The Role of the Physiotherapist in Rheumatoid Arthritis
Living with any long-term condition can leave a person prone to losing fitness and maybe even struggling with day-to-day tasks. Rheumatoid arthritis (RA) can be particularly troubling, with its impact on the joints as well as possible impact on the muscles, the heart and the lungs. Although less of an issue these days, delay to diagnosis can mean muscle strength, joint flexibility and general fitness are lost. There is also a potential of suffering these limitations due to RA flares or periods where medications are changed, or lose their impact. All of these issues, and more, make keeping active and exercising an important part of daily self-management for people with RA.
In addition to exercise to maintain and regain; it has been more recently found that exercise can actually act as an anti-inflammatory all by itself. Exercise carried out regularly and at the correct level for an individual can help control RA better.
We would hope most people with RA will become exercise self-managers; however there is a key role for physiotherapists in assessing, monitoring and prescribing exercise for people with RA. Most, but not all, rheumatology departments in the UK have good links to a specialised rheumatology physiotherapist.
Who is your Physiotherapist?
Physiotherapists are members of the multi-disciplinary team involved in the treatment and management of people with rheumatoid arthritis. They work with you and other members of the team to make sure that you feel supported, and that your short and long-term needs are addressed. They work closely with multi-disciplinary team colleagues, such as occupational therapists, podiatrists and orthoptists and will refer you to them when necessary.
The precise role of the physiotherapist will slightly vary across different departments, dependent on which other members of the team are available. Usually the physiotherapist will take a lead role in the assessment of physical fitness. They may well suggest an exercise programme to keep you active. They may advise on your day-to-day physical activities, including your role at work.
Physiotherapists also usually have a role in advising on pain management options. They may offer access to warm water exercise, namely hydrotherapy or aquatic therapy. They may also recommend non-drug treatments such as the use of ice packs, or heat packs. In some departments the physiotherapist will take a lead in assessment and management of fatigue (in some hospitals the occupational therapist take this role).
When will you see a Physiotherapist?
Physiotherapists have a key role throughout the course of the disease. The extent of their involvement with you will vary throughout that time, dependent upon your needs. You will often be referred to a physiotherapist soon after you are diagnosed with RA. At this stage their input may be to give you information and advice about your condition, teaching you what symptoms to expect and how to manage them.
The Physiotherapist may continue to be involved until there is a degree of disease control and you feel confident enough to ‘self-manage’, using the techniques you have been taught.
What to expect
When you are first seen by a physiotherapist you will be assessed. Usually this will be an extended appointment of around 30-45 minutes. Assessment will involve the physiotherapist asking questions about your symptoms and any difficulties you are having with movement or activities of daily living. This enables them to identify any problems you may have and decide with you the most appropriate course of action.
You may need to partially undress so that the physiotherapist can examine your joints and muscles and see how you perform functional activities. It is often helpful to wear loose, comfortable clothes. You will be able to have someone with you, or ask for a chaperone if you choose.
Once the assessment is completed, the physiotherapist will talk through their findings with you. They will make some suggestions, and agree with you a management plan.
What Physiotherapy can offer you?
After diagnosis the physiotherapist will offer education and advice, which is likely to include:
• information regarding how to recognise and manage a flare,
• when to rest and when to exercise,
• advice on how to modify activities in order to protect the joints.
Physiotherapists can help by teaching and encouraging safe stretching and strengthening exercises; to increase movement and strength, allowing better function.
Physiotherapists will also analyse the way you stand and walk, looking for whether it may be necessary to suggest, for example, balance exercises, insoles to reduce pain and restore good foot posture, or even a walking aid. Some physiotherapists will also have access to a hydrotherapy pool, where patients can do strengthening exercises while the water supports their joints.
Fatigue management and pain relief will also be considered and non-drug treatment recommended.
It is important to find a safe way to exercise that is enjoyable and sustainable. It is also important to try to find ways to continue with normal activities such as staying in work.
You will continue to have regular reviews with a rheumatology consultant and specialist nurse. In some places, physiotherapists are routinely part of this review, and in other places, patients will be re-referred to physiotherapy if necessary. In some places you may have open review or direct access to physiotherapy.
“The advances in pharmacological treatment for RA enable many individuals to live a full and active lifestyle” Law et al. 2012
Exercise Tips and Self-Assessment
GOVERNMENT GUIDELINES: Adults (19-64 years old) should aim to stay active daily. Over a week activity should add up to 150 minutes of moderate intensity activity in bouts of 10 or more minutes. Adults should also undertake physical activity to improve muscle strength on at least 2 days a week. All adults should minimise the amount of time spent being sedentary (sitting) for extended periods.
With any activity it is always advisable to start at a low intensity and gradually build up the amount you do. For RA it has been recently found that more benefit is attained where the exercise is at a higher intensity.
Preparation is key. Make sure you warm up before starting your activity. Well fitting, shock absorbing footwear, suitable for the activity, may also be a factor.
Don’t underestimate the importance of doing an activity you enjoy, as you are much more likely to continue doing it! Also, exercising with someone else can make exercising more enjoyable and help with motivation.
If after starting a new activity you find that at first it seems to make you worse, there are changes to your exercises that you can try. It is probably worth reducing how often you do the activity and the amount you do to see if this helps, then gradually build up the time or intensity.
If you are in a flare up it is best to focus on letting the joints settle down and doing range of movement exercises rather than other exercise activities. Once the flare subsides then you can gradually return to an increased level of exercise.
Thinking about your current, or planned future exercise/activity habits, it is good to ask yourself the following:
• Is it measurable?
• Is it sustainable?
• Is it fun?
• Alone / with other people?
• Does anyone congratulate you for having done your exercise?
• Do you reward yourself for doing your exercise routine?
• Is your fitness improving? OR Are you maintaining your fitness?
• What happens during flare up/on a bad day?
• Are you meeting general guidelines?
• Are you meeting RA specific guidelines?
Any increase in your activity levels could help with your RA and your overall health. The level of exercise you do can be built up gradually, so whatever your starting point, you should be able to find an exercise that suits you. However, if you are unsure where to start, a physiotherapist will be able to steer you in the right direction. Your Rheumatology team will be able to link you to your physiotherapist; or may in some cases be able to give the advice themselves. Regular exercise or physical activity will help your RA and do remember every little helps and it is never too late to start!
Exercise section of the NRAS website
References available on request
Will Gregory MSc BSc (Hons) MCSP
Consultant Physiotherapist (Rheumatology)
Rehabilitation Services / Rheumatology Directorate
Salford Royal NHS Foundation Trust
Salford Care Organisation
Part of the Northern Care Alliance NHS Group