module two: The early stages of rheumatoid arthritis

What is the early stage of rheumatoid arthritis?

The early stage of rheumatoid arthritis (RA) is usually described as the first two years after diagnosis. The main clinical signs and symptoms are outlined in Module One.

Clinical guidelines have been developed and are available for best-practice management of early RA (eg. RACGP, Therapeutic Guidelines). Non-pharmalogical clinical guidelines, including the Ottawa’s panel’s education, therapeutic exercise and electrotherapy and thermotherapy guidelines and Forrestier non-drug treatment guidelines are also available.

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

Physiotherapists need to consider a number of important issues, taking into account the biological, psychological and social impacts of RA. Key issues include:

Varied disease course

Flares occur as part of the disease process, with periods of increased disease activity resulting in any combination of increased pain, swelling and fatigue. Flare ups of pain and fatigue can also occur due to the individual’s approach to activity management (see Activity Management below) and psychosocial factors such as stress.

Some people experience RA from childhood (usually termed juvenile idiopathic arthritis (JIA) or juvenile chronic arthritis (JCA)), while others experience the onset of symptoms in adulthood.

Important

The course of RA varies between people. Most people experience a slowly progressive disease, with intermittent exacerbations (flares). A small proportion of people have a more severe form of RA, resulting in more joint destruction, deformity and disability.

Early medical treatment is critical

Early diagnosis and appropriate medical treatment is critical, as poorly controlled RA is associated with increased risk of cardiovascular disease and death, reduced ability to participate in the workforce, and increased need for joint replacement surgery. Pharmacologic management of RA is the mainstay of disease control and most effective when initiated early.

"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 reality for most if seen early enough by a rheumatologist, or other specialist physician.

Early on-referral for suspected RA (or other inflammatory arthropathy) is, therefore, critical for optimising prognosis.

Response to drug therapy

RA symptoms may be severe in the early stage of the disease. Some drug treatments take up to 12-16 weeks to take effect, and individuals may be prescribed several different medication regimens until an effective agent(s) is identified. In Australia, individuals are required to trial several different drug combinations before biological disease modifying therapy (bDMARD) subsidies are provided.

Practice point

Some people experience significant pain, fatigue, stiffness and impaired function while waiting for drug treatments to take effect. Some people may be prescribed steroids as a combination over this period, which may be associated with secondary skeletal impairments.

Psychosocial impact of diagnosis

Receiving a diagnosis of RA can be upsetting and stressful. Both the diagnosis itself and the disease process can have a substantial impact upon the person’s psychological and social well-being.

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

Person-centred care

Each person with RA will have a unique perspective on their problems, expectations, goals, and the impact on their functional capacity and quality of life.

Practice point

Individuals present with varying levels of perceived needs, knowledge and skills, as well as different levels of readiness to engage in co-management of their condition. Additionally, individual’s needs, wants and priorities change over time, and as their experience with the disease develops.

The person’s management plan must take these factors into account. An appropriate approach to integrated care is to provide services that focus on the needs of the person, not the structural organisation of the services themselves. Ideally, health and social care services should be provided to optimise outcomes.

Co-morbid conditions

People with RA may have co-morbid health conditions and/or injuries. These conditions/injuries may be present initially, or occur at any time during the course of the disease. Module 4 describes the extra-articular features and comorbidities related to the pathogenesis of RA and its therapies.

Obesity adversely affects RA disease activity, and reduces the chance of achieving and maintaining remission.

RA also has implications for pregnancy (See Module 3 for details).

What is my role as a physiotherapist in this stage?

The physiotherapist’s role is to co-manage the person with RA - in partnership with the person with RA, and the other members of the person’s healthcare team. A person-centred treatment plan needs to be developed collaboratively, and include short and long-term functional goals.

Practice point

Assessment and management should take into account the relevant biological, psychological and social factors affecting the person’s function and quality of life.

The physiotherapist’s role includes:

  • Assessment
  • Education and communication
    • Disease specific factors impacting on current status
    • Flare management
    • Activity management
    • The role of physiotherapy
    • Therapeutic window
    • Joint protection and functional strategies
    • Communication
    • Further information
  • Self management support
  • Exercise
  • Taping and splinting
  • Electrophysical agents

There is evidence for the efficacy of physiotherapy for RA (see bibliography at the end of the module and our evidence table on non-pharmacological management).

Assessment

Undertake a thorough musculoskeletal assessment and record findings as a baseline (See Module 1).

