Rheumatoid Arthritis (RA): Clinical Features & Physiotherapy Management

Subarna Debbarma (BPT, DNHE)

Rheumatoid Arthritis (RA) is a chronic polyarthritis and a diffuse, multisystem, connective tissue disease. The hallmarks of RA are a positive test for immunoglobulin M (IgM) rheumatoid factor (RF); bilateral, usually symmetrical joint inflammation; erosive changes noted radiographically; and persistent inflammatory synovitis of many joints, especially the hands.

RHEUMATOID ARTHRITIS: Physiotherapy Management of RA

Epidemiology of Rheumatoid Arthritis

The prevalence of rheumatoid arthritis is approximately 1%, and increases with increasing age. Women are affected about three times as frequently as men, although this gender difference is reversed in older patients. RA has a worldwide distribution. A genetic predisposition exists, because first-degree relatives of persons with seropositive erosive disease are five to six times more likely to develop severe RA. A strong association with the major histocompatibility complex gene product, HLA-DR4, and a preponderance of whites and Japanese with classic or definite RA have been demonstrated.

Etiology and Pathology of Rheumatoid Arthritis

Various theories have been advanced to explain rheumatoid arthritis, including infective agents, cellular hypersensitivity, genetic predisposition, and immune complex involvement. None has gained unequivocal acceptance.

A probable early event in the disease process is an antigen- antibody reaction at the synovial level with activation of complement. Acute pathologic findings include microvascular injury, edema of sub synovial tissues, and synovial lining cell proliferation and joint exudates.

Examination of the synovium reveals edema, villous synovial projections, and hypertrophy and hyperplasia of the synovial lining cells (both A and B type cells). Vascular changes such as capillary obstruction, neutrophil infiltration, areas of thrombosis, and perivascular hemorrhage are common. Mononuclear cells pre-dominate in the sub synovial stroma. As inflammation continues, pannus, an inflammatory synovial tissue, is produced and ultimately invades the bone and cartilage and leads to cartilage and soft tissue damage.

Clinical Features of Rheumatoid Arthritis

The onset of RA is usually gradual; however, 15% to 20% of patients present acutely.

Symptoms of fatigue, anorexia, malaise, weight loss, weakness, and generalized "aches and pains" usually herald the onset of RA, which is initially polyarticular in approximately 75% of patients. The small joints of the hands and feet are affected early and other joints such as the knees, cervical spine, feet, and temporomandibular shoulders are commonly affected later. Morning stiffness of greater than 30 minutes duration, considered a result of synovial congestion, joint capsule thickening, and synovial fluid, is common. Approximately 10% of patients have a mild, transient poly- arthritis followed by a lasting remission and 10% have inexorable downward progression.

The remaining 80% exhibit a characteristic waxing and waning of symptoms. The degree of articular severity and the presence of extra particular manifestations may not correlate; however, both of these manifestations are more likely to be severe in patients with high titers of RF.

Patients rarely die of RA; death results from associated features such as vasculitis, cervical spine subluxation, complications of drug therapy, and infection. The course of the disease varies with the individual patient, but certain aspects indicate a less favorable outcome. These include insidious onset, youthful onset, being female and/or Caucasian, presence of rheumatoid nodules, high titers of RF and C-reactive protein, and markedly elevated sedimentation rate.

Pharmaceutical Management

Management of rheumatoid arthritis can serve as a general model for physiatric care of many of the arthritides. The comprehensive management of the RA patient involves prescription of appropriate medications as well as use of a variety of resources familiar to physiatrists. Aspirin, in doses of 3 to 6 g daily, is often the initial drug of choice. Levels should be monitored, and a level producing tinnitus obviously must be reduced. Doses below 3 g/day are usually only analgesic.

If aspirin is contraindicated, cannot be tolerated, or does not produce the desired therapeutic effect, a trial of nonsteroidal anti-inflammatory drugs (NSAIDs) is indicated. If these agents fail to suppress the disease adequately, a variety of drugs such as gold, steroids, penicillamine, and antimalarials are available. In addition, there are a variety of newer very effective medications such as methotrexate, leflunomide, etanercept, and infliximab. Consultation with a rheumatologist is recommended at this level of disease management.

Physiotherapy Management of Rheumatoid Arthritis

The goals of rheumatoid arthritis rehabilitation for physiotherapist  are as follows:

• Maintain or improve range of motion: prevent deformities
• Limit disability
• Protect susceptible joints
• Decrease pain and stiffness
• Use joints and muscles efficiently and safely
• Improve strength in selected muscles and overall endurance
• Control weight and maintain appropriate nutrition


  • Passive (maintains ROM)
  • Active assistive (increases ROM)
  • Active (maintains ROM, improves endurance)
  • Resistive (increases strength)
  • Stretching
  • Reeducation
  • Coordination
  • Relaxation
  • Postural
  • Deep breathing

Heat Agents

• Infrared lamp
• Baker
• Contrast baths
• Hydrocolator packs
• Fluidotherapy
• Whirlpool
• Hot tub bath
• Paraffin baths
• Electric blankets
and heating pads


  • Cold water
  • Ice packs
  • Ice massage
  • Slush
  • Evaporants


• Whirlpool
• Hubbard tank
• Wading tank
• Therapeutic pool
• Showers
• Contrast baths

Splints and Assistive Devices

Splinting should enforce the beneficial effects of rest and result in symptomatic decrease of inflammation, especially in the acute disease.

The major goals are to:
• Relieve pain
• Maintain position of function
• Discourage abuse of affected joints
• Assist function, both pre surgically and post surgically

Other Therapeutic Agents

  • Local injections
  • TENS
  • Biofeedback
  • Acupuncture
  • Operant conditioning
  • Pressure gloves
  • Shortwave
  • Microwave
  • Ultrasound

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