Sie sind auf Seite 1von 24


Chapter 16

Inflammatory arthritis
Anne OBrien MPhil Grad Dip Phys MCSP School of Health and Rehabilitation, MacKay Building,
University of Keele, Keele, UK

Catherine Backman PhD OT(C) FCAOT Department of Occupational Science & Occupational Therapy,
The University of British Columbia, Vancouver, BC, Canada

CHAPTER CONTENTS Hydrotherapy 223

Cryotherapy 223
Introduction 212 Thermotherapy 223
Electrotherapy 224
Characteristics of rheumatoid arthritis 212
Acupuncture 224
Prevalence and incidence 212
Pathology and immunology 212 Occupational therapy interventions 225
Diagnosis, differential diagnosis and Patient education: supporting
special tests 213 self-management 225
Monitoring disease activity, progression and Splinting 226
prognosis 214 Assistive devices and environmental
Radiographic features 214 modifications 226
Activity adaptation at home and work 228
Clinical evaluation 215
Subjective assessment 215 Referral to specialist services 228
History of presenting condition 215 Conclusion 228
Past medical history 215
Drug history 215
Social and functional history 215 Key points
Objective examination 216 n Initial detailed assessment is important in
Observation 218 identifying where therapies can be most efficacious
Palpation 218 opportunities for subsequent review allow timely
Range of movement 218 response, especially in flares.
Joint stability/muscle strength 218 n Early therapy interventions minimise inflammation,
Functional mobility and transfers 219 pain, joint damage, deconditioning, and functional
Assessment of occupational performance limitation.
(functional assessment) 220 n Self-management programmes that emphasize
Important first treatments - early recognition of self efficacy and behaviour change improve health
signs and symptoms 220 outcomes in RA.
Identification of red flags 220 n Physical activity is vital to maintaining activities of
daily living and quality of life.
Rehabilitation interventions for RA 222 n Work disability can be delayed or prevented.
Physiotherapy evidence-based treatment n Relate any exercise to improving performance of
programmes 222 individually relevant functional tasks; individualise
Exercise therapy 222 range, resistance, eccentric, concentric muscle work,
length of hold of contraction
2010 Elsevier Ltd
DOI: 10.1016/B978-0-443-06934-5.00016-4
212 Rheumatology Evidence-Based Practice for Physiotherapists and Occupational Therapists

n Wherever possible, minimise pain first (personal characteristics) influences perceived

n Avoid uncontrolled end of range movements health, as will the environment, such as accessibil-
n Aim to improve exercise tolerance as well as ity of the physical or built environment or support
increasing range of movement/muscle strength and provided by institutional policies. For example,
joint stability work disability begins early in RA, affecting over
n Reassure new exercisers that joint/muscle aches may one-third, depending on disease severity, age of
last up to 3060 minutes after exercise this is normal! onset and job demands (Burton et al 2006). RA has
n Dosage should be individualised most benefit from a substantive physical, psychosocial, and economic
some daily exercise (ARC, Keep Moving leaflet 2005) impact. Rehabilitation services are important in
n Modify exercise during a flare; focus on maintaining maintaining, restoring and improving patient func-
range but without resistance tion as well as enhancing quality of life.
n Minimise use of equipment so exercise can easily be
performed at home
n Written information should support exercise
Characteristics of rheumatoid
instructions and include SOS contact details.

Prevalence and incidence

The prevalence of RA is remarkably consistent
at 0.51% of the population in Western nations
Introduction and women are affected twice as much as men
(Kremers& Gabriel 2004, Symmons et al 2002).
Inflammatory arthritis is a category of rheumatic There is a genetic susceptibility, supported by a
conditions involving inflammation of the synovial higher prevalence in North American aborigi-
joints and includes specific forms such as rheuma- nal populations (up to 7%) and lower rates in
toid arthritis, psoriatic arthritis, systemic lupus ery- China, Japan and rural Africa (Ferucci et al 2004).
thematosus, ankylosing spondylitis, reactive arthritis Incidence varies but is typically close to 40 per
and juvenile idiopathic arthritis, among others. This 100,000 (Symmons 2002), although declining over
chapter will focus on rheumatoid arthritis (RA), as a the past few decades, possibly due to increased oral
common presentation of inflammatory arthritis. contraceptive use, dietary influences and cohort
RA is a systemic, autoimmune disease character- effects (Symmons 2002). However, a recent cohort
ized by symmetrical involvement of the peripheral study suggested rising incidence of RA in women
joints, especially the small joints of the hands and after four decades of decline (Gabriel et al 2008).
feet, wrists, elbows, shoulders, knees and cervi- Mortality studies show RA decreases life expectancy,
cal spine. Symptoms include joint pain, stiffness possibly due to its associated co-morbidities, includ-
and generalized fatigue, with exacerbations and ing cardiovascular, respiratory and gastrointestinal
remissions. Its aetiology is unknown and there is problems (Kremers & Gabriel 2004). Co-morbidities
no cure. Despite significant recent improvements in may be due to chronic illness effects (e.g. de-condi-
medical management, RA remains a chronic condi- tioning leading to cardiovascular problems) or treat-
tion resulting in mild to severe limitations in mobil- ments (e.g. non-steroidal anti-inflammatory drugs
ity and participation in everyday activities. RA leading to gastrointestinal problems). The increased
has an impact across the spectrum of International mortality associated with RA has been relatively
Classification of Functioning, Disability and Health stable over the past few decades. Recent changes
(ICF: World Health Organization, 2002) (see Ch. 4). in medical management will take several years to
In terms of body structure and function, joint mobil- effect mortality rates (Kremers & Gabriel 2004).
ity, muscle function, hand strength and dexterity are
frequently impaired. Activity limitations, such as
Pathology and immunology
difficulty walking or handling objects, may subse-
quently restrict participation in self care, household RA is an autoimmune disease with abnormal anti-
work, employment, social relationships and leisure. body and T-cell responses to an auto-antigen (Haynes
The available resources and way a person responds 2004). The result is a wide-spread inflammatory
to their illness and the challenges it presents process in the synovial cells lining joint capsules
Chapter 16 Inflammatory arthritis 213

and other body tissues, manifesting as a range of

extra-articular features. The normal joint has a thin Table16.1 Revised criteria for classification of RA
(Arnett et al 1988)
synovium lining the joint capsule. These cells pro-
duce synovial fluid which lubricates and provides Criterion Definition
nutrition to the articular cartilage. In early RA, lym-
phocytes infiltrate the joint capsule, proliferation 1. Morning Morning stiffness in and around the joints,
of the synovial lining occurs, resulting in increased stiffness lasting at least 1 hour before maximal
synovial fluid production. This presents as swollen, improvement
warm, red and painful joints. Prolonged periods of 2. Arthritis of At least 3 joint areas simultaneously have
3 or more joint had soft tissue swelling or fluid (not bony
inflammation stress the surrounding ligaments and areas overgrowth alone) observed by a physician.
tendons causing laxity and subsequent joint instabil- The 14 possible areas are right or left PIP, MCP,
ity. Therefore, intervention focuses on reducing the wrist, elbow, knee, ankle and MTP joints.
inflammatory response. In more advanced stages 3. Arthritis of At least 1 area swollen (as defined above) in a
pannus forms: the synovium proliferates with fibro the hand joints wrist, MCP or PIP joint
blasts, macrophages, T cells, and blood vessels. The 4. Symmetrical Simultaneous involvement of the same joint
arthritis areas (as defined in 2) on both sides of the body
pannus invades and erodes articular cartilage, even-
(bilateral involvement of PIPs, MCPs or MTPs is
tually exposing the bone. Bone resorption and remod- acceptable without absolute symmetry)
elling may occur in end-stage disease when cartilage 5. Rheumatoid Subcutaneous nodules, over bony prominences
destruction may be unavoidable. Intervention for nodules or extensor surfaces or in juxta-articular
end-stage disease is typically joint replacement. regions, observed by a physician
Synovitis (inflammation of synovium) is not limi 6. Serum Demonstration of abnormal amounts of serum
ted to joint capsules. The long tendons of the hand rheumatoid rheumatoid factor by any method for which the
factor results have been positive in 5% of normal
pass through synovial sheaths and this tenosynovi-
control subjects
tis may restrict tendon gliding, causing stiffness 7. Radiographic Radiographic changes typical of rheumatoid
and limited finger mobility. Other tendon sheaths changes arthritis on postero-anterior hand and wrist
may be similarly affected. RA is said to be active radiographs, which must include erosions or
or exacerbated when joints are inflamed and labo- unequivocal bony decalcification localized in
ratory indicators of disease activity, such as eryth- or most marked adjacent to the involved joints
rocyte sedimentation rate (ESR) are elevated. RA (osteoarthritis changes alone do not qualify)
is said to be in remission or controlled when Key: MCP, metacarpophalangeal; MTP, metatarsophalangeal; PIP, proximal
inflammation is minimal. interphalangeal
Extra-articular features of RA include a range of
inflammatory processes: cutaneous changes such
as vasculitis (inflammation of the small blood ves- established criteria for the diagnosis of RA (Arnett
sels) and rheumatoid nodules (fibrosis nodes in etal 1988), listed in Table 16.1. Diagnosis is confirmed
subcutaneous tissue, commonly near the elbow); if a patient has at least four of the seven criteria. The
inflammation of tissues in the eye (scleritis, uveitis); first four must have been present for at least 6 weeks.
cardiac disease (myocarditis, pericarditis and effu- Rheumatoid factor (RF) is important for both diagno-
sions); lung and pleural disease; kidney disease and sis and prognosis of RA (Shin et al 2005).
peripheral neuropathies (Haynes 2004). Generally Other tests aid monitoring disease activity. Most
speaking, extra-articular manifestations suggest commonly ESR and C-reactive protein (CRP) blood
more severe disease. Therapeutic recommendations tests assess levels of inflammation and are known
and interventions need to accommodate systemic as inflammatory markers. CRP is a better indicator
symptoms and impairments as well as joint disease. of the acute phase response in the first 24 hours, but
a more expensive test. (See Chapter 3 for details).
Raised markers often indicate a flare of RA, but
Diagnosis, differential diagnosis
the possibility of infection causing this elevation
and special tests
should always be considered.
Diagnosis results from a careful history together with Therapists should be aware of a patients haemo-
physical examination, radiological and serological globin (Hb) because, not only may RA patients present
tests. The American College of Rheumatology (ACR) with anaemia of chronic disease, but as inflammatory
214 Rheumatology Evidence-Based Practice for Physiotherapists and Occupational Therapists

markers rise, Hb may fall and vice versa. Consequently,

a patient with low Hb, may not be as able to actively
participate with therapy; appearing pale and possibly
reporting overwhelming fatigue.

