Module three: The chronic stage of rheumatoid arthritis

What defines the chronic stage of rheumatoid arthritis?

This stage is usually described as 2 or more years after initial diagnosis. Clinical practice guidelines usually refer to management in the first 2 years and beyond 2 years. Given some people are diagnosed with rheumatoid arthritis in childhood (usually termed juvenile idiopathic arthritis (JIA)), the chronic stage may begin in childhood.

What are the main issues to be aware of?

  • There will be a range of clinical presentations during the chronic stage. With appropriate medical management a patient may present in remission with little disease activity and disability
  • As rheumatoid arthritis is a systemic disease, without appropriate medical and pharmacological management patients will experience deterioration of key body systems (musculoskeletal, neurological, pulmonary, cardiac)
  • A therapeutic window should be used for physiotherapy treatment where possible
    • Pharmacotherapy and physiotherapy should work together
  • Expect periodic flares in symptoms
  • Rheumatoid arthritis has implications for pregnancy
    • The body's immune system changes during pregnancy to accommodate the foetus. For some patients with rheumatoid arthritis, this is associated with a transient remission of disease symptoms while others (up to 20%) experience a worsening of joint symptoms and fatigue. These symptoms may become particularly acute post-partum. Patients with rheumatoid arthritis have an increased risk of pre-eclampsia, Caesarean section, and premature or low birth weight neonates. Conception, pregnancy and breast feeding have implications for drug therapy regimens which may also impact on symptoms and a patient's emotional wellbeing. Further information about drug therapy issues for patients with rheumatoid arthritis during pregnancy is available from the ARA website. Patients planning pregnancy or discontinuing medications during pregnancy and breast feeding should consult their rheumatologist early.
    • Pharmacological management may need to be reviewed. Drug implications for pregnancy may be found from the ARA website, under the medicine information sheets
  • There are contraindications to treatment and red flags associated with rheumatoid arthritis.

Practice point: pregnancy with rheumatoid arthritis

In practice this means the physiotherapist needs to educate the patient regarding advice and strategies for the impending increase in work/demands associated with motherhood (Ackerman et al, 2015). A decision aid has been developed in Australia to assist people with rheumatoid arthritis make informed choices about starting a family. Other resources for women and their families are limited.

Practical considerations for the physiotherapist working with a pregnant woman and her family, include:

  1. Educating on ways to lift and carry a baby to reduce stress on joints
  2. Recommending alternative holding positions for breastfeeding/bottle-feeding a baby
  3. Providing aids/devices/supports to assist with day-to-day tasks such as changing nappies, getting a baby in and out of a car seat or cot
  4. Educating on practical suggestions e.g. buying clothes with zips or Velcro rather than press studs.

This video may be a helpful resource for pregnant women and their families. It is also important to provide information about other sources of support or assistance, for example:

  1. Local state/territory Arthritis Foundations
  2. Online support groups (e.g. see Young Women's Arthritis Support Group website)
  3. Access to home help services 

What happens in the chronic stage of rheumatoid arthritis?

  • Systemic inflammation continues causing further articular, peri-articular and extra-articular manifestations. The systemic inflammation leads to destruction of bone, cartilage, and synovial and connective tissues (see Figure 1 below).
  • Vasculitis causing body system and organ-specific complications
  • The personal and physical burden of the condition can contribute to psychological co-morbidities
    • You can measure depression, anxiety and stress in the clinic using a simple instrument called the Depression Anxiety Stress Scale (DASS)
  • Team-based and advocacy care becomes increasingly important (e.g. GP, occupational therapist, podiatrist, social worker, clinical psychologist)
Joint degeneration in rheumatoid arthritis

Figure 1: Joint degeneration in rheumatoid arthritis

The video below demonstrates how rheumatoid arthritis can lead to joint deformity and more.

What is your role as a physiotherapist during this stage?

Physiotherapists have long-term involvement in managing patients with rheumatoid arthritis and are often one of "the constants" in their life. Below is a video that discusses the role of a physiotherapist during the chronic stage of rheumatoid arthritis.

