid arthritis affects about 2% of the Australian population
  • For more information on rheumatoid arthritis, see the 2013 Australian Institute of Health and Welfare Report and the 2013 Australian socioeconomic report on musculoskeletal health conditions, "A problem worth solving"

Rheumatoid arthritis is a progressive, chronic, systemic, inflammatory disease that if not treated early and appropriately leads to substantial disability and increased mortality.

How does rheumatoid arthritis start?

While the cause of rheumatoid arthritis is unknown, multiple factors such as genetic and environmental influences have been linked with the onset of rheumatoid arthritis. An unknown event or stressor is thought to trigger abnormal activity in the body's immune system, causing synovial tissue and adjacent structures to be affected.

What happens in rheumatoid arthritis?

Rheumatoid arthritis is associated with systemic inflammation. The primary structures affected by this systemic inflammation include:

  • Synovial-lined structures, leading to persistent synovial joint inflammation
  • Blood vessels, leading to vasculitis. Vasculitis manifests as signs and symptoms of ischaemic changes in the affected organs and tissues

Secondary manifestations of systemic inflammation include:

  • Degeneration of articular cartilage and subchondral bone, presenting as secondary osteoarthritis. Watch this video to learn more about consequences of articular inflammation.

Below you will see a range of joint erosion examples.

  • Severe joint erosion - hands

    Severe joint erosion - hands

    Radiograph illustrating rheumatoid arthritis associated deformities of the hands at MCP and IP joints.

  • Joint erosion - feet

    Joint erosion - feet

    Radiograph illustrating RA-associated deformities of the feet at MTP and IP joints (Hallux valgus and hammer toe).

What is the impact of rheumatoid arthritis?

Rheumatoid arthritis is associated with substantial personal and societal burdens including pain, disability and psychosocial consequences. Rheumatoid arthritis affects people during their peak income-earning and child-bearing years and its prevalence is expected to increase. Current and projected public health costs are substantial (e.g., government-subsidised drug therapies). Depression is very common in rheumatoid arthritis (Matcham et al, 2013).

The video below describes some individuals’ experiences of living with rheumatoid arthritis.

What are the main clinical features of early rheumatoid arthritis and how would you recognise them in practice?

Listen for:

  • Fluctuating pattern of joint pain and joint tightness
  • Reports of pain worse at night (This is usually indicative of inflammatory-mediated pain).
  • History of insidious onset of joint pain and swelling
  • Prolonged morning joint stiffness (>30 minutes) and stiffness after inactivity
  • Feeling of heat in the joints
  • Symptoms of malaise and fatigue
  • Triggers to onset. For example, a major life stress event, such as the loss of a loved one, can trigger auto-immune responses and may be associated with the onset of rheumatoid arthritis (Stovanovich & Marisavljevich, 2008).
  • Reports of a decline in functional ability

Physiotherapists need to listen for features which may indicate rheumatoid arthritis. The video below gives examples of how a patient may describe typical symptoms, including: stiffness, fatigue, swelling, flares, pain and extra-articular features.

Look for:

  • Symmetrical pattern of joint involvement in the appendicular skeleton and/or the axial skeleton
  • Synovial joint swelling
  • Synovitis; presenting as swelling, pain
  • Bursitis
  • Tenosynovitis
  • Heat
  • Redness
  • Decreased active and passive joint range of movement
  • Functional impairment in hands and feet (fine and gross motor skills)
  • Synovial joint deformity* - postural, subluxation, dislocation
  • Joint instability* (e.g. disruption of ligamentous support)
  • Joint degeneration - joint erosion which may only be identifiable on MRI or CT (predominantly small joints in hands and feet plus or minus larger joints)

* Predominantly small joints in hands and feet plus or minus larger joints.

What are the common articular and peri-articular features that I might encounter in practice?

Common articular and peri-articular features associated with rheumatoid arthritis present clinically and may impact on function. For more information about articular and peri-articular features, download our articular and peri-articular features summary table [.pdf 67 kB] and see our accompanying image slider below.

  • Cervical spine instability extension

    Cervical spine instability flexion

    Plain radiograph of the cervical spine showing 5 mm of anterior subluxation (arrowed) of C1 on C2, reflected in an increased anterior atlanto-dens interval (AADI) on flexion.

  • Cervical spine instability flexion

    Cervical spine instability extension

    While the anterior atlanto-dens interval (AADI) increases on flexion, it is reduced with cervical extension.

  • Active movement of joint

    Deformity

  • Swan neck

    Swan neck

    Swan neck deformity (4th digit).

  • 4th digit swan neck, 5th digit mallet finger

    Swan neck and mallet finger

    Swan neck deformity (4th digit) and mallet finger (5th digit).

  • Foot hallux valgus weight bearing

    Hallux valgus

    Bunion deformity.

  • Mallet toe

    Hammer toe

    Hammer toe (2nd digit).

  • Nodules elbow

    Nodules elbow

    Subcutaneous nodule on ulnar side of forearm.

  • Nodules ankle

    Nodules ankle

    Subcutaneous nodule on anterior aspect of lower leg.