Monitoring disease activity,

progression and prognosis
Predicting prognosis is challenging, but outlook
is now more positive with recent significant phar-
macological advances and the advent of anti-TNF
therapies (see Ch. 15). A sero-positive rheumatoid
factor (RF), at, or soon after diagnosis, indicates a
worse prognosis in terms of long term erosive joint
disease (Shin et al 2005). Auto-antibodies against
cyclic citrullinated peptide (CCP) may be more
specific than RF, not only for predicting progno-
sis (Kastbom et al 2004), but also diagnosing RA
(Nishimura et al 2007). El Miedany et al (2008)
suggest longer duration of early morning stiffness Figure 16.1 Illustrating erosions on the radial and ulnar
(EMS), greater percentage change in health assess- aspects of the proximal interphalangeal joint as seen on
ment questionnaires (HAQ) and anti-CCP positiv- radiology. With permission from: Theodorou DJ et al 2003
ity are all predictors of persistent arthritis. Ongoing Ch. 71 Imaging of rheumatoid arthritis. In: Hochberg MC et al
disease activity, both clinically and serologically, (eds) Rheumatology 3rd edn, Elsevier, London. Fig. 71.1 p801.
has been linked to increasing morbidity, loss of
function and mortality. Therapists should be aware
of anticipated prognosis and pro-actively target progression in RA and assisting in diagnosis
therapies accordingly. (Cimmino et al 2004). Bony erosions caused by RA
Felson et al (1993) published a core set of disease may be visible from a few months following symp-
activity measures for use in RA clinical trials. These tom onset. They are found at lateral joint margins,
include articular indices (joint counts), the patients typically first seen in the small joints of the hands and
assessment of their pain and physical function and feet (Fig. 16.1). Joint spaces may also be narrowed as
both the patient and clinicians global assessment the thickness of hyaline cartilage of synovial joints is
of disease activity, as well as results of one acute reduced. Osteopaenia and peri-articular osteoporosis
inflammatory marker. Therapists should be aware may be seen around these small joints on x-ray, but
of these valid and reliable measures, but may use are more accurately quantified on DEXA scans, used
them in isolation and/or combination with other to quantify the osteoporosis presenting in many RA
functional measures of therapy progress. Twenty patients (Tourinho et al 2005) particularly in early
percent, 50% and 70% response criteria (known inflammatory arthritis (Murphy et al 2008).
as ACR 20, 50 and 70) have been defined to iden- Synovial joint subluxation may also be seen on
tify improvement in RA (Felson et al 1995), which x-ray. On examination, the hands can present with
therapists should understand. The Disease Activity deformities associated with RA: the swan-neck,
Score, calculated on 28 specific joints (DAS-28), is a boutonnire and ulnar-deviation affecting the inter-
standard approach to monitoring RA progress and phalangeal (IP) and metacarpo-phalangeal (MCP)
drug response (Prevoo et al 1995). joints and Z deformity affecting the thumbs. Any
level of the cervical spine can also be affected. The
consequences of subluxation of the atlanto-axial and
atlanto-occipital joints are the most serious (com-
Radiographic features
pression of the spinal cord, nerve roots or cervical
Conventional plain film x-rays remain the most artery). Lateral views with the cervical spine in flex-
frequently used method of evaluating disease ion or extension help assess this as well as views of
Chapter 16 Inflammatory arthritis 215

the odontoid peg from an anterior to posterior view a patients capacity for therapy. Key questions
through the mouth. include:
Magnetic resonance imaging (MRI) aids evalu- l Previous surgery?
ating synovitis, tenosynovitis and bursitis in the l Previous hospital admissions with outcomes?
hands and feet of newly diagnosed patients (Boutry
l Co-morbidities: cardio-vascular, respiratory,
et al 2003). MRI may be used more in future for
neurological or other conditions?
monitoring purposes (Cimmino et al 2004) as it is
l Diabetes or epilepsy?
more sensitive, detecting both soft tissue and bony
changes (Uetani 2007). l Fractures of unknown cause, indicating possible
More recent research has focussed on using ultra- osteoporosis?
sound scanning (USS) imaging in RA (Filippucci l Ongoing/outstanding medical investigations?
et al 2007), particularly to detect sub-clinical synovi- Ask the patient if there is anything they believe to
tis or bony erosions not evident with conventional be important to assess that has not yet been discussed.
Drug history
Clinical evaluation This provides clues to disease severity and helps
determine optimal timing for therapy. Relevant
Initial assessment and ongoing evaluation will be aspects to note are:
undertaken by many multidisciplinary team mem- l Current prescribed and recently discontinued
bers. Although overlap is inevitable, therapists medication.
have a unique line of inquiry to establish a baseline l Current or recently prescribed corticosteroids
level of function, particularly related to activities of (orally, inhaled, intra-articular, intramuscular or
daily living, as well as identifying current clinical intravenous) or anticoagulant therapy.
problems. Ay et al (2008) reported that RA patients l Non-prescribed alternative or complimentary
experience most functional challenges with grip- medicines patients may need prompting to
ping, hygiene and grooming, running errands and discuss these.
shopping. For those in acute flare up, only a subjec- The timing of medication may also be relevant,
tive history may be possible, perhaps with part of especially for patients who have recently started or
an objective examination. Therapists work collabo- stopped disease-modifying anti-rheumatic drugs
ratively with patients to establish functional goals (DMARDs), biologics or received intra-articular
and devise plans to achieve them. injections. Knowing the timescale for drugs to reach
full efficacy is important when planning therapy.
Subjective assessment See Chapter 15 for further details.
It will be important for therapists to be aware of
History of presenting condition allergic reactions, including latex (for Theraband
purposes or if gloves are required).
The patients main problems must be identified
from the outset. Some information may be provided
on referral documentation. Therapists may have Social and functional history
access to in-patient or on-line records, but a careful This provides an understanding of the patients
and logical history will elicit: roles and responsibilities, typical daily activities
l Current symptoms, e.g. joint pain or EMS (which and any difficulties encountered in these as a result
may signal a flare up of arthritis). of symptoms or joint impairment. Understanding
l Any difficulty with family, work or leisure life. the activities the patient needs and wants to do
l Recent changes triggering referral to therapies. helps establish functional goals. Occupational per-
formance areas should be assessed (Law et al 2005):
l Self care: eating, bathing, grooming, toileting,
Past medical history dressing, taking medication
A relevant past medical history is needed, as cer- l Productivity: household work, caring for children/
tain treatments may be contraindicated or alter family members, employment, going to school
216 Rheumatology Evidence-Based Practice for Physiotherapists and Occupational Therapists

l Leisure: engaging in recreational pursuits and Case study 16.1 Newly diagnosed
socializing with others, both within the home patient-subjective history
and community.
The context in which these are performed is Ms Sarah Jones, aged 38, a part-time computer
also important to query, such as where the patient programmer and mother of two young children,
lives and works, household members, sociocultural consults her general practitioner. She complains of
expectations, community resources and transporta- a 6 month history of wrist and hand pain, increasing
tion. This helps establish priorities for intervention weakness in her grip and general fatigue. Initially, she
relevant to the patient. thought her symptoms related to a house move, but on
When problems are noted in self-care, productivity questioning, she admits things have not improved over
or leisure, probe for contributing factors, including time. She reports general body stiffness experienced
pain, physical factors (strength, endurance, mobility), in the mornings, recently lasting over an hour, and
or environmental factors (physical barriers, lack of episodes of swelling in the small joints of her fingers.
proper equipment for a particular task). This deter- This has made it difficult for her to work and she is
mines which observational assessments are neces- concerned as she has had to take some time off. She
sary. Discussing social roles provides an opportunity describes how she has trouble dressing my two-year-
to inquire about psychological status, such as depres- old and peeling vegetables. She has had some relief
sion resulting from withdrawal from valued activi- taking Ibuprofen medication.
ties or roles (Katz & Yelin 1994), cultural beliefs and
expectations, intimate relationships or coping issues.
Although not feasible to assess every area in an ini-
tial evaluation, one should be alert to those most rel- Case study 16.2 Patient with more
evant to the individual, their circumstances and stage established disease-subjective history
of illness. Some may be ready to act while others
may still be adjusting to the diagnosis or a change in Mrs Edwards, aged 62, has had RA for 22 years. She is
functional status and wondering how to cope. People referred to out-patient therapy following a right total
with more established disease may come to therapy knee arthroplasty 10 days previously. Medically, her RA
for specific and well-delineated purposes, as they are is managed with combination therapy (methotrexate
already experienced in managing their illness. and sulfasalazine). Over the years, she has learned
Asking the patient to describe their usual levels to listen to her body and recognizes how to pace
of mobility (including mobility aids and if mobility activities to manage fatigue. As a result of increasing
level has recently changed) helps the therapist plan knee pain and decreasing mobility prior to surgery,
objective assessment safely. Ask about estimated she was unable to maintain her exercise routine, and
walking distance, what limits this, e.g. pain or reports declining general strength and stamina. She
shortness of breath, whether steps or stairs have to is a little concerned about the stress placed on her
be negotiated (with or without banisters/stair lifts, hand and wrist while using a walking stick/cane as
etc.) and corroborate ability in objective examina- she recovers from surgery, because several joints are
tion. Subjective evaluation may include self-report subluxed. Mrs Edwards is a retired office manager and
measures of health and functional status (discussed lives in a small, one-level house with her husband.
later, and in Chs 4 & 5). Both are avid gardeners.
These two case examples illustrate how sub-
jective findings will guide organizing the objec-
tive examination. The presenting issues and Objective examination
functional priorities differ for each patient. When
time or patient tolerance is limited, focus on a few If possible objective examination should follow the
key issues for the objective examination and begin subjective history, but if a patient is acutely unwell,
priority interventions to establish the therapeutic this may not be feasible. A logical approach ensures
relationship. When necessary, evaluation and inter- nothing of great importance should be missed if
vention planning can evolve over subsequent visits. performed over several sessions. Whilst the focus
See the clinical pathway in Fig. 16.2 for a compari- will usually be the musculoskeletal system, a full
son of functional goals, assessment and interven- respiratory or neurological assessment may be
tion plan for Ms Jones and Mrs Edwards. required with some patients (see Table 16.2).
Chapter 16 Inflammatory arthritis 217

Issues not resolved: Issues resolved

return to any stage = discharge.

