module two: The early stages of rheumatoid arthritis

What is the early stage of rheumatoid arthritis?

The early stage of rheumatoid arthritis is usually described as disease duration of less than two years after diagnosis. Clinical practice guidelines have been developed and are available for best-practice management of early rheumatoid arthritis. Non- pharmalogical clinical guidelines like the Ottawa’s panel’s education, therapeutic exercise and electrotherapy and thermotherapy guidelines and Forrestier non-drug treatment guidelines are also available.

Symptoms of rheumatoid arthritis may be severe in the early stage of the disease since some drug treatments may take up to 12 weeks to take effect. Moreover, patients may be prescribed several different regimens of medications until an effective agent(s) is identified. Some people experience rheumatoid arthritis from childhood (usually termed juvenile idiopathic arthritis (JIA)), while others experience the onset of symptoms in adulthood.

What are the important issues in the early stage of rheumatoid arthritis?

Receiving a diagnosis of rheumatoid arthritis will be upsetting and stressful for most people. In this context, compassion, support and listening are critical skills. In practice, this means:

Practice point

  • The physiotherapist should endeavor to take all reasonable measures to ensure the patient has seen a rheumatologist and started treatment early. Early intervention is critical for an improved prognosis.
  • Listen and look for signs of stress, anxiety, depression, hopelessness. On-refer if appropriate. You can use tools such as the Depression Anxiety Stress Scales (DASS) to measure some of these psychosocial issues
  • For more information on the assessment of psychological factors, and relevant practice tools to address psychological health impairments, such as mindfulness, refer to the painHEALTH website and also to our evidence summary on managing psychological factors.
  • Identify the patient’s/family’s main concerns or uncertainties.

Patients may have difficulty in coping with pain, fatigue, stiffness and impaired function, particularly when waiting for drugs to take effect. During this time, a physiotherapy management plan will need to accommodate these symptoms. In practice, this means:

  • Determine whether a therapeutic window exists where a therapeutic intervention may be applied.
  • Determine, through subjective assessment, when and where the person is best able to function in the day (e.g. after early morning stiffness subsides or after analgesia)
  • Determine the level of physical activity appropriate (e.g. home exercises, hydrotherapy) to the person’s exercise tolerance and disease symptoms (see our evidence summary table for exercise based interventions)
  • Determine the level of fluctuation in disease symptoms with physiotherapy intervention
  • Communicate with other care team members about an appropriate inter-disciplinary management plan

The impact of being diagnosed with rheumatoid arthritis can be substantial. The individual in this video describes her experience of being diagnosed with rheumatoid arthritis.

What is my role as a physiotherapist in this stage?

Physiotherapy should be patient-centred and therefore based on a holistic approach. There is evidence for the efficacy of physiotherapy for rheumatoid arthritis (see bibliography at the end of the module). Key features of physiotherapy management during the early stage of rheumatoid arthritis include:

  • Communication
  • Education
  • Self-management support
  • Development and implementation of a client-centred management plan

Communication

  • Listening is critical in order to understand the impact of rheumatoid arthritis and the specific issues for the patient
    • What are the patient’s main concerns, and can these be addressed?
  • Advocating on behalf of the patient in the workplace and with community support agencies
  • Communicating with other members of the health care team and family members

The video below highlights what you should aim to achieve when communicating with a patient if they show symptoms of the early stage of rheumatoid arthritis.

Education

  • Considering what information (if any) has already been conveyed to the patient and where physiotherapy-specific information can value-add
  • The role of physiotherapy – what to expect in the short and long term
    • Short term: symptom relief, address inflammation, education about the disease
    • Long term: strength and aerobic training, functional rehabilitation
  • What to expect with rheumatoid arthritis – pain, functional impairments, flares
    • How to use a therapeutic window
  • Where to seek further information, such as:

Practice points

Pacing means:
  • Helping patients compartmentalise activity into small bundles
  • Determining the appropriateness of the ‘activity bundle’ by discussing symptoms relative to time and activity

Important

Education has been identified as an effective intervention to improve outcomes for people with rheumatoid arthritis in the areas of:
  • Reducing disease activity, morning stiffness, pain intensity
  • Increasing grip force, endurance, exercise compliance
  • Developing knowledge of the illness
  • Improving functional status; joint protection, energy conservation, self-efficacy, patient as well as physician global assessment and,
  • Enhancing psychological well-being and quality of life (QOL) (Brosseau et al (2011).
  • Problem based learning could be considered to facilitate empowerment, lifestyle change, sleep & fatigue (Arvidsson et al, 2013)
  • See our evidence summary table for more detailed information about the evidence underpinning education interventions

Self-management support

Self-management is defined as “active participation in one’s healthcare”. This means:

  • 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)

Strategies to develop effective self-management support can be found at the Self Management Support website provided by the Department of Health, Western Australia.

Practice points

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

The physiotherapist can promote self-management of rheumatoid arthritis by empowering patients with knowledge about the disease (education), and self-management support. This video clip is a recollection of the impact physiotherapy has had on 3 consumers with a long history of rheumatoid arthritis.