Your role as a physiotherapist for patients at this stage of chronic rheumatoid arthritis includes:

  • Monitoring
  • Managing
  • Encouraging
  • Working in partnerships with
  • Promoting self-management

Monitoring

  • Disease activity
    • Several tools are available (Anderson et al, 2012) and have been reviewed including:
      • Clinical Disease Activity Index
      • Disease Activity Score
      • Simplified Disease Activity Index
      • Patient Activity Scale
      • Routine Assessment of Patient Index
  • Patient progress
  • Quality of life
    • We know RA can have a negative impact on health related quality of life (HRQOL) including domains such as:
      • physical and social function
      • pain
      • mental health
      • emotional health
    • Regular re-assessment of these domains (e.g. using Tools such as the SF-36 (or its shorter versions such as the SF-12), AQoL or EuroQoL) can assist clinicians in targeting appropriate access to multi-disciplinary services (Matcham et al, 2014)
  • Fatigue

Managing

  • Symptoms and improving function using physiotherapy methods (exercise, stabilisation, manual therapy) and the "therapeutic window."

Practice point

Physiotherapists should encourage patients to comply with medication regimes and monitoring schedules, eg blood tests, and to seek help from their treating rheumatologists if side effects become apparent.

Encouraging

  • Maintenance of physical activity, strength, aerobic fitness
  • Use of joints to maintain function. Emphasise that using joints does not equal damaging joints

Important!

Monitor cardiovascular responses to exercise carefully (e.g. unexpected dyspnoea, chest pain)

Working in partnerships with

  • The patient and their carer/family
  • Other members of the care team

Partnership with my patient will include:

  • Building rapport over time to determine and understand:
    • functional limitations
    • short and long-term functional goals
    • experience with physiotherapy in the past
    • expectations of physiotherapy
    • self-management of their disease
  • Setting patient-focussed treatment plans and goals collaboratively
  • Providing education about what to expect in the chronic phase of the disease, including:
    • The role of physiotherapy
    • Strategies to deal with pain. Practical and evidence-based strategies can be learned from painHEALTH
    • Strategies to overcome functional limitations

Partnership with other members of the care team will include:

  • Referring on when in doubt, for example in the presence of red flags or apparent psychological health issues
  • Maintaining communication about disease and function with other team members
  • Participating in interdisciplinary care planning

Promoting self-management

Self-management is defined as "active participation in one's healthcare". This includes:

  • Finding the right information (e.g. asking health professionals).
  • Using the information to make decisions about one's healthcare (e.g. setting goals)
  • Taking action to address one's healthcare (e.g. attending a course)

The role of the health professional is to provide self-management support. In practice, this includes:

  • Helping people to take a central role in managing their health as a partner with their healthcare team.
  • Providing people with accurate information to make informed choices
  • Supporting and encouraging healthy behaviour choices (e.g. quitting smoking)

Strategies to develop effective self-management support can found be at the self-management support website provided by the Department of Health, Western Australia. Patient education is a fundamental part of self-management support provided by a practitioner. Self-management support is essential for facilitating improved self-management of a chronic condition like RA. See our evidence review table on patient education for more detailed information.

Are there any safety issues to be alert to and how do you approach them?

Yes, there are a wide range of safety issues you need to consider during the chronic stage of rheumatoid arthritis. To approach these safety issues, you should:

  • Look
  • Listen
  • Refer

Safety issues to be alert to including red flags:

Joint instability:

  • Pathologic processes associated with rheumatoid arthritis may lead to joint instability
  • Recognising joint instability in the upper cervical spine is critical. Instability can lead to sudden, unexpected death or quadriplegia.
  • Cervical instability can be asymptomatic, so clinical vigilance is critical, especially when using manual therapy techniques.