Stages Screening; Select Plan and

in the Identify Main Theoretical Set Goals for Implement Monitor Evaluate
Clinical Assessment Therapy Progress Outcomes
Functional Approach Intervention
Pathway* Concerns

Screen referral; Use theory to Subjective data: Help patient identify Based on assessment Monitor Use
Example review health guide medical history, priorities and establish findings, develop plan response to interview
content record; conduct assessment and symptoms (pain, behavioural goals: to achieve each goal. interventions, and
at each initial interview; intervention: for fatigue, mood), specific, measurable, Physical modalities: disease observation
stage identify key example, priorities, daily realistic, with timeframe electrotherapy, ice, status, as well as
concerns re: biopsychosocial, activities, role for achievement. heat, hydrotherapy; functional outcome
pain, fatigue, biomechanical, participation General goals: reduce Exercise; status, measures to
mobility self rehabilitative, (employment, pain, fatigue and Joint protection (JP) progress determine
care, self-efficacy household, hobbies, stiffness; improve ROM and energy toward effect of
productivity, theory. social, intimate and strength; minimize conservation (EC); patient goals. intervention
leisure. relationships), illness external forces on Reassess & on body
Splints, assistive
Document perceptions, beliefs, joints; maintain general revise plan structures,
consent expectations fitness, improve task as required. activity,
Objective data: performance; enable Document participation,
modifications at
Active joint count, participation. throughout. and quality
ROM, muscle of life.
strength, mobility, Engage
hand function, patient in
functional status. evaluating
whether or
not goals

Pathway Reports Biomechanical Newly diagnosed, 1. learn new ways to 1. Analyze tasks, apply Monitor and Evaluate
applied to difficulty with & rehabilitative concerned about manage child care, JP & EC principles modify effect goals.
Ms Jones computer work, approaches; impact on daily household, work 2. ergonomic evaluation of treatment. Measure
(early RA) dressing child, self-efficacy activities, not sure 2. implement office and solutions for outcomes
preparing (educate re: self- how to manage ergonomics, resume work (keyboard) (joint count,
meals; hand management) illness. Active joint work 3. ice, relaxation hand
pain, swelling. count = 17; grip 3. learn to manage pain function,
4. exercise
strength, hand 4. maintain mobility overall
dexterity, and function,
function. participation).

Reports Biomechanical, Resilient, well- 1. obtain appropriate 1. provide forearm Monitor and Evaluate
concern about rehabilitative educated on arthritis walking aids crutches modify effect goals.
applied to
walking with approaches. management. 2. increase walking 2. graduated walking of treatment. Measure
Mrs Edwards
aids post-op Manages household, tolerance programme outcomes
(stress on supportive husband. 3. refresh knowledge 3. gardening (walking
hands); wants Has post-op pain, of adaptive equipment, programme, speed and
to get fit for restricted ROM, JP & EC to work in assistive devices duration,
gardening. decreased stamina garden social
and walking participation).

*stages in this pathway based upon the Occupational Performance Process Model (Fearing & Clark 2000)
Figure 16.2 Clinical pathway for physiotherapy and occupational therapy for individuals with rheumatoid arthritis.
218 Rheumatology Evidence-Based Practice for Physiotherapists and Occupational Therapists

Table 16.2 Components of the objective examination

Component Description Additional Note

General Transfers, amount of assistance required, quality of Observe patients response to proposed therapy,
observation movement, sitting/standing postures, eye contact willingness to actively participate
UL joint Swelling and/or erythema especially MCP, IP and wrist Severity of hand signs and symptoms may not correlate
observations joints with poorer hand function
LL joint Foot posture whilst weight-bearing; medial arch flattening, Document regularly used assistive, orthotic devices
observations tendo-achilles angle, subluxation of MTP joints, tread on
Palpation Small joints of hands especially but any symptomatic joints; DAS-28 joint scoring adopted internationally (Prevoo
active or inactive synovitis, tenderness etal 1995)
Range of For UL, LL and spinal joints measure actively and passively. Should be linked with a functional goal
movement Note reason for limitation of range, muscle length and Reliability of goniometry disputed: standard errors
neurodynamics as appropriate. between 15 and 30
Measure with manual or electronic goniometry or eye-ball
Muscle Note hand dominance power grip and key grip most Jamar dynamometry and pinch/key grip dynamometry
strength functional (Mathiowetz et al 1984)
Individual and key muscle groups should be assessed Oxford scale method (Medical Research Council, 1976)
depending on functional challenges
UL wrist extensors and rotator cuff muscles
LL quadricep and gluteal muscle groups
Joint stability Some agonist muscles may be a lot stronger than Key joints: wrists, MCP and IP joints in hands, knees, MTP
antagonist exacerbating instability at a joint joints and cervical spine
Mobility Gait patterns / mobility aids and support required Note quality of gait including stride length, cadence, heel
Steps/stairs strike, and distance the patient can (or cannot) walk
Note ability and safety
Transfers Sit to stand, lie to sit / assistive devices Make as functional and replicate home circumstances as
Note ability and safety much as possible
Exercise Borg scale (Borg 1985) is a speedy and pragmatic method Most patients have reduced exercise tolerance
tolerance where patients state their rate of perceived exertion (RPE)

Key: UL, upper limbs; LL, lower limbs; MTP, metatarsophalangeal, MCP, metacarpophalangeal; IP, interphalangeal

Observation Range of movement

Welsing et al (2001) identified that functional capacity Caution is needed when assessing passive range,
is most reduced with higher disease activity in early especially in the cervical spine. In most instances this
RA and with joint damage in late RA. Very often is not advisable and could elicit symptoms of cervical
initial impressions can be deceptive; someone with artery insufficiency. Assessing joint range can be very
apparently established and significant hand deformi- time consuming if all spinal, UL and LL joints are
ties may have accommodated and adapted over time included. The therapist may direct range of move-
and have good residual hand function. However, the ment (ROM) assessment to specific joints impacting
opposite can also be true (see Fig. 16.3a-d). on previously identified key functional difficulties.

Palpation Joint stability/muscle strength

The DAS-28 joint scoring method identifies pain RA often affects joints bilaterally, but a symmetrical
and swelling on joint palpation and is part of a distribution of either joint range or muscle power
disease activity score (DAS), including patient and should not be presumed. Power grip can be reliably
clinician opinion, questionnaires and ESR levels as measured using a Jamar dynamometer (Mathiowetz
part of disease and drug monitoring (Prevoo et al et al 1984) but may not always be comfortable for
1995). Knowing which joints are most affected helps patients with RA (see Fig. 16.4). Key grip however,
therapists to plan relevant and targeted treatment. is rarely uncomfortable to assess (e.g. using B&L
Chapter 16 Inflammatory arthritis 219


Figure 16.3 Clinical features that may be observed in advanced RA in the hand and foot in RA. (A) Ulnar deviation and
rheumatoid nodules, (B) Swan-neck and Boutonniere deformities, (C) RA- forefoot deformity with callosity under MT head.
With permission from: (A) Matteson EL Ch.69 Extra-articular features of rheumatoid arthritis and systemic involvement,
Fig 69.4 p782, (B) Gordon DA and Hastings DE 2003 Ch. 68 Clinical features of rheumatoid arthritis Fig 68.7 p771,
(C) Gordon DA and Hastings DE 2003 Ch. 68 Clinical features of rheumatoid arthritis Fig 68.15 p776. In: Hochberg MC et al
(eds) Rheumatology 3rd edn, Elsevier, London.

Engineering Pinch Gauge) and other dynamometers

are valid and reliable tools to use (e.g. MIE digital
grip measures (MIE Medical Research, Leeds UK);
Grippit digital measure, AB Detektor, Sweden).
Some units may have more sophisticated elec-
tronic methods of measuring muscle strength (e.g.
isokinetic machines), both isometrically as well as
isotonically within a stated range of motion. Whilst
affording more accuracy for research, it is not essen-
tial for patients in standard clinical settings. Using
isokinetic machines may, however, be contraindicated
in patients with active inflammatory joint disease.

Functional mobility and transfers

The get up and go test quantifies mobility, espe-
cially in more elderly patients (Wall et al 1998,
Podsiadlo & Richardson 1991). Alternatively, a
quick timed 10 metre walk test needs only a meas- Figure 16.4 Jamar dynamometer. Reproduced, with
ured walk way and stop watch for equipment. permission, from the Benefits Now website-http://www.
Slippers and soft-soled slip-on shoes with minimal
220 Rheumatology Evidence-Based Practice for Physiotherapists and Occupational Therapists

support should be discouraged and trainer type Important first treatments - early
footwear, possibly with velcro fastening, promoted recognition of signs and symptoms
for both safety and joint protection reasons.
Because RA is episodic, recognising when a patient
is entering a flare up phase is very important.
Assessment of occupational Patients should be aware of a sudden increase in
performance (functional joint swelling with associated pain, increasing EMS
assessment) as well as over-whelming fatigue. Experienced
patients will recognise signs and symptoms and
The initial interview identifies priority occupational
appropriately self-manage, but the newly diag-
performance issues and guides selecting additional
nosed may need guidance. Therapists are ideally
evaluations to determine underlying performance
positioned to help the patient to identify tell-tale
components or environmental conditions contri
signs, and manage the situation to best advantage.
buting to the problem (Backman & Medcalf 2000).
For example, for acute joint effusions (red, warm,
In addition to ROM, strength, and mobility, evalua-
swollen and painful joints), local treatments like ice
tion may include:
and resting splints are indicated. To alleviate more
l Hands-on evaluation of soft-tissue integrity systemic pain and fatigue, balancing rest and activ-
l Hand dexterity (e.g. pegboard tests) ity will help significantly. Some gentle daily activity
l Hand function (pottering in the home, gentle stretching) is impor-
l Symptoms affecting occupational performance, tant to prevent soft tissue shortening, but during the
e.g. pain and fatigue acute few days of a flare many patients will benefit
l Specific activities of daily living (ADL), from additional chair or bed rest. The balance is spe-
instrumental ADL (IADL), work, or leisure cific to each individual and dependant upon which
assessments, as indicated by the clients joints are involved. Ensuring family members and
problems and priorities. significant others understand this principle is essen-
tial and therapists can often play an important role
Useful measures are summarized in Table 16.3
acting as an advocate for the individual.
and outcome measures for baseline and follow up
Flare ups can be induced by stress and signifi-
assessments are discussed in chapters 4 and 5.
cant life events (Curtis et al 2005, Straub et al 2005)
During formal evaluation, particular attention is
but the aetiology may also be unexplained. Early
given to assessing hand function because RA typi-
recognition and prompt management can minimise
cally affects these joints and the hands are involved
effects. Appropriate medication, as well as using
in almost all daily activities. Early hand involvement
ice (with hot joints, unless Raynauds phenomenon
is one of the strongest predictors of poor outcomes
is an issue) or heat in the form of hot packs, warm
in RA (Schumacher et al 2004). Early detection and
showers or baths when muscular spasms are pain-
intervention through hand therapy may be one
ful, can all ease symptoms.
way to improve outcomes. Questionnaires measur-
ing overall function may not be sensitive enough to
capture specific problems with hand use in every- Identification of red flags
day activity (OConnor et al 1999). Detailed obser-
vations of joint effusions, synovial proliferation, l Joint instability of the cervical spine occurs
ligamentous integrity and deformity also contribute as a consequence of repeated flare ups and
to a comprehensive hand assessment. Combining over-stretching of the surrounding ligaments
subjective and objective measures gives an overall (Dreyer & Boden, 1999). Patients may report
picture of functional status. sensory or motor changes, e.g. paraesthesia/
The ICF (World Health Organization, 2002) dis- anaesthesia, a history of dropping items or
tinguishes between activity limitations and par- recent falls without obvious cause. A detailed
ticipation restrictions. To capture these changes, neurological examination should follow to
specific measures of activity and participation are include dermatomes, myotomes and reflexes for
being developed or refined, potentially as part of both upper and lower limbs. Symptoms should
a core set of outcome measures (Uhlig et al 2007). be promptly reported to the Rheumatology
Staying abreast of emerging tools will improve Consultant. Follow-up may include onward
comprehensive and valid functional assessment. referral to either orthotists for assessment for
Chapter 16 Inflammatory arthritis 221