  • Nodules elbow alternative

    Nodules elbow

    Subcutaneous nodule over left elbow.

Extra-articular features also present clinically in several body systems. For more information about common extra-articular features, see Module 4: extra-articular features of rheumatoid arthritis and co-morbid conditions.

What is my role as a physiotherapist if I suspect my patient has rheumatoid arthritis?

Your role as a physiotherapist is to:

  • Recognise
  • Co-manage
  • Assess and refer

Below is an example of an individual who has had a long history of symptoms of rheumatoid arthritis.

Recognise

Physiotherapists are often the first point of contact for patients presenting with features consistent with rheumatoid arthritis. Current best practice management for people with rheumatoid arthritis includes prompt symptom management and early implementation of disease modifying anti-rheumatic drugs (DMARDs) (within the first 12 weeks).

Important

Early recognition of rheumatoid arthritis and on-referral to a medical practitioner is critical to optimise prognosis. The Early inflammatory Arthritis Detection Tool may be appropriate for physiotherapy clinical practice to help clinicians identify rheumatoid arthritis.

The European League Against Rheumatism (EULAR) defines rheumatoid arthritis based on:

  • A) Synovitis in at least 1 joint which cannot be explained by an alternative diagnosis, and
  • B) Symptom duration, and
  • C) Serologic abnormality, and
  • D) Elevated acute-phase response.

For more information, download our European League Against Rheumatism guidelines table [.pdf 80 kB].

Physiotherapists are well placed to identify the Synovitis and Symptom Duration (B) criteria. You can record the patient's joint involvement using a joint count [.pdf 159 kB].

Co-manage

Co-manage means to:

Assess and refer

Practice point

The DAS28 is the assessment tool most commonly used in clinical practice in Australia.
  • Record findings from subjective and objective exam as a baseline. Use standard instruments where possible and describe the history of onset e.g. a disease activity score in 28 joints (DAS28) or the Clinical Activity Disease Index (CDAI). Here is an example of a completed DAS28 [.pdf 80kB] and the CDAI tool [.pdf 206kB].
  • Squeeze test across MCP and/or MTP joints. See the video below for an example.
  • Synovial joint effusion
  • Muscle strength / atrophy (e.g. hand dynamometry). See video below for an example
  • Standard musculoskeletal examination - active and passive range of movement, strength, posture, joint stability, function, neurological assessment (as appropriate)
  • Refer to a medical practitioner if there is the slightest possibility that the patient has an inflammatory arthropathy - download our example referral letter template [.docx 15.6kB]

The video below demonstrates the squeeze test across MCP joints of the hand and MTP joints of the foot.

Practice points

While there are a range of hand dynamometers available, many may be unsuitable for patients with rheumatoid arthritis because of their hand deformities. A pneumatic dynamometer is usually appropriate for patients with rheumatoid arthritis and will increase the reliability of force measures.

The video below demonstrates a patient's left and right grip strength being tested. Muscle strength testing is important to evaluate functional capacity.

What is the medical management for rheumatoid arthritis and where do you fit in?

Pharmacologic management of rheumatoid arthritis is the mainstay of disease control and most effective when initiated EARLY. Early diagnosis and appropriate medical treatment is critical, as poorly controlled rheumatoid arthritis is associated with, for example, increased risk of death, increased risk of cardiovascular disease, increased loss of ability to participate in the workforce, and increased need for joint replacement surgery. "Time to rheumatologist" is recognised as a key factor in differing disease progressions with decreased time leading to better clinical outcomes. Remission or low disease activity is now the goal and the reality for most if seen early enough by a rheumatologist.

Medications are used to slow down disease progression and to relieve symptoms. Early treatment with disease modifying anti-rheumatic drugs (DMARDs) or biologic agents (bDMARDs) reduces joint destruction and disability and improves clinical outcomes. For further information on commonly used therapies for the treatment of rheumatoid arthritis in Australia, visit the Australian Rheumatology Association.

Medical management is also often consistent with the "treat-to-target" paradigm. This means regular review and modifying therapy to achieve the agreed "target".

Other pharmacological management include:

  • Anti-inflammatories
  • Analgaesics
  • Muscle relaxants

Medical and surgical interventions include:

  • Injections
    • Corticosteroid injections
      • Joints
      • Bursae
      • Tendon sheaths
  • Synovectomies: Removal synovial sheath enveloping structure
  • Joint replacement
  • Joint fusion

Where does the physiotherapist fit in?

  • Communicates with the medical practitioner about a co-operative management plan
  • Identifies with the patient the ideal times for physiotherapy, based on a drug regime or surgical intervention
  • Contributes to post-operative rehabilitation (e.g. after a total joint replacement)

Summary

  • Rheumatoid arthritis is more than a musculoskeletal condition! It is an autoimmune, systemic and progressive condition that affects synovial joints and multiple other body (extra-articular) systems.
  • People with rheumatoid arthritis may experience substantial disability throughout the disease course and increased mortality.
  • As primary contact practitioners, physiotherapists have an important role in identifying the early features of rheumatoid arthritis and referring patients early for diagnosis and early medical management.

Bibliography

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