Managing Rheumatoid Arthritis with Physical Therapy

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease that involves inflammation of the synovial lining of joints, causing swelling, pain, stiffness, and eventual erosion of the affected joints over time. Physical therapy plays a key role in helping patients with RA maintain muscle strength, flexibility, and joint range of motion as well as prevent long-term disabilities through a targeted exercise program. Physical therapy works together with medical drug treatments to improve the quality of life, optimize overall fitness and cardiovascular health, and maintain the ability to perform daily activities in those with rheumatoid arthritis.

Understanding Rheumatoid Arthritis

Rheumatoid arthritis is a chronic autoimmune disease that affects the soft tissues and synovial lining around the body’s joints, causing inflammation, pain, and stiffness in joints. While the cause is not known, rheumatoid arthritis occurs due to a faulty immune response that causes the body to attack the synovial lining of joints, leading to swelling and eventually erosion of the joint itself over time.

In the early stages, rheumatoid arthritis (RA) normally affects smaller joints in the body, such as the hand, wrist, and toes. It is often symmetrical, meaning that if you’re experiencing inflammation in the right hand, you’re likely to have the same level of inflammation in the left hand. As RA progresses, larger joints like the knees, hips, and shoulders can become inflamed. Due to the increased production of systemic inflammatory agents (at levels 100 times that of healthy adults) in those with RA, vital organs such as the heart, lungs, and eyes can also be negatively impacted.

The development of rheumatoid arthritis is thought to be a combination of genetics, environment, and hormonal factors. It is normally diagnosed in mid-life around age 40 and is significantly more common in women than in men (women are 2 to 3 times more likely to develop RA than men).

Rheumatoid arthritis alternates between times of remission and flare-ups, but even during the inactive remission states, systemic levels of inflammation remain dysregulated. Rheumatoid arthritis can cause decreased flexibility, muscle weakness and atrophy, and an increased risk of heart disease.

Symptoms of rheumatoid arthritis can include:

• Stiff joints that feel worse in the morning

• Painful swollen joints on both sides of the body, beginning in smaller joints like the fingers and hands and over time moving to larger joints like the knees

• Bouts of fatigue and general discomfort

• Low-grade fever

• Loss of joint function and range of motion

• Redness, warmth, and tenderness around affected joints

• “Rheumatoid cachexia,” which is accelerated loss of muscle mass

Today, doctors use disease-modifying anti-rheumatic drugs along with biologic therapies to reduce overall RA disease activity and related joint degeneration. Treatment is usually escalated until a target of remission or low disease activity is reached.  

Physical Therapy Support for Rheumatoid Arthritis

Physical therapy plays a key role in helping patients with rheumatoid arthritis maintain muscle strength, flexibility, and joint range of motion as well as prevent long-term disabilities through a targeted exercise program. Physical therapy works together with medical drug treatments to improve the quality of life, optimize overall fitness and cardiovascular health, and maintain the ability to perform daily activities in those with rheumatoid arthritis.

First, the physical therapist conducts a comprehensive evaluation of the RA patient, assessing posture, muscle imbalances, and overall body mechanics. The therapist then designs a customized therapeutic exercise program to ease pain, increase range of motion, improve muscle strength, and enhance movement patterns. Physical therapists design the exercise program with modifications to ensure the RA patient’s safety while effectively targeting functional limitations.

Physical therapy for rheumatoid arthritis can include:

• Passive modalities to manage pain, which can include ice, heat, TENs therapy, or ultrasound. Ice is used to manage RA flare-ups and reduce swelling by slowing circulation. Heat is used to trigger the body’s natural healing process by relaxing joints and muscles and increasing blood flow to the affected area, bringing oxygen and nutrients to the area. TENS therapy involves electrodes placed on the skin that send small electrical currents along the nerve pathway, which triggers the release of endorphins, the body’s natural pain killers. Ultrasound involves the use of sound waves to create heat that increases blood circulation to deep tissues, which can help reduce inflammation, stiffness, and pain.

• Manual therapy involving soft tissue and joint mobilizations to relax joints and muscles and gently restore range of motion in the affected joints.

• Stretching can be done in non-inflamed major joints to prevent contracture formation and to maintain the joints’ current range of motion and flexibility. Contractures cause tissues to become stiff, constricted, and shortened which can interfere with the joints function and cause deformities in the joint.

• Low-intensity aerobic exercise such as walking, biking, rowing, swimming, or using the elliptical to improve cardiorespiratory fitness and muscular endurance.

• Aquatic therapy involves exercising in a warm water therapy pool. This allows RA patients to engage in aerobic and strength training without placing additional stress on their joints. The warm compressive force of the water also can relieve pain.

• Resistance training improves joint stability and muscular strength using free weights, resistance bands, and weight machines.

• Gait and balance training improves walking pattern and balance for better coordination and stability.

• Patient education on joint protection techniques, activity pacing, and proper body mechanics to enhance function. Joint protection means adjusting the way certain activities are performed to avoid pain and use alternative muscle groups. Activity pacing is also important in order to conserve energy and manage fatigue. Proper body mechanics allows the body to function more optimally without placing unnecessary stress on affected joints.

• Assistive device training is essential if the RA has progressed and the patient requires use of crutches, canes, or walkers to move around. The therapist can provide training for the proper and safe use of these mobility-assistive devices.

Research shows that exercise interventions are effective in improving physical ability, alleviating pain, and improving aerobic function in RA patients. Studies show that exercise does not worsen RA symptoms and that exercise is a critical treatment to reduce disability associated with RA. Exercise has been shown to reverse loss of muscle mass, reduce RA-related fatigue, restore joint motion, and improve physical function in RA patients without exacerbating symptoms.

Researchers have found that both low-intensity aerobic exercise and resistance training increase aerobic capacity and joint mobility in RA patients, while safely reversing rheumatoid cachexia. A two-year study of early-stage RA patients who engaged in a dynamic strength training program showed considerable improvements in muscle strength as well as reductions in systemic inflammation, pain, morning stiffness, and disease activity.

Rheumatoid arthritis is a life-long condition that requires careful and targeted management. Work with our physical therapists, who can help you navigate the condition and maintain strength, function, and range of motion in your joints safely.