Table 16.3 Selected functional tests/measures of activity and participation

Test Description Reference

Performance-based Tests of hand function

Arthritis Hand Function Test 11-item test of hand strength, dexterity, and functional tasks for Backman et al 1991; Poole
(AHFT) adults with RA, osteoarthritis, and scleroderma et al 2000
Sequential Occupational Dexterity Measures ability to do 12 functional tasks, with difficulty scored by van Lankveld et al 1996
Assessment (SODA) both occupational therapist and client
Self-report assessments of hand and upper limb function
Cochin Evaluates level of difficulty performing 18 functional tasks Duruoz et al 1996
Rheumatoid Hand Disability Scale
Disabilities of the Arm, Shoulder 30-items evaluate level of pain and difficulty with functional tasks; Beaton et al 2001 (includes
and Hand (DASH) optional modules for sports, work, and musicians; for any diagnosis entire questionnaire)
Michigan Hand Outcomes Scores symptoms, function, and aesthetics for pre- and Chung et al 1998 (includes
Questionnaire (MHQ) postoperative evaluations entire questionnaire)
Overall health and functional status
Arthritis Impact Measurement Self-report of mobility, physical, household and social activities, ADL, Meenan et al 1992
Scales 2 (AIMS-2) pain, depression & anxiety
Canadian Occupational Semi-structured interview, rating performance and satisfaction with Law et al 2005
Performance Measure (COPM) performance in self care, productivity, leisure on 110 scale
Evaluation of Daily Activities Self-report or interview rating performance of 102 ADL with and Nordenskiold et al 1998
Questionnaire (EDAQ) without assistive devices/ adapted methods (UK version in development)

Health Assessment Questionnaire HAQ: Self-report of difficulties performing 20 ADL tasks (in 8 Fries et al 1980
Disability Index (HAQ) and HAQ-II categories). HAQ-II: 10 item version. Wolfe 2005

Medical Outcomes Study Short Health survey with 8 subscales: physical function, social function, Ware & Kosinski, 2001
Form-36 (SF-36) mental health, pain, physical role limitations, emotional role
limitations, energy/fatigue, and general health
Impact of fatigue on function
Multi-dimensional Assessment of 16-item questionnaire addressing fatigue severity, frequency, Belza 1995
Fatigue (MAF) distress and impact on ability to perform 11 activities
Parenting disability
Parenting Disability Index Self-report of difficulty caring for children 5 yrs, 612 yrs, and/ Katz et al 2003
or 12 yrs
Keele assessment of participation Self-report, 11-item questionnaire; measures whether or not one is Wilkie et al 2005
engaging in activities when and as they would like
Social role participation Self-report questionnaire rating salience and satisfaction with 10 Gignac et al 2008
questionnaire domains of social participation
Work disability
Ergonomic Assessment Tool for Customized self-assessment and semi-structured interview re: work Backman et al 2008
Arthritis organization, job demands and environment
Work Limitations Self-report questionnaire rating difficulty performing 25 specific job Lerner et al 2001
Questionnaire demands
Work Instability Self-report, 23-item questionnaire to identify risk for problems Gilworth et al 2003
Scale believed to lead to work disability

cervical collar/brace or to spinal surgeons. For but many orthopaedic surgeons also manage RA
approximately 50% of patients, neurological patients with spinal instability. Ignoring signs
deficit can subside following surgery to of spinal instability could lead to tetraplegia, so
improve cervical instability, but mortality vigilance by the therapist is required.
rates can be significant (Ronkainen et al 2006). l RA patients receiving steroid therapy may
Neurosurgeons may be the preferred first option, notice excessive bruising often due to low
222 Rheumatology Evidence-Based Practice for Physiotherapists and Occupational Therapists

platelet counts. Consequently, it is important (Heller & Shadick 2007). The purpose and intended
therapists handle patients carefully to avoid skin outcome for each stage of therapy should be dis-
damage. Healing in general may be slow in RA cussed to clarify realistic expectations. As a rule
(Boardman et al 2001) and ulceration from skin the earlier a referral is made to therapists, the more
abrasions can take months to heal. Precautions successful interventions will be, especially if joint
include keeping nails short, removing jewellery protection principles are adopted early on in joint
(e.g. wrist watches or rings) that may catch disease. However for some individuals the shock
on the skin and ensuring that foot plates are of diagnosis may mean time is required to contem-
correctly positioned to avoid calf contact during plate, before any actions can be positively adopted.
wheelchair transfers. Patients receiving anti-TNF Therapists should include promotion of long term
therapies may also have slower healing rates and health in their treatment strategies (see Ch. 6) and
more infection complications, especially post facilitate the patient to remain in work or education.
surgery, although some dispute this (Bibbo & In the context of inter-professional practice, physio-
Goldberg 2004). therapy and occupational therapy colleagues work
collaboratively with patients to achieve shared ther-
apy objectives. Increasingly, therapy will be deliv-
Rehabilitation interventions for RA ered in community settings and the emphasis will
continue to be on empowering the individual to
Guidelines for pharmacological and non-pharmaco- manage their own symptoms.
logical management of RA have been documented
in both the United States (American College of
Rheumatology 2002) and Britain (Luqmani et al Exercise therapy
2006, NICE 2009). Special attention has been given Exercise therapy, in its many possible settings, is the
to early RA management to minimize disability mainstay of physiotherapy treatment (Hurley et al
(Hennell & Luqmani 2008), and to rehabilitation 2002, Lineker et al 2006). Exercise is prescribed to:
interventions (Hammond 2004). There is some evi- improve joint range and muscle power, maximise
dence to show RA symptoms are relieved by ther- joint stability, increase exercise tolerance, reduce
motherapy, laser therapy, acupuncture, splints morning stiffness/muscle spasm and thereby asso-
and assistive devices; and that pain and function ciated pain. The overall aim is to optimise function
can improve with patient education, joint protec- in ADL. Physiological benefits are well known,
tion behaviours, exercise therapy, hand exercises, but Hurley et al (2003) also documented many
and cognitive-behavioural therapy. However since psychosocial benefits of exercising in osteoarthri-
Hammonds review in 2004 few treatment studies tis, much of which is applicable in RA. Lee et al
have been published and well-designed rehabilita- (2006) evaluated exercising three times a week for
tion trials are still required to identify which treat- at least 20 minutes for more than 6 months and
ments work best for patients at different disease found that exercisers with RA experienced signifi-
stages. cantly less fatigue and disability compared with
Figure 16.2 introduced a clinical pathway from non-exercisers. Patients report that pain remains
assessment to outcome evaluation, providing an a significant barrier to their exercising (Bajwa &
overview of occupational therapy and physical Rogers 2007) so unless this is addressed and an end
therapy management. Specific interventions are purpose understood, exercise may seem irrelevant
summarized in turn below. at best, painful at worst and therefore rarely under-
taken independently.
Physiotherapy evidence-based Key features of exercising with RA:
treatment programmes l Relate any exercise to improving performance
The Association of Rheumatology Health Profes of individually relevant functional tasks;
sionals has published standards of care document- individualise range, resistance, eccentric,
ing physical therapy competencies in rheumatology concentric muscle work, length of hold of
(2006), based on work by Moncur (1988). Treatment contraction
programmes must be individualised and devised l Wherever possible, minimise pain first
in agreement and collaboration with the patient l Avoid uncontrolled end of range movements
Chapter 16 Inflammatory arthritis 223

l Aim to improve exercise tolerance as well as muscle atrophy and general deconditioning help
increasing range of movement/muscle strength the individual to maximise quality of life long term.
and joint stability Patients should be reassured it is never too late
l Reassure new exercisers that join/muscle aches to start and regular exercise can be beneficial for
may last up to 30-60 minutes after exercise this everyone.
is normal! Research has demonstrated that hand exer-
l Dosage should be individualised most benefit cises improve hand function over a six month
from some daily exercise (ARC, Keep Moving period (OBrien et al 2006). A combination of daily
leaflet, 2005) stretching and strengthening exercises improved
l Modify exercise during a flare; focus on
hand function as measured by the Arthritis Impact
maintaining range but without resistance Measurement Scales upper limb function subscale.
Further research into this is ongoing.
l Minimise use of equipment so exercise can easily
be performed at home
l Written information should support exercise Hydrotherapy
instructions and include SOS contact details. Hydrotherapy uses the properties of water, buoy-
Within the United Kingdom, Arthritis Care ancy, turbulence and drag during exercise to
and Young Arthritis Care organisations encourage achieve an end functional goal. Hydrotherapy
individuals to exercise in groups. This is popular remains popular, despite efficacy having been chal-
and helps individuals remain motivated. Similarly, lenged in some studies (Verhagen et al 1997, 2004).
People with Arthritis Can Exercise (PACE) pro- However, benefit has been demonstrated (Hall et al
grammes operate in the USA and JointWorks and 1996) with patients reporting continued pain relief
Waterworks are offered by the Arthritis Society and reduced morning stiffness by diminishing mus-
in Canada. These group initiatives are cost effective cle spasm. Some consider this an expensive resource
and for many peer support is invaluable. For others, (Epps et al 2005) not available to all. Consequently,
exercising 1:1 with a therapist or alone is preferred therapists should be clear about their rationale for
(Bajwa & Rogers 2007) and therapists should select prescribing hydrotherapy as opposed to land-based
or produce audio-visual material to support this. exercise. However, it may be cost-effective if suf-
Tai Chi has become increasingly popular among ficient numbers utilise the resource throughout
people with arthritis. Whilst evidence is limited, the day.
Han et al (2004) report no detrimental affects in RA
patients. A higher level of participation and gen-
erally greater enjoyment was also documented,
compared with a traditional range of movement For many patients cryotherapy can be a useful
exercise class. adjunct to treatment of hot swollen joints (Robinson
Previously, concern has been raised about exer- et al 2006) before or after exercise. For most patients
cise potentially increasing joint pain and exacerbat- a simple ice pack can be replicated at home by using
ing inflammatory disease, especially during a flare frozen peas or equivalent to ease symptoms tem-
up. However, many studies reassure therapists porarily (Hirvonen et al 2006). Information relating
and patients alike that appropriately prescribed to optimal dosage and frequency remains illusive.
exercises are significantly beneficial (Bearne et al Contraindications should be checked prior to treat-
2002, Kennedy 2006, American Physical Therapy ment, e.g. a significant number of RA patients have
Association Ottawa Panel 2004a, Panel 2004, Van Raynauds phenomenon.
den Ende et al 2000, 2006).
The frequency of exercise required remains gen-
erally poorly documented and evaluated. Many
recommend daily practice of simple stretching exer- Some patients experiencing muscle spasm or morn-
cises to maintain or improve joint range for all large ing stiffness report benefits from applying heat and
joints e.g. shoulder, hip and knee, and strength many report a morning shower minimises morn-
exercises most days (ARC 2005). ing stiffness. Simple hot packs can be used, heated
For all, early exercise therapy should be encour- up in microwaves at home. Evidence for thermo-
aged. Prophylactic exercises to prevent contractures, therapy remains limited, but no detrimental effects
224 Rheumatology Evidence-Based Practice for Physiotherapists and Occupational Therapists