Monitor, and be prepared to respond to, changes in:

  • Baseline findings. This will include the changing priorities of the person as their experience with the disease develops.
  • Articular and peri-articular manifestations (See Module 1)
  • Extra-articular manifestations (See Module 4)

Fatigue is very common and can have a profound impact on a person’s mental and physical wellbeing. Several tools are available for measuring fatigue, for example the Bristol Rheumatoid Arthritis Fatigue Scale (BRAF-MDQ) and the Bristol Rheumatoid Arthritis Fatigue Numeric Rating Scales (BRAF-NRS). These tools can be used to monitor the effects of intervention on fatigue.

As well as the RA disease process, consider other potential contributors to pain and fatigue such as: other medical conditions, the person’s approach to activity management, sleep impairment, mood, and loss of fitness.

It is important to identify and address psychosocial issues as appropriate to the individual:

  • Identify the person’s/family’s main concerns or uncertainties.
  • Listen and look for signs of stress, anxiety, depression, hopelessness.
  • If appropriate, use tools such as the Depression Anxiety Stress Scales (DASS) to measure some of these psychosocial issues.
  • On-refer if appropriate.

Practice point

In Australia, a physiotherapist can refer directly to a psychologist/clinical psychologist. Some individuals may be eligible to access Medicare subsidised psychological therapies through the Better Access initiative, which requires a general practitioner’s referral.

RA can have a negative impact on quality of life, including domains such as: physical and social function, pain, mental health and emotional health. Regular monitoring of these domains using tools such as the SF-36, SF-12, AQoL or EuroQoL can assist clinicians in targeting appropriate access to multi-disciplinary services (Matcham et al, 2014).

The painHEALTH website and our evidence summary on managing psychological factors provide additional information on the assessment and management of psychological and social factors.

Education and communication

Disease specific factors impacting on current status

  • Assist the person to understand RA and the factors contributing to their current status.
  • Consider what information (if any) has already been conveyed to the person and where physiotherapy-specific information can value-add.
  • Consider lifestyle factors. People who are overweight or are currently smoking have a poorer prognosis. Smoking is a significant risk factor for disease progression and increased mortality. Support to discontinue smoking is critical to improving prognosis and outcomes.

Education may include how to recognise and understand the association between pain, fatigue, flares, impaired function and feelings of depression, anxiety, hopelessness and stress. Include strategies to deal with pain and fatigue as appropriate.

Practical and evidence-based strategies about pain can be learned from painHEALTH. Refer to our evidence table for further information on managing fatigue.

Flare management

Flares occur as part of the disease process, with periods of increased disease activity resulting in any combination of increased pain, swelling and fatigue. Flare ups of pain and fatigue can also occur due to the individual’s approach to activity management (see Activity Management below) and psychosocial factors such as stress.

  • Assist the person to recognise and manage flares.
  • Flares due to an increase in disease activity mean that the current pharmacologic management may not be appropriate for the stage of the disease. The person should be reviewed by their rheumatologist.
  • Physiotherapists can assist individuals to better manage their flares by helping them to:
    • Identify and manage triggers
    • Make a flare plan
    • Learn to pace activity (see Activity Management below)

Activity management

Individuals usually change their activity levels in response to pain. Some tend to avoid activity, while others push harder. Neither approach works in the long term, with increased pain, disability and flares. An approach to activity management called ‘pacing’ enables people to break tasks down into manageable bits and slowly build up their activity levels in a planned and consistent way.

  • Assist the person to recognise their current approach to activity.
  • Provide education on pacing.
  • Assist the person to develop and implement a pacing plan.

Refer to painHEALTH for more information on pacing.

The role of physiotherapy

Provide information on how physiotherapy can help individuals to manage their RA. It can be helpful to provide information on what to expect from physiotherapy in the short and long term.

Gain an understanding of the person’s expectations and their past experience with physiotherapy.

Therapeutic window

Align the timing of physiotherapy and exercise with the effects of medication to ensure the greatest benefit. This is particularly important in the early stage of the disease, as some drug treatments take up to 12-16 weeks to take effect.

In practice, using a therapeutic window means:

  • Determine when and where the person is best able to function (e.g. after early morning stiffness subsides or after analgesia).
  • Determine the level of exercise and/or physical activity appropriate to the person’s individual presentation.
  • Monitor fluctuation in disease symptoms with physiotherapy intervention.
  • Communicate with other care team members as appropriate.

Joint protection and functional strategies

  • Provide information on joint protection techniques.
  • Encourage use of joints to maintain function, particularly using joints through their full range of motion.
  • Emphasise that using joints does not equal damaging joints.
  • Use taping, splinting and strengthening as appropriate (see Taping, Splinting and Compression below).
  • Work with the person to determine strategies to overcome functional limitations.
  • On-refer as needed (e.g. podiatry, occupational therapy).

For more information about joint protection techniques, download our joint protection techniques summary and the evidence table for orthoses, splinting and joint protection.