Vasculitis-driven dysfunction in other body systems:

Treatment-mediated conditions:

Disease flares:

  • Result in exacerbation of symptoms (pain, inflammation, fatigue, malaise, impaired function) which require:
    • Responsive and timely physiotherapy to ameliorate acute symptoms
    • Communication with other care team members including updating interdisciplinary team care plans during/following a disease flare
  • Cervical spine instability flexion

    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 extension

    Cervical spine instability extension

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

Summary

  • Rheumatoid arthritis is a chronic condition and patients will deteriorate without appropriate interventions
  • Physiotherapy treatment is more than just treating symptomatic joints
  • Co-morbidities and psychological wellbeing impact on treatment decisions and outcomes
  • There are important treatment contraindications and safety issues relevant to physiotherapy practice
  • Communication and timely on-referral to other care team members is critical - know who these people are and how to contact them

Bibliography

  1. Ackerman IN, Jordan JE, Van Doornum S, Ricardo M, Briggs AM. Understanding the information needs of women with rheumatoid arthritis concerning pregnancy, post-natal care and early parenting: A mixed-methods study. BMC Musculoskelet Disord. 2015;16:194. [Journal link]
  2. Anderson, J., Caplan, L., Yazdany, J., Robbins, M. L., Neogi, T., Michaud, K., et al. (2012). Rheumatoid Arthritis Disease Activity Measures: American College of Rheumatology Recommendations for Use in Clinical Practice. [Article]. Arthritis Care & Research, 64(5), 640-647. doi: 10.1002/acr.21649 [PubMed]
  3. Brosseau, L., G. A. Wells, et al. (2012). Ottawa Panel evidence-based clinical practice guidelines for patient education in the management of Rheumatoid Arthritis (RA). Health Education Journal 71(4): 397-451 [Link]
  4. de Man, Y. A., Dolhain, R. J., van de Geijn, F. E., Willemsen, S. P., & Hazes, J. M. (2008). Disease activity of rheumatoid arthritis during pregnancy: results from a nationwide prospective study. Arthritis Rheum, 59(9), 1241-1248. doi: 10.1002/art.24003 [PubMed]
  5. Depression Anxiety Stress Scales (DASS) [Link]
  6. Forestier, R., Andre-Vert, J., Guillez, P., Coudeyre, E., Lefevre-Colau, M. M., Combe, B., & Mayoux-Benhamou, M. A. (2009). Non-drug treatment (excluding surgery) in rheumatoid arthritis: clinical practice guidelines. Joint Bone Spine, 76(6), 691-698. doi: 10.1016/j.jbspin.2009.01.017 [PubMed]
  7. Fransen, J., & van Riel, P. L. (2009). The Disease Activity Score and the EULAR response criteria. Rheum Dis Clin North Am, 35(4), 745-757, vii-viii. doi: 10.1016/j.rdc.2009.10.001 [PubMed]
  8. Luqmani, R., Hennell, S., Estrach, C., Birrell, F., Bosworth, A., Davenport, G., et al. (2006). British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (the first two years). Rheumatology (Oxford), 45(9), 1167-1169. doi: 10.1093/rheumatology/kel215a [Pdf]
  9. Luqmani, R., Hennell, S., Estrach, C., Basher, D., Birrell, F., Bosworth, A., et al. (2009). British Society for Rheumatology and British Health Professionals in Rheumatology guideline for the management of rheumatoid arthritis (after the first 2 years). Rheumatology (Oxford), 48(4), 436-439. doi: 10.1093/rheumatology/ken450a [Pdf]
  10. Matcham, F., Scott, I.C., Rayner, L., Hotopf, M., Kingsley, G.H., Scott, D.L. & Steer, S. (2014) The impact of rheumatoid arthritis on quality-of-life assessed using the SF-36: a systematic review and meta-analysis. Semin Arthritis Rheum; 44(2): 123-130 [PubMed]
  11. Royal Australian College of General Practitioners. (2009). Clinical guideline for the diagnosis and management of early rheumatoid arthritis. Melbourne: RACGP. [Link]
  12. Slater, H., Briggs, A.M., Fary, R.E., & Chan, M. (2013). Upper cervical instability associated with rheumatoid arthritis: What to 'know' and what to 'do'. Manual Therapy, 18(6): 615-619 [PubMed]