have been reported (Welch et al 2002). Wax therapy, Management Physiotherapy Physiotherapy
previously popular especially for hands, is less methods short term aims long term aims
favoured today as being too passive a treatment.
Benefit is only maintained if followed by hand exer- Physical modalities: Reduce/minimise Independently
pain, fatigue and manage symptoms,
cises (Dellhag et al 1992). Therapists should be cau- Heat, ice,
morning stiffness recognise a flare
tious of applying heat to joints with active synovitis. hydrotherapy and know when/
where to seek
Some evidence indicates that metalloproteinases are further
Improve joint management
activated with increasing temperature which could range of advice
Exercise therapy movement
accelerate degeneration of hyaline cartilage (Yasura
et al 2006). However, the clinical relevance of this is
Maximise joint
yet to be established in RA patients. Improve muscle range, muscle
power power and
with general
mobility, transfers
Electrotherapy Application of joint
Improve /maintain and all activities
cardiovascular of daily living
protection, energy fitness
Many electrotherapy modalities have historically conservation and
been used, but studies have been criticised for lack principles Enable
of methodological rigour as well as low sample Minimise external performance of
forces acting on self care,
sizes. The American Physical Therapy Association joints productivity and
Splints, orthoses leisure occupations
Ottawa Panel has published practice guidelines and assistive in support of major
(2004b) for electrotherapy in RA. This panel recom- devices
life roles (parent,
partner, employee,
mends the use of therapeutic ultrasound, low level performance of student, etc.)
specific tasks: grip,
laser, transcutaneous electrical nerve stimulation Environmental walking, transfers;
(TENS), electrical stimulation and thermotherapy. modifications at at home, e.g.
home or workplace cooking and work,
Berliner & Piegsa (1997) studied the physiologi- e.g. keyboarding Facilitate optimal
quality of life,
cal effects of continuous therapeutic ultrasound in health and well-
a water bath on skin microcirculation and tempera- being

ture in RA patients. Comparing healthy participants

with patients with high and low disease activ- Management Occupational Occupational
methods therapy therapy
ity, they concluded (based on a single treatment short term aims long term aims
intervention) that microcirculation increased sig-
nificantly in healthy participants, but least in those Figure 16.5 Management of RA by occupational and
with high inflammatory activity. physiotherapists.
A meta-analysis of low level (non-thermal) laser
therapy concluded this has small short term effects
on pain relief, range of movement and reduction
in morning stiffness (Brosseau et al 2005). This sys-
tematic review highlights that future research must Acupuncture has been reported to have anti-
investigate dosage, wavelength, site of application inflammatory properties (Zijlstra et al 2003) and is
and treatment duration. increasingly used for symptomatic treatment of RA.
Transcutaneous electrical nerve stimulation As with many other modalities, data are not compel-
(TENS) is used for pain relief. It can be independ- ling and there are often methodological limitations
ently applied by the patient and used with many in trials, but its popularity with patients suggests
peripheral and spinal joints at home. Brosseau et al an anecdotal analgesic benefit. Casimiro et al (2005)
(2003) systematically reviewed effects of TENS in report benefit from electro-acupuncture in knee
the rheumatoid hand. TENS significantly reduced pain in RA, but conclusions are limited due to few
resting pain and joint tenderness, and improved trials and small sample sizes. Results to date sug-
grip strength. However there were conflicting gest no effect on inflammatory markers, swollen or
results between the differing modalities of TENS tender joint counts or analgesic intake. Figure 16.5
(conventional and acupuncture-like TENS). summarises the management of a patient with RA
Further research is needed, with increased power, from a physiotherapy and occupational therapy
to draw more meaningful conclusions. perspective.
Chapter 16 Inflammatory arthritis 225

Occupational therapy support of valued activities (Backman et al 2004). To

interventions be effective, general principles of joint protection and
energy conservation need to be demonstrated and
Occupational therapy interventions are directed applied to the patients specific roles and activities
at resolving functional limitations identified by (see Table 16.4). Compared to standard care, compre-
the patient while managing symptoms like pain hensive joint protection education has been shown to
and fatigue. It is important to stay involved and reduce pain and morning stiffness, and improve ADL
connected with family, friends, and community, performance (Hammond et al 1999; Hammond&
because withdrawal from everyday activities, Freeman 2001). See chapters 1 and 6 for further
including housework, leisure and social activities, is descriptions of techniques and evidence.
more closely linked to poor psychological outcomes The psychosocial impact of RA cannot be under-
than difficulty with ADL (Katz & Alfieri 1997). estimated: symptoms may significantly impact
Patients may grieve the loss of participation in daily routines, and depression often accompanies
valued roles or experience mood changes, such as RA. For example, morning stiffness can delay self
depression or anxiety, as they negotiate living with care routines and present a challenge getting to
chronic illness. Engaging in meaningful activities is work on time, or frustrate a mother needing to care
critically important to maintaining a sense of iden- for a young child waking early or during the night.
tity and positive self-worth. To have the greatest Fatigue may limit participation in family events or
impact on health and well-being, it is highly recom- recreational activities if all ones energy is expended
mended that occupational therapists take time to in obligatory paid and unpaid work activities.
evaluate the occupations of greatest value to the cli- Ongoing disruption to daily routines creates dis-
ent and focus on improving participation in these. tress and coping difficulties for many patients.
Comprehensive occupational therapy programmes There may be added worries regarding employ-
have demonstrated sustained improvements in func- ment, financial issues, or family obligations.
tion (Helewa et al 1991, Steultjens et al 2002). Typical One-to-one and group educational programmes
programmes involve: patient education (including (including joint protection and energy conserva-
joint protection, energy conservation, psychosocial tion mentioned above) help patients develop self-
support and cognitive-behavioural approaches to management skills and identify reasonable ways
improve coping); splinting; assistive devices and envi- to plan ahead and adjust routines where possible
ronmental modifications; and activity adaptation. to minimize pain and fatigue while doing daily
activities. Cognitive-behavioural approaches and
counselling assist patients to recognize ineffective
Patient education: supporting
thought processes, feelings and behaviours, then
set goals and implement practical strategies to cope
Arthritis self-management programmes improve with the emotional consequences of RA (Backman
health outcomes for people with RA (Lorig & 2006). For example, stress management and relaxa-
Holman 2006, Riemsma et al 2003). Successful pro- tion techniques might focus on changing attitudes
grammes are based on enhancing self efficacy, i.e. the and responses to challenging situations, rhythmic
patients confidence that they can adopt behaviours breathing and guided imagery. Because of differing
to control disease symptoms and enhance func- priorities among patients and the episodic nature
tion. Facilitating new habits through counselling on of RA, it is wise to offer a range of strategies and
joint protection, energy conservation and cognitive- encourage patients to select those most applicable
behavioural approaches are the cornerstone of occu- to their unique situation.
pational therapy patient education, which focuses Involving family members in education and
on practical strategies to engage in life despite pain, counselling sessions may be welcomed, as social
fatigue, depression, and physical challenges. support is important to living with RA. In many
Joint protection principles are based upon biome- ways, RA affects the entire family, and spouses,
chanical and ergonomic guidelines and aim to reduce parents or children may have questions of their
pain and local inflammation during task perform- own. Sometimes, problem-solving involves coordi-
ance, preserve the integrity of vulnerable joint struc- nating the efforts of several members of the health
tures and improve function (Backman et al 2004). care team, for example, coordinating medications,
Energy conservation principles involve planning and ROM exercises, and joint protection techniques to
pacing activities, to balance energy and fatigue in optimize performance, or engaging the services of a
226 Rheumatology Evidence-Based Practice for Physiotherapists and Occupational Therapists

Table 16.4 Joint-protection and energy-conservation principles and sample techniques

Principle Sample techniques or application

Respect your pain Reduce time and/or effort spent on an activity if pain occurs and lasts for more than 2 hours after
the activity has been discontinued. Avoid nonessential activities that aggravate your pain
Balance rest and work Take short breaks during your work. For example, take a 5-minute rest at the end of an hour of
work. Intersperse more active tasks with more passive or quiet work
Reduce the amount of effort needed Use assistive devices such as a jar opener or lever taps. Slide pots across the counter instead of
to do the job lifting. Use a trolley to transport heavy items. Use a raised toilet seat and seat cushion to reduce
stress on hips, knees, and hands. Use frozen vegetables to minimize peeling and chopping
Avoid staying in one position for Change position frequently to avoid joint stiffness and muscle fatigue. For example, take a 30-
prolonged periods of time second range of motion break after 1020 minutes of typing or holding a tool; after standing for
20 minutes perch on a stool for the next 20 minutes; walk to the mailroom after 2030 minutes
sitting at your desk
Avoid activities that cannot Plan ahead. Be realistic about your abilities so you dont walk or drive too far, or leave all your
be stopped immediately if you shopping and errands to a single trip
experience pain or discomfort
Reduce unnecessary stress on your Use a firm mattress for support. Sleep on your back with a pillow to support the curve in your
joints while sleeping neck. If you prefer to lay on your side, place a pillow between your knees and lay on the least
painful side
Maintain muscle strength and joint Do your prescribed exercises regularly. Strong muscles will help support your joints. Regular
range of motion exercise will reduce fatigue
Use a well-planned work space Organize your work space so that work surfaces and materials are at a convenient height for you,
to ensure good posture. Place frequently used items within close reach. Reduce clutter by getting
rid of unnecessary items, or storing less frequently used items away from the immediate work

Note. From the Mary Pack Arthritis Program, Vancouver Coastal Health, Vancouver, BC Canada. Used with permission.

