What is the role of physical medicine and rehabilitation (PM&R) in managing rheumatoid arthritis?

Role of Physical Medicine and Rehabilitation in Rheumatoid Arthritis

Physical medicine and rehabilitation (PM&R) plays a crucial role in managing rheumatoid arthritis by improving physical function, reducing pain, and enhancing quality of life through comprehensive rehabilitation interventions that should be initiated early in the disease course. 1

Exercise Recommendations

The American College of Rheumatology (ACR) strongly recommends consistent engagement in exercise for patients with rheumatoid arthritis (RA), with specific conditional recommendations for:

• Aerobic exercise: Improves physical function with very low to low certainty evidence 1
• Aquatic exercise: Improves physical function with low certainty evidence 1
• Resistance exercise: Improves both physical function and pain with very low to low certainty evidence 1
• Mind-body exercise (yoga, Tai Chi, qigong): Improves physical function with very low to low certainty evidence 1

The ACR emphasizes that exercise prescription should be tailored based on disease activity, joint damage/deformities, and comorbidities. Proper supervision by physical therapists or qualified exercise professionals is particularly important for resistance exercise to prevent harm 1.

Comprehensive Rehabilitation Services

Physical Therapy (PT)

The ACR conditionally recommends comprehensive physical therapy over no PT based on very low certainty evidence showing improvements in pain and physical function 1. Physical therapists provide:

• Exercise prescription and supervision
• Functional training and mobility assessment
• Pain management techniques including thermal therapy
• Gait training and assistive device instruction
• Manual therapy techniques

Occupational Therapy (OT)

The ACR conditionally recommends comprehensive occupational therapy over no OT based on very low certainty evidence showing improvements in pain and physical function 1. Occupational therapists provide:

• Activities of daily living (ADL) evaluation and training
• Joint protection techniques
• Energy conservation strategies
• Work simplification and fatigue management
• Environmental adaptations
• Assistive device recommendations

Site-Specific Interventions

For patients with specific joint involvement, the ACR conditionally recommends:

1. Hand involvement: Hand therapy exercises over no hand exercises (low certainty evidence) 1
2. Hand/wrist involvement: Splinting, orthoses, and/or compression (very low certainty evidence) 1
3. Foot/ankle involvement: Bracing, orthoses, and/or taping (very low certainty evidence) 1
4. Knee involvement: Bracing and/or orthoses (very low certainty evidence) 1

Timing of Rehabilitation Interventions

The ACR guidelines emphasize that rehabilitation interventions should be considered throughout the RA disease course, with early referral being particularly beneficial 1. Patient panel members in the ACR guideline development reported wishing they had been referred to occupational and physical therapists earlier in their disease course 1.

Additional Supportive Interventions

• Self-management programs: Conditionally recommended to improve self-efficacy 2
• Cognitive-behavioral therapy: Can help reduce depression, anxiety, and fatigue in RA patients 2
• Thermal modalities: Provide symptomatic relief 3

Implementation Considerations

Potential Barriers

• Limited access to rehabilitation services due to availability or insurance coverage 1
• Patient preferences regarding comfort, cost, and burden of engaging in rehabilitation interventions 1
• Lack of awareness among healthcare providers about the benefits of early rehabilitation 1

Multidisciplinary Approach

Coordination between rheumatologists and rehabilitation specialists is essential for optimal outcomes 2. The primary goal should be to complement pharmacological treatment (DMARDs) with rehabilitation interventions to maximize functional outcomes 1, 4.

Clinical Pearls

• Rehabilitation interventions should be initiated early in the disease course, not just when significant functional limitations develop 1
• Prescription and supervision of rehabilitation interventions by qualified professionals is important to ensure appropriate selection and fit of devices and prevent harm 1
• The comprehensive nature of PT and OT interventions highlights the importance of expertise in tailoring these interventions through shared decision-making 1
• Rehabilitation should be considered an integral component of RA management alongside pharmacological treatment, not just as an adjunct when medications fail 1, 4

By incorporating PM&R interventions early and consistently in RA management, clinicians can help patients maintain function, reduce pain, and improve quality of life throughout the disease course.