Communication

  • Listening is critical in order to understand the impact of RA and the person’s specific issues.
  • Engage with other members of the health care team.
    • Determine who the other team members are
    • Communicate your management plan
    • Maintain communication about disease and function
    • Participate in team care planning
    • On-refer as needed (e.g. podiatry, occupational therapy, clinical psychology, medical practitioner). Refer to our evidence table on occupational interventions
  • Engage with family members as appropriate.
  • Advocate on behalf of the person in the workplace and with community support agencies.

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

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

Further information

Provide individuals with guidance on where to find further information. For example:

Important

Education has been identified as an effective intervention to improve outcomes for people with RA 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 and self-efficacy.
  • Enhancing psychological well-being and quality of life.

See our evidence table on education interventions.

Self-management support

Self-management is a critical component of management in all chronic health conditions. It is defined as “active participation in one’s healthcare”. This means that the person has the knowledge and skills to:

  • Find the right information (e.g. asking health professionals)
  • Use the information to make decisions about their healthcare (e.g. setting goals)
  • Take action to address their healthcare (e.g. attending a course)

The role of the health professional is to provide self-management support.

Practice Point

In practice, self-management support means:

  • Helping individuals to take a central role in managing their health as a partner with their healthcare team.
  • Providing individuals with accurate information to make informed choices.
  • Helping individuals to develop self-management behaviours (eg goal setting, identifying their needs, action planning).
  • Supporting and encouraging healthy behaviour choices (e.g. quitting smoking).

Physiotherapists can promote self-management of RA by empowering individuals with education and self-management support. This video clip is a recollection of the impact physiotherapy has had on three consumers with a long history of RA.

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

Refer to Further Assistance for consumer resources.

Exercise

Practice point

Exercise is an essential part of management for all people with chronic health conditions. It reduces disability and increases life expectancy, and is a part of all RA clinical guidelines.

Specifically, exercise can help to:

  • Increase flexibility and reduce joint stiffness.
  • Improve function and joint protection through increased strength, endurance, fitness and balance.
  • Improve muscle and bone health.
  • Improve circulation and oxygen distribution.
  • Promote hormones associated with wellbeing and mood.
  • Maintain a healthy weight.

Issues to consider include:

  • Ensure exercise prescription is goal driven.
  • Determine and address the perceived exercise barriers and facilitators. Barriers and facilitators commonly experienced by persons with RA are outlined in the table below.
  • Individually tailor the type, intensity and frequency of exercise. This will depend on the symptoms, general health and preferences of the individual.
  • Individualise progression, dependent on the response of the individual.
  • The agreed exercise program needs to be enjoyable, as exercise needs to be completed regularly and over a long period of time.
  • The exercise program will require modification over time, in response to changing needs, wants and preferences, and the person’s disease activity and co-morbidity profile.
  • Individuals will need a flare up plan and the knowledge and skills of how to modify their exercise program in the context of a flare.
  • People with RA often respond well to hydrotherapy.

For more information about exercise-based interventions, download our evidence tables for exercise.

The following table outlines the common exercise barriers and facilitators experienced by individuals with RA, as research by Veldhuijzen van Zanten et al.

Perceived barriers Pain

Fatigue

Mobility

Stiffness

Lack of RA exercise programs
Perceived facilitators Support
Exercise instructors
Healthcare provider
Family/friends
Strength and aerobic capacity

Taping and splinting

Taping and splinting may assist pain relief and improved grip strength. Taping and splinting should not be used as an isolated treatment, but incorporated into an active management plan.

See our evidence table on orthoses, splinting and joint protection.

Electrophysical agents

Electrophysical agents can assist pain relief. Electrophysical agents should not be used as an isolated treatment, but incorporated into an active management plan.

See our evidence table on electrophysical agents.

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

  • Avoid high intensity exercise and 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 or where the person with RA has secondary and advanced bone fragility, eg osteoporosis (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 taping.
  • Assess neurological integrity before applying electro-physical agents.

Summary

  • The early stage of RA is usually described as the first two years after diagnosis.
  • The disease course varies between people. Most people experience a slowly progressive disease, with intermittent exacerbations (flares).
  • Early recognition of RA and on-referral to a medical practitioner is critical to optimise clinical outcomes.
  • Symptoms may be severe in the early stage of the disease, with some drug treatments taking up to 12-16 weeks to take effect.
  • Both the diagnosis itself and the disease process can have a substantial impact upon the person’s psychological and social well-being.
  • Physiotherapists play an important role in the early stage of the disease course, particularly in the development of flexible and tailored management plans that include education, exercise and self-management support.
  • Co-management is important, with health professionals working in partnership with the person with RA and the other members of the person’s healthcare team.
  • Physiotherapists need to be aware of safety issues when treating individuals with RA.

Bibliography

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