vocational counsellor, social worker or psychologist dexterity (Haskett et al 2004). During flares, rest-
to resolve complex employment, family, or emo- ing splints may be recommended for the wrists and
tional issues. hands, knees, or elbow, at night use or during day-
time rests. A systematic review concluded there is lit-
tle evidence that resting splints improve function, yet
patients prefer using them rather than going with-
Splints support and protect joints, minimize pain, out, suggesting they alleviate pain (Egan et al 2001).
and enhance function. They may provide localized For prolonged MCP joint effusion, MCP protec-
rest to reduce pain and inflammation (e.g. a hand tion splints may be indicated. These restrict flexion
resting splint, see Fig. 16.6a); enhance joint stability and ulnar deviation at the MCP joints with the intent
to improve function (e.g. a wrist splint to improve to prevent or minimize subluxation. One study, using
ability to grasp, lift and carry items, see Fig. 16.6b); x-rays to evaluate 27 hands with RA, showed that
align joints in a stable anatomical plane to minimize while worn the splints corrected the alignment of
deformity and stretching of the joint capsule and liga- all MCP joints except the index finger (Rennie 1996),
ments (e.g. a silver ring splint to position a swan-neck although long-term benefits have not been evaluated.
deformity of the finger into a slightly flexed posture, Foot orthoses in combination with supportive shoes
see Fig. 16.6c); or facilitate recovery from surgery (e.g. (Fig. 16.6d) support the transverse and longitudinal
dynamic flexion or extension splints following arthro- arches of the foot, alleviate metatarsalgia, and enable
plasty or tendon repairs to encourage early finger people with RA to walk comfortably (Chalmers et al
motion in a controlled range (Backman et al 2004). 2000, Hawke et al 2008) (see also Ch. 13).
A more comprehensive discussion of splinting
is presented in chapter 12. With respect to RA, evi-
dence suggests that wrist splints improve hand Assistive devices and environmental
strength (Haskett et al 2004, Pagnotta et al 1998) and modifications
reduce pain (Haskett et al 2004, Veehof et al 2008), Dozens of assistive devices are available to accom-
and after a break-in period, do not compromise modate physical limitations or promote adherence to
Chapter 16 Inflammatory arthritis 227



Figure 16.6 Splints used in RA. (A) hand resting splint; (B) wrist splint; (C) anti-swan neck silver ring splint; (D) foot orthosis
and supportive shoe.

joint protection principles. Common devices include stress on the hands and wrists, counteracting the
jar openers (to accommodate for weak grasp), long- intended benefit. Devices that fail to resolve the
handle shoe horns, sock aids, or dressing sticks (to functional problem are not used. However, in one
accommodate limited motion), and raised toilet seats follow-up study, as many as 91% of kitchen devices
(to reduce stress on hips, knees, and hands, because reduced pain and were still in use by women with
the higher seat means less need to push up). Once only RA 6 to 12 months after they were first provided
available through therapy departments and medical (Nordenskiold 1994). Not all patients are ready to
supply catalogues, the move toward universal acces- consider multiple assistive devices and environ-
sibility means many helpful devices can be found in mental modifications at once, and some devices
department, hardware, office supply and other shops. reinforce beliefs about being disabled. Limit rec-
For example, cook shops have an array of utensils with ommendations to the most important problems
large grips, making grasp easier for all, not just people first, and build on successes as they occur.
with RA. They also have lightweight dishes and small Home modifications may enhance independ-
appliances for easy use at counter height. Ergonomic ence and functional capacity. Physical environment
office equipment, appropriately selected, facilitates modifications can be divided into three categories
improved posture to minimize pain and fatigue. (Mann et al 1999): re-arranging the living environ-
Not all assistive devices will fit all patients, ment, such as moving dishes to lower shelves; add-
and careful assessment and patient education may ing to the environment, such as the placement of
be necessary to prevent inappropriate suggestions. hooks and storage bins to keep frequently used sup-
The long-handled reacher that accommodates plies within easy reach; and structurally modifying
decreased range of motion may present a mechani- the environment, such as installing a walk-in shower
cal disadvantage in some situations, putting greater or ramps in place of stairs. Such modifications help
228 Rheumatology Evidence-Based Practice for Physiotherapists and Occupational Therapists

people compensate for physical limitations aris- Conclusion

ing from RA. In a small qualitative study, women
described physical modifications, such as stair lifts Proactive therapists will enjoy working with
and grab bars, accessing services such as home deliv- patients who have diverse and challenging prob-
ery of groceries, and involving friends and family to lems arising from inflammatory arthritis. Therapists
assist with tasks like home maintenance to success- have an integral role within multi-disciplinary teams
fully adapt to living with RA (Moss 1997). Similar and their early targeted intervention maximises
accommodations, individualized to the patients cho- functional outcome. Evidence is increasing to sup-
sen activities, delay or prevent disability at home and port therapy interventions and further studies are
work. essential to advance the practice of physical and
occupational therapy and improve the health and
well-being of people living with arthritis.
Activity adaptation at home and work
For many patients, what matters most is actively
engaging in parenting, household work, employ-
ment, socializing and similar roles. Mothers with
arthritis describe learning to adjust expectations Study activities
and set priorities, and recommend strategies such
1. Log on to
as omitting non-essential tasks, delegating to oth-
n Identify the inflammatory disorders section then
ers, and figuring out how to adapt tasks to match
the RA extra-articular manifestations section
their physical ability and energy (Backman et al
n Read how the systems of the body may
2007). Work place transitions are also common
potentially be affected by RA
(Gignac et al 2008), with patients identifying fluc-
n Make notes relevant to your clinical practice.
tuations in productivity, job changes, and job loss.
2. Ms Sarah Jones (introduced earlier) continues to
Assessing workplace ergonomics (Backman et al
experience inflammation in her MCP joints, and
2008a, Backman 2008b) and adapting the workplace
upon examination you notice joint subluxation,
to accommodate arthritis symptoms may support
ulnar deviation and ligamentous laxity.
productivity. Specific education on job accommoda-
n What evidence is there for the effectiveness of
tion legislation, vocational rehabilitation resources,
splinting the MCP joints in terms of preventing
and problem-solving in the workplace may reduce
deformity, reducing pain, or improving hand
work disability (Lacaille et al 2007, 2008).
n List three principles of joint protection and
advise Sarah on how to specifically apply them to
Referral to specialist services household work and family leisure activities.
n Subsequently, Sarah is referred to a hand surgeon
Ideally patients with RA should have access to a and receives MCP joint replacements (index,
diverse multi-disciplinary team (Hennell & Luqmani middle, ring and little fingers in her right hand).
2008). Within a secondary care environment this may Investigate the typical post-operative protocol.
include specialist nurses, podiatrists, social welfare 3. Consider your own clinical practice working with
staff, dieticians, orthotists and others. In the primary patients with inflammatory arthritis
care setting staff involved include general practition- n Select three new outcome measures you are
ers with a specialist interest in rheumatology and not familiar with but think you could usefully
specialist community nurses. Employers may need employ.
to be advised of their employees health challenges, n With a few colleagues obtain and critically
if the patient is willing to disclose their arthritis. appraise the original papers and subsequent
Therapists are often the key staff who undertake papers reporting on their validity and reliability
workplace assessments with their patients and may n Establish if you need to obtain a licence to use
involve a Disability Employment Advisor. Within a them
school or college environment, therapists may assess n Pilot their use in your own clinical environment
young people and liaise closely with parents and over a 3-month period
dedicated special needs staff.
Chapter 16 Inflammatory arthritis 229

Useful websites

Arthritis and Musculoskeletal Alliance (ARMA). British Health Professionals in Rheumatology (BHPR).
Standards of Care for people with inflammatory
arthritis. The Health Talk Online Website personal experiences
Association of Rheumatology Health Professionals of health and illness Rheumatoid Arthritis. http://
(ARHP), 2006. Standards of practice: Physical
therapy competencies in rheumatology http://www. The Wright Stuff Arthritis Supplies. www.
Musculoskeletal Services Framework Document Able Data, hundreds of assistive devices and
Department of Health UK. technologies.
uk/en/Publicationsandstatistics/Publications/ Arthritis Foundation (US), includes community-based
PublicationsPolicyAndGuidance/DH_4138413 self-management, exercise programs and resources
Arthritis Research Campaign (UK). for living well.
To obtain the exercise leaflet - Keep moving. php. Arthritis Society (Canada), includes Arthritis
Hydrotherapy Association of Chartered Physiotherapists - Self-Management
UK guidelines. Program information and a storefront for patients to purchase educational materials and assistive devices.
Joint zone a study of rheumatology UK. http://www. Psychometric Laboratory for Health Sciences references to useful scales & outcome measures.
National Rheumatoid Arthritis Society (NRAS) UK. htm.
NHS Evidence (UK): Musculoskeletal Specialist Library. The DAS-28 for disease activity monitoring. http://www.

References and further reading

American College of Rheumatology, ARC, 2005. Keep Moving Education in patients with degenerative
2002 Guidelines for the management Leaflet. Chesterfield, UK. Online. and inflammatory arthritis.
of rheumatoid arthritis 2002 Available: Int. J. Rehabil. Res. 31 (2),
update. Arthritis Rheum. 46 (2), (accessed 9.2.09.). 159163.
328346. Arnett, F.C., Edworthy, S.M., Bloch, Backman, C.L., 2006. Psychosocial
American Physical Therapy D.A., et al., 1988. The American aspects in the management of
Association Ottawa Panel 2004a Rheumatism association 1987 arthritis pain. Arthritis Res. Ther.
Evidence-based clinical practice revised criteria for the classification 28, 221. (doi:10.1186/ar2083).
guidelines for therapeutic exercises of rheumatoid arthritis. Arthritis Backman, C., Mackie, H., Harris, J.,
in the management of rheumatoid Rheum. 31 (3), 315324. 1991. Arthritis Hand Function Test:
arthritis in adults. Phys. Ther. 84, Association of Rheumatology Health Development of a standardized
934972. Professionals, 2006. Standards assessment tool. Occup. Ther. J. Res.
American Physical Therapy of practice: Physical therapy 11, 245256.
Association, Ottawa Panel 2004b competencies in rheumatology. Backman, C., Medcalf, N., 2000.
evidence-based clinical practice Online. Available: http://www. Identifying components and
guidelines for electrotherapy and environmental conditions
thermotherapy interventions in standards 17 July 2007. (accessed contributing to occupational
the management of rheumatoid 9.2.09.). performance issues. In: Fearing,
arthritis in adults 2004. Phys. Ther. Ay, S., Tur, B.S., Kucukdeveci, A., 2008. V.J., Clark, J. (Eds.) Individuals
84 (11), 10161143. Evaluation of disability in Context: A Practical Guide to
230 Rheumatology Evidence-Based Practice for Physiotherapists and Occupational Therapists