Develop and implement a client-centred management plan

Important

In practice, flares usually mean that the current pharmacologic management may not be appropriate for the stage of the disease. The patient may experience an exacerbation of symptoms and therefore should be reviewed by their rheumatologist.
  • MANAGE SIGNS AND SYMPTOMS to minimise impact on the patient’s activities of daily living therefore maximising/ promoting ‘normal’ function
    • Decrease pain and inflammation – electrotherapy, compression, stabilisation, pacing. See our evidence table on electrophysical agents.
    • Improve strength and functional capacity specific muscle strengthening for power and endurance, functional re-training, hydrotherapy, joint protection strategies (refer to evidence tables for exercise and joint protection).
    • Improve joint stability – taping splinting, strengthening, joint protection strategies. For more information about joint protection techniques, download our joint protection techniques summary [.pdf 392kB] and the evidence table for orthoses, splinting and joint protection.
  • ADOPT A PATIENT CENTERED APPROACH
    • Provide patient-centred home exercise programme
    • Support patient self-management strategies underpinned by the principles of chronic disease self-management: goal setting, understanding the disease and identifying needs.
  • ENGAGE with other healthcare providers. For example:
    • Determine who the other team members are
    • Communicate your management plan
    • Participate in team care planning
    • On-refer as needed (e.g. podiatry, occupational therapy, clinical psychology, medical practitioner)

Watch the video below to listen to an advocate of interdisciplinary care describe her experience.

  • MONITOR disease activity and severity
    • Several tools are available including:
      • Clinical Disease Activity Index (CDAI) [.pdf 206kB]
      • Disease Activity Score
      • Patient Activity Scale
      • Routine Assessment of Patient Index and
      • Simplified Disease Activity Index

Please refer to Anderson et al [.pdf 269 kB] for a systematic review of rheumatoid arthritis disease activity measures.

Are there any safety issues of which I need to be aware of?

  • Avoid high intensity exercise or manual techniques during a flare. Instead, manage pain, fatigue and inflammation
  • Be aware of presenting limitations (symptoms and signs)
  • Avoid high intensity and end-of range joint mobilisation/manipulation, especially in the upper cervical spine (see Module 4)
  • Avoid techniques that may put increased stress on areas where skin is fragile due to age or corticosteroid use, for example high-pressure manual therapy or use of kinesthetic taping
  • Assess neurological integrity before applying electro-physical agents

Summary

  • Patients are usually distressed in the early stage of the disease; listening to and support of patients is critical
  • Physiotherapists play an important role in the early stage of the disease course, particularly in education, self-management support and development of flexible and tailored management plans
  • Disease flares are not uncommon and require responsive physiotherapy
  • Physiotherapists need to be aware of safety issues when treating patients with rheumatoid arthritis

Bibliography

  1. 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]
  2. Arvidsson, S., Bergman, S., Arvidsson, B., Fridlund, B. & Tingstrom, P. (2013) Effects of a self-care promoting problem-based learning programme in people with rheumatic disease: A randomized controlled study. J Adv Nurse, 69(7), 1500-1514. [PubMed]
  3. Bell, M. J., Lineker, S. C., Wilkins, A. L., Goldsmith, C. H., & Badley, E. M. (1998). A randomized controlled trial to evaluate the efficacy of community based physical therapy in the treatment of people with rheumatoid arthritis. J Rheumatol, 25(2), 231-237. [PubMed]
  4. 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]
  5. Chronic conditions self-management support websites: [Department of Health Chronic Conditions Self-Management, Medicare Chronic Disease]
  6. Depression Anxiety Stress Scales (DASS) [link]
  7. 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]
  8. Glasgow, N. J., Jeon, Y. H., Kraus, S. G., & Pearce-Brown, C. L. (2008). Chronic disease self-management support: the way forward for Australia. Med J Aust, 189(10 Suppl), S14-16. [PubMed]
  9. Hewlett, S., Ambler, N., Almeida, C., Cliss, A., Hammond, A., Kitchen, K., et al. (2011). Self-management of fatigue in rheumatoid arthritis: a randomised controlled trial of group cognitive-behavioural therapy. Ann Rheum Dis, 70(6), 1060-1067. doi: 10.1136/ard.2010.144691 [PubMed]
  10. Hurkmans, E., van der Giesen, F. J., Vliet Vlieland, T. P., Schoones, J., & Van den Ende, E. C. (2009). Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis. Cochrane Database Syst Rev(4), CD006853. doi: 10.1002/14651858.CD006853.pub2 [PubMed]
  11. Hurkmans, E. J., Jones, A., Li, L. C., & Vliet Vlieland, T. P. (2011). Quality appraisal of clinical practice guidelines on the use of physiotherapy in rheumatoid arthritis: a systematic review. Rheumatology (Oxford), 50(10), 1879-1888. doi: 10.1093/rheumatology/ker195 [PubMed]
  12. Li, L. C., Davis, A. M., Lineker, S. C., Coyte, P. C., & Bombardier, C. (2006). Effectiveness of the primary therapist model for rheumatoid arthritis rehabilitation: a randomized controlled trial. Arthritis Rheum, 55(1), 42-52. doi: 10.1002/art.21692 [PubMed]
  13. 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]
  14. McCracken, L. M., & Samuel, V. M. (2007). The role of avoidance, pacing, and other activity patterns in chronic pain. Pain, 130(1-2), 119-125. doi: 10.1016/j.pain.2006.11.016 [PubMed]
  15. Ottawa Panel (2004). Ottawa Panel evidence-based clinical practice guidelines for therapeutic exercises in the management of rheumatoid arthritis in adults. Phys Ther, 84(10), 934-972. [PubMed]
  16. Ottawa Panel (2004). Ottawa Panel Evidence-Based Clinical Practice Guidelines for Electrotherapy and Thermotherapy Interventions in the Management of Rheumatoid Arthritis in Adults. Phys Ther, 84(11), 1016-1043. [PubMed]
  17. Royal Australian College of General Practitioners. (2009). Clinical guideline for the diagnosis and management of early rheumatoid arthritis. Melbourne: RACGP. [Link]