Client Centred Practice. Slack Inc, Bibbo, C., Goldberg, J.W., 2004. supportive shoes. J. Rheumatol. 27,
Thorofare, NJ, pp. 5567. Infectious and healing 16431647.
Backman, C.L., Fairleigh, A., Kuchta, G., complications after elective Chung, K.C., Pillsbury, M.S., Walters,
2004. Occupational therapy. In: St orthopaedic foot and ankle surgery M.R., et al., 1998. Reliability and
Clair, E.W., Pisetsky, D.S., Haynes, during tumor necrosis factor-alpha validity testing of the Michigan
B.F. (Eds.) Rheumatoid Arthritis. inhibition therapy. Foot Ankle Int. Hand Outcomes Questionnaire. J.
Lippincott Williams & Wilkins, 25 (5), 331335. Hand Surg. [Am] 23, 575587.
Philadelphia, pp. 431439. Boardman 3rd, N.D., Cofield, R.H., Cimmino, M.A., Parodi, M., Silvestri,
Backman, C.L., Del Fabro Smith, Bengtson, K.A., et al., 2001. E., et al., 2004. Correlation between
L., Smith, S., et al., 2007. The Rehabilitation after total shoulder radiographic, echographic and MRI
experiences of mothers living arthroplasty. J. Arthroplas. 16 (4), changes and rheumatoid arthritis
with inflammatory arthritis. 483486. progression. Reumatismo 56 (1),
Arthritis Rheum. 57 (1), Borg, G.E., 1985. An Introduction 2840.
381388. to Borgs RPE scale. Ithaca, Curtis, R., Groarke, A., Coughlan, R.,
Backman, C.L., Village, J., Lacaille, D., New York. et al., 2005. Psychological stress
2008a. The ergonomic assessment Boutry, N., Lard, A., Lapgue, F., as a predictor of psychological
tool for arthritis (EATA): et al., 2003. Magnetic resonance adjustment and health status in
development and pilot testing. imaging appearance of the hands patients with rheumatoid arthritis.
Arthritis Rheum. 59 (10), 14951503. and feet in patients with early Patient Edu. Counsel. 59 (2),
Backman, C., 2008b. The Ergonomic rheumatoid arthritis. J. Rheumatol. 192198.
Assessment Tool for Arthritis 30 (4), 671679. Dellhag, B., Wollersjo, I., Bjelle,
(Ergotool). http://ergotool. Brosseau, L., Welch, V. & Wells, G.A., A., 1992. Effect of active hand (accessed et al., 2005. Low level laser therapy exercise and wax bath treatment
14.1.09.). (Classes I, II and III) for treating in rheumatoid arthritis patients.
Bajwa, H.A., Rogers, L.Q., 2007. rheumatoid arthritis. Cochrane Arthritis Care Res. 5, 8792.
Physical activity barriers and Database of Systematic Reviews Dreyer, S.J., Boden, S.D., 1999. Natural
program preferences among (4) Art. No.: CD002049. DOI: history of rheumatoid arthritis of
indigent internal medicine patients 10.1002/14651858.CD002049.pub2. the cervical spine. Clin. Orthop.
with arthritis. Rehabil. Nurs. 32 (1), Brosseau, L., Yonge, K.A. & Welch, Relat. Res. 366, 98106.
3134 40. V., et al., 2003. Transcutaneous Duruoz, M.T., Poiraudeau, S.,
Bearne, L.M., Scott, D.L., Hurley, electrical nerve stimulation (TENS) Fermanian, J., et al., 1996.
M.V., 2002. Exercise can reverse for the treatment of rheumatoid Development and validation of
quadriceps sensorimotor arthritis in the hand. Cochrane a rheumatoid hand functional
dysfunction that is associated Database of Systematic Reviews disability scale that assesses
with rheumatoid arthritis without (2) Art No. CD004377. DOI: functional handicap. J. Rheumatol.
exacerbating disease activity. 10.1002/14651858.CD004377. 23 (7), 11671172.
Rheumatology 41 (2), 157166. Burton, W., Morrison, A., Maclean, R., Egan, M., Brosseau, L. & Farmer, M.,
Beaton, D.E., Katz, J.N., Fossel, A.H., et al., 2006. Systematic review of et al., 2001. Splints and Orthosis
et al., 2001. Measuring the whole or studies of productivity loss due to for treating rheumatoid arthritis.
the parts? Validity, reliability, and rheumatoid arthritis. Occup. Med. Cochrane Database of Systematic
responsiveness of the disabilities 56 (1), 1827. Reviews (4) Art No. CD004018. DOI:
of the arm, shoulder and hand Casimiro, L., Barnsley, L. & Brosseau, 10.1002/14651858.CD004018.
outcome measure in different L., et al., 2005. Acupuncture El Miedany, Y., Youssef, S., Mehanna,
regions of the upper extremity. J. and electroacupuncture for the A.N., et al., 2008. Development of
Hand Ther. 14 (2), 128146. treatment of rheumatoid arthritis. a scoring system for assessment of
Belza, B., 1995. Comparison of self- Cochrane Database of Systematic outcome of early undifferentiated
reported fatigue in rheumatoid Reviews (4) Art No. CD003788. inflammatory synovitis. Joint, Bone,
arthritis and controls. J. Rheumatol. DOI: 10.1002/14651858.CD003788. Spine 75 (2), 155162.
22 (4), 639643. pub2. Epps, H., Ginnelly, L., Utley, M.,
Berliner, M., Piegsa, M., 1997. Effects of Chalmers, A.C., Busby, C., Goyert, et al., 2005. Is hydrotherapy cost-
therapeutic ultrasound in a water J., et al., 2000. Metatarsalgia effective? A randomised controlled
bath on skin microcirculation and and rheumatoid arthritis: A trial of combined hydrotherapy
skin temperature in rheumatoid randomized, single blind, programmes compared with
arthritis. Eur. J. Phys. Med. Rehabil. sequential trial comparing 2 physiotherapy land techniques in
7 (2), 4649. types of foot orthoses and children with juvenile idiopathic
Chapter 16 Inflammatory arthritis 231

arthritis. Health Technol. Ass. 9 Hammond, A., Lincoln, N., Sutcliffe, Musculoskeletal Care 6 (2),
(39), 159 iii-iv, ix-x. L., 1999. A crossover trial evaluating 97107.
Fearing, V.G., Clark, J., 2000. an educational-behavioural joint Hirvonen, H.E., Mikkelsson, M.K.,
Individuals in context: A practical protection programme for people Kautiainen, H., et al., 2006.
guide to client centred practice. with rheumatoid arthritis. Patient Effectiveness of different
Slack Inc, Thorofare, NJ. Edu. Counsel. 37, 1932. cryotherapies on pain and disease
Felson, D.T., Anderson, J.J., Boers, M., Hammond, A., Freeman, K., activity in active rheumatoid
et al., 1993. The American College 2001. One-year outcomes of arthritis. A randomised single
of Rheumatology preliminary core a randomized controlled trial blinded controlled trial. Clin. Exp.
set of disease activity mea-sures for of an educational-behavioural Rheumatol. 24 (3), 295301.
rheumatoid arthritis clinical trials. joint protection programme for Hurley, M.V., Mitchell, H.L., Walsh, N.,
Arthritis Rheum. 36, 729740. people with rheumatoid arthritis. 2003. In osteoarthritis, the
Felson, D.T., Anderson, J.J., Boers, M., Rheumatology 40, 10441051. psychosocial benefits of exercise
et al., 1995. The American College Hammond, A., 2004. Rehabilitation are as important as physiological
of Rheumatology preliminary in rheumatoid arthritis: a critical improvements. Exerc. Sport Sci.
definition of improvement in review. Musculoskeletal Care 2 (3), Rev. 31 (3), 138143.
rheumatoid arthritis. Arthritis 135151. Hurley, M.V., Dziedzic, K., Bearne, L.,
Rheum. 38, 727735. Han, A., Judd, M. & Welch, V., et al., 2002. The clinical and cost-
Ferucci, E.D., Templin, D.W., Lanier, et al., 2004. Tai chi for treating effectiveness of physiotherapy
A.P., 2004. Rheumatoid arthritis rheumatoid arthritis. Cochrane management of elderly people
in American Indians and native Database of Systematic Reviews with common rheumatological
Alaskans: A review of the literature. (3) Art No. CD004849. DOI: conditions. The Chartered Society
Semin. Arthritis Rheum. 34, 10.1002/14651858.CD004849. of Physiotherapy, London.
662667. Haskett, S., Backman, C., Porter, B., Kastbom, A., Strandberg, G.,
Filippucci, E., Iagnocco, A., et al., 2004. A crossover trial of Lindroos, A., et al., 2004. Anti-
Meenagh, G., et al., 2007. commercial versus custom-made CCP antibody predicts the disease
Ultrasound imaging for the wrist splints in the management course during 3 years in early
rheumatologist VII. Clin. Exp. of inflammatory polyarthritis. rheumatoid arthritis. Ann. Rheum.
Rheumatol. 25 (1), 510. Arthritis Rheum. 51, 792799. Dis. 63, 10851089.
Fries, J.F., Spitz, P.W., Kraines, R.G., Hawke, F., Burns, J. & Radford, J.A., Katz, P.P., Alfieri, W.S., 1997.
et al., 1980. Measurement of patient et al., 2008. Custom-made foot Satisfaction with abilities and well-
outcome in arthritis. Arthritis orthoses for the treatment of foot being: Development and validation
Rheum. 23, 137145. pain. Cochrane Database of Systematic of a questionnaire for use among
Gabriel, S., Crowson, C.S., Kremers, Reviews (3) Art No. CD006801. persons with rheumatoid arthritis.
H.M., et al., 2008. The rising DOI: 10.1002/14651858.CD006801. Arthritis Care Res. 10 (1), 8998.
incidence of rheumatoid arthritis. pub2. Katz, P.P., Pasch, L.A., Wong, B., 2003.
Arthritis Rheum. 58 (conference Haynes, B.F., 2004. Pathology. In: St Development of an instrument to
supplement), 773. [abstract]. Clair, E.W., Pisetsky, D.S., Haynes, measure disability in parenting
Gignac, M.A.M., Cao, X., Lacaille, D., B.F. (Eds.) Rheumatoid Arthritis. activity among women with
et al., 2008. Arthritis-related work Lippincott Williams & Wilkins, rheumatoid arthritis. Arthritis
transitions: A prospective analysis Philadelphia, pp. 118139. Rheum. 48, 935943.
of reported productivity losses, Helewa, A., Goldsmith, C.H., Lee, P., Katz, P.P., Yelin, E.H., 1994. Life
work changes and leaving the labor et al., 1991. Effects of occupational activities of persons with
force. Arthritis Rheum. 59 (12), therapy home service on patients rheumatoid arthritis with and
18051813. with rheumatoid arthritis. Lancet without depressive symptoms.
Gilworth, G., Chamberlain, A., Harvey, 337, 14531456. Arthritis Care Res. 7 (2), 6977.
A., et al., 2003. Development Heller, J.E., Shadick, N.A., 2007. Kennedy, N., 2006. Exercise therapy for
of a work instability scale for Outcomes in rheumatoid patients with rheumatoid arthritis:
rheumatoid arthritis. Arthritis arthritis: incorporating the safety of intensive programmes and
Rheum. 49 (3), 349354. patient perspective. Curr. Opin. effects upon bone mineral density
Hall, J., Skevington, S.M., Maddison, Rheumatol. 19 (2), 101105. and disease activity: a literature
P.J., et al., 1996. A randomised and Hennell, S., Luqmani, R., 2008. review. Phys. Ther. Rev. 11 (4),
controlled trial of hydrotherapy in Developing multidisciplinary 263268.
rheumatoid arthritis. Arthritis Care guidelines for the management Kremers, H.M., Gabriel, S.E., 2004.
Res. 9, 206215. of early rheumatoid arthritis. Epidemiology. In: St Clair, E.W.,
232 Rheumatology Evidence-Based Practice for Physiotherapists and Occupational Therapists

Pisetsky, D.S., Haynes, B.F. (Eds.) over three years. Occup. Ther. J. to evaluate the effects of
Rheumatoid Arthritis. Lippincott Res. 19, 126146. assistive devices and altered
Williams & Wilkins, Philadelphia, Mathiowetz, V., Weber, K., Volland, working methods in women
pp. 110. G., et al., 1984. Reliability and with rheumatoid arthritis. Clin.
Lacaille, D., White, M.A., Backman, validity of grip and pinch strength Rheumatol. 17, 616.
C.L., et al., 2007. Problems faced evaluations. J. Hand Surg. (Am) 9, OBrien, A.V., Jones, P., Mullis, R.,
at work due to inflammatory 222226. et al., 2006. Conservative hand
arthritis: new insights gained Medical Research Council, 1976. Aids therapy treatments in rheumatoid
from understanding patients to the Investigation of Peripheral arthritis. Rheumatology 45,
perspective. Arthritis Rheum. 57 Nerve Injuries. HMSO, London, 577583.
(7), 12691279. UK. OConnor, D., Kortman, B., Smith, A.,
Lacaille, D., White, M.A., Rogers, P.A., Meenan, R.F., Mason, J.H., Anderson, et al., 1999. Correlation between
et al., 2008. Employment and J.J., et al., 1992. AIMS2: the content objective and subjective measures
arthritis: making it work A proof and properties of a revised of hand function in patients with
of concept study. Arthritis Rheum. and expanded Arthritis Impact rheumatoid arthritis. J. Hand Ther.
59 (11), 16471655. Measurement Scales Health Status 12, 323329.
Law, M., Baptiste, S., Carswell, A., Questionnaire. Arthritis Rheum. 35 Pagnotta, A., Baron, M., Korner-
et al., 2005. Canadian Occupational (1), 110. Bitensky, N., 1998. The effect of
Performance Measure, fourth ed. Moncur, C., 1988. Discipline-specific a static wrist orthosis on hand
CAOT Publications, Ottawa, ON. standards of care: Physical therapy function in individuals with
Lerner, D., Amick, B.C., Rogers, W.H., competencies in Physical Therapy rheumatoid arthritis. J. Rheumatol.
et al., 2001. The work limitations Management of Arthritis. Churchill 25, 879885.
questionnaire. Med. Care 39, Livingstone, New York p 29-41. Podsiadlo, D., Richardson, S., 1991.
7285. Moss, P., 1997. Negotiating spaces in The timed Up & Go: a test of
Lee, E.O., Kim, J.I., Davis, A.H., et al., home environments: older women basic functional mobility for frail
2006. Effects of regular exercise living with arthritis. Soc. Sci. Med. elderly persons. J. Am. Geriat. Soc.
on pain, fatigue and disability in 45, 2333. 39 (2), 142148.
patients with rheumatoid arthritis. Murphy, E., Bresnihan, B., Fitzgerald, Poole, J.L., Gallegos, M., OLinc, S.,
Fam. Commun. Health 29 (4), O., 2008. Measurement of 2000. Reliability and validity of
320327. periarticular bone mineral density the Arthritis Hand Function Test
Lineker, S.C., Hurley, L., Wilkins, A., in the hands of patients with early in adults with systemic sclerosis
et al., 2006. Investigating care inflammatory arthritis using dual (scleroderma). Arthritis Care Res.
provided by physical therapists energy x-ray absorpitometry. Clin. 13 (1), 6973.
treating people with rheumatoid Rheumatol. 27 (6), 763766. Prevoo, M.L., vant Hof, M.A., Kuper,
arthritis: pilot study. Physiother. NICE. (2009). Rheumatoid Arthritis: H.H., et al., 1995. Modified disease
Can. 58 (1), 5360. National clinical guideline for activity scores that include twenty-
Lorig, K.R., Holman, H., 2006. management and treatment eight joint counts. Development
Self-management education: in adults http://www.nice. and validation in a prospective
history, definition, outcomes, and longitudinal study of patients with
mechanisms. Ann. Behav. Med. 26, CG79FullGuideline.pdf(accessed rheumatoid arthritis. Arthritis
17. 13.9.09) Rheum. 38 (1), 4448.
Luqmani, R., Hennell, S., Estrach, C., Nishimura, K., Sugiyama, D., Kogata, Y., Rennie, R.J., 1996. Evaluation
et al., 2006. British Society for et al., 2007. Meta-analysis: of the effectiveness of a
Rheumatology and British Health diagnostic accuracy of anti-cyclic metacarpophalangeal ulnar
Professionals in Rheumatology citrullinated peptide antibody and deviation orthosis. J. Hand Ther. 9,
guideline for the management rheumatoid factor for rheumatoid 371377.
of rheumatoid arthritis (the arthritis. Ann. Intern. Med. 146 (11), Riemsma, R.P., Kirwan, J.R. & Taal, E.,
first 2 years). Rheumatology 45, 797808. et al., 2003. Patient education for
11671169. Nordenskiold, U., 1994. Evaluation adults with rheumatoid arthritis.
Mann, W.C., Tomita, M., Hurren, D., of assistive devices after a course Cochrane Database of Systematic
et al., 1999. Changes in health, in joint protection. Int. J. Technol. Reviews (2) Art No. CD003688. DOI:
functional and psychosocial status Assess. Health Care 10, 293304. 10.1002/14651858.CD003688.
and coping strategies of home- Nordenskiold, U., Grimby, G., Dahlin- Ronkainen, A., Niskanen, M.,
based older persons with arthritis Ivanoff, S., 1998. Questionnaire Auvinen, A., 2006. Cervical
Chapter 16 Inflammatory arthritis 233

spine surgery in patients with Uhlig, T., Lillemo, S., Moe, R.H., et al., users of Version 1, second ed.
rheumatoid arthritis: longterm 2007. Reliability of the ICF Core Quality Metric, Lincoln, RI.
mortality determinants. J. Set for rheumatoid arthritis. Ann. Welch, V., Brosseau, L. & Casimiro,
Rheumatol. 33 (3), 517522. Rheum. Dis. 66, 10781084. L., et al., 2002. Thermotherapy for
Shin, Y., Choi, J., Nahm, D., et al., 2005. Van den Ende, C.H., Breedveld, F.C., treating rheumatoid arthritis.
Rheumatoid factor is a marker le Cessie, S., et al., 2000. Effect Cochrane Database of Systematic
of disease activity in Korean of intensive exercise on patients Reviews (2) Art No. CD002826. DOI:
rheumatoid arthritis. Yonsei Med. J. with active rheumatoid arthritis: 10.1002/14651858.CD002826.
46 (4), 464470. a randomised clinical trial. Ann. Welsing, P.M., van Gestel, A.M.,
Straub, R.H., Dhabhar, F.S., Rheum. Dis. 59, 615621. Swinkels, H.L., et al., 2001. The
Bijlsma, J.W.J., et al., 2005. How Van den Ende, C.H., Vliet Vlieland, relationship between disease
psychological stress via hormones T.P.M., Munneke, M., et al., 2006. activity, joint destruction and
and nerve fibers may exacerbate Dynamic exercise therapy for functional capacity over the course
rheumatoid arthritis. Arthritis treating rheumatoid arthritis: a of rheumatoid arthritis. Arthritis
Rheum. 52 (1), 1626. systematic review. Coch. Lib. (4). Rheum. 44, 20092017.
Schumacher, HR., Habre, W., van Lankveld, W., vant Pad Bosch, P., Wilkie, R., Peat, G., Thomas, E.,
Meador, R., Hsia, E.C., 2004. Bakker, J., et al., 1996. Sequential et al., 2005. The Keele assessment
Predictive factors in early arthritis: occupational dexterity assessment of participation: A new instrument
long-term follow-up. Semin. (SODA): a new test to measure hand to measure participation restriction
Arthritis Rheum. 33 (4), 264272. disability. J. Hand Ther. 9 (1), 2732. in population studies. Combined
Steultjens, E.M.J., Dekker, J., Bouter, Veehof, M.M., Taal, E., Heijnsdijk- qualitative and quantitative
L.M., et al., 2002. Occupational Rouwenhorst, L.M., et al., 2008. examination of its psychometric
therapy for rheumatoid arthritis: a Efficacy of wrist working splints in properties. Qual. Life Res. 14,
systematic review. Arthritis Rheum. patients with rheumatoid arthritis: 18891899.
47, 672685. A randomized controlled study. Wolfe, F., 2005. Why the HAQ-II can be
Symmons, D., Turner, G., Webb, R., Arthritis Rheum. 59 (12), 16981704. an effective substitute for the HAQ.
et al., 2002. The prevalence of Verhagen, A.P., de Vet, H.C.W., Clin. Exp. Rheumatol. 23 (Suppl
rheumatoid arthritis in the United de Bie, R.A., et al., 1997. Taking 39), S29S30.
Kingdom: New estimates for a new baths: the efficacy of balneotherapy World Health Organization, 2002.
century. Rheumatology 41, 793800. in patients with arthritis. A International Classification of
Symmons, D.P.M., 2002. Epidemiology systematic review. J. Rheumatol. 24, Functioning, Disability and Health.
of rheumatoid arthritis: 19641971. World Health Organization,
Determinants of onset, persistence Verhagen, A.P., Bierma-Zeinstra, S. Geneva.
and outcome. Best Prac. Res. Clin. M.A. & Boers, M., et al., 2004. Yasura, K., Nakagawa, Y., Kobayashi, M.,
Rheumatol. 16 (5), 707722. Balneotherapy for rheumatoid et al., 2006. Mechanical and
Tourinho, T.F., Stein, A., Castro, J. arthritis. Cochrane Database of biochemical effect of monopolar
A., et al., 2005. Rheumatoid Systematic Reviews (1) Art No. radiofrequency energy on human
arthritis: evidence for bone loss CD000518. DOI: 10.1002/14651858. articular cartilage: an in vitro
in premenopausal women. J. CD000518. study. Am. J. Sports Med. 34 (8),
Rheumatol. 32 (6), 10201025. Wall, J.C., Bell, C., Campbell, S., et al., 13221327.
Uetani, M., 2007. Imaging approach 1998. The expanded timed get up Zijlstra, F.J., van den Berg-de-Lange,
for the evaluation of the bone and and go test. Gait Post. 7, 187. I., Huygen, F.J., et al., 2003.
joint destruction in rheumatoid Ware, J.E., Kosinski, M., 2001. The SF- Anti-inflammatory actions of
arthritis. Clin. Calcium 17 (4), 36 Physical and Mental Health acupuncture. Mediators Inflam. 12
453462. Summary Scales: A Manual for (2), 5969.