Rheumatoid Arthritis Treatment

Our mission at COR is to help people move, feel, and perform better. Using the most up to date research on injury prevention and treatment is how we achieve this mission. Being diagnosed with Rheumatoid Arthritis can be an overwhelming journey at times, so we hope that this article regarding the current research on rheumatoid arthritis treatment helps you along your way.

If you really want to ease Your Stubborn Rheumatoid arthritis, apply for an evaluation

What is Rheumatoid Arthritis

Before we go into treatment and how physical therapy and personal training can help those with rheumatoid arthritis, it is essential to understand the pathophysiology and occurrence of rheumatoid arthritis.

According to the website, Move Forward PT:

“Rheumatoid arthritis (RA) is a chronic inflammatory disease that affects approximately 1% of the United States population. RA often results in pain and inflammation in joints on both sides of the body, and can become disabling due to its effect on the immune system.”

RA is an autoimmune disorder where the body’s immune system attacks its own body. In fact, it is the most common type of autoimmune disorder. 1.3 million Americans are affected by RA and 75% are women (American College of Rheumatology, 2017). This may begin at any age, but is most common to begin in midlife.

Cause of Rheumatoid Arthritis

There is no known cause of RA, though evidence suggests that it may run in families. Here are a few risk factors and interesting facts you may not know about rheumatoid arthritis:

Genetics (Angelotti 2017):
- The HLA-DRB1*01, *04, and *10 alleles are the strongest genetic risk factor for RA development, in particular for ACPA-positive rheumatoid arthritis (Huizinga 2005).
- Many other genetic factors show correlations with rheumatoid arthritis and are being researched (Derksen 2017).
Environmental factors:
- Exposure to cigarette smoke (CS) is an accepted risk factor for rheumatoid arthritis, as having a first degree relative (FDR) smoke more than 10 pack/years and younger than 50 years of age representing the highest risk of developing inflammatory joint signs (Damgaard 2015).
Microbiota:
- Several studies have demonstrated that the composition of gut microbiota is altered (dysbiosis) in rheumatoid arthritis patients. Chen (2016) et al. showed that patients with rheumatoid arthritis exhibited decreased gut microbial diversity compared with healthy individuals, which correlated with disease duration and autoantibody levels.

Symptoms and Diagnosis of Rheumatoid Arthritis

Symptoms can often flare up and down (going into remission). Signs of a flare-up or RA symptoms include:

Stiff joints that feel worse in the morning.
Painful and swollen joints on both sides of the body.
Bouts of fatigue and general discomfort.
Fever.
Loss of joint function.
Redness, warmth, and tenderness in the joint areas.

Rheumatoid arthritis is most commonly diagnosed by a rheumatologist, through pain and inflammation at the joint line and the number of joints involved. A rheumatologist may also diagnosis rheumatoid arthritis through a blood-test.

People with rheumatoid arthritis often have an elevated erythrocyte sedimentation rate (ESR, or sed rate) or C-reactive protein (CRP), which may indicate the presence of an inflammatory process in the body. Other common blood tests look for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibodies.

*Serology = the scientific study or diagnostic examination of blood serum, especially with regard to the response of the immune system to pathogens or introduced substances.

**APR = elevated acute phase reactant

Treatment Team for Rheumatoid Arthritis Patients

Although a rheumatologist diagnoses the condition, any professional may be the first to recognize the signs and symptoms of rheumatoid arthritis. This makes it essential to know the signs of rheumatoid arthritis.

A team based approach is necessary for ideal rheumatoid arthritis treatment. Healthmonitor.com notes the following professionals as a possible treatment team for patients with PA:

Primary care physician (PCP): Your PCP is trained in general medicine, family practice or some other entry-level-of-care medicine. While a PCP can evaluate and treat arthritis, he or she may refer you to a rheumatologist for arthritis-specific care.
Rheumatologist: This doctor specializes in the medical treatment of arthritis and other diseases of the joints. Generally, for RA patients, the Rheumatologist is captain of the team.
Physical therapist (PT). A physical therapist focuses on improving your mobility by helping you improve joint flexibility and muscle strength.
Occupational therapist (OT): Occupational therapists can help teach you how to do everyday tasks, like dressing and driving, in a way that minimizes arthritis pain and stiffness. They also recommend helpful assistive devices.
Nurse practitioner: An Advanced Practice Nurse who can provide high-quality care and treatment to patients. They can diagnose and treat a variety of health problems and inform patients about lifestyle changes that can improve their health.
Physician assistant: Health professionals licensed to practice medicine with physician supervision. They perform a comprehensive range of medical duties, from basic primary care to high-technology specialty procedures.
Nurse: In addition to helping your doctors, nurses can explain the thinking behind your treatment plan and suggest practical ways to carry it out. If there’s something about your diagnosis or treatment that you don’t understand, your nurse is a good person to ask!
Podiatrist: These “foot doctors” are licensed to prescribe medication and do surgery on your feet or ankles. If your arthritis affects your feet, a podiatrist can prescribe special shoes or other devices that can help.
Ophthalmologist: This eye specialist can examine and treat you for possible complications caused by your rheumatoid arthritis.
Therapist/counselor: These “talk therapy” professionals can help you explore and cope with the emotional issues that can arise when you’re dealing with a chronic illness like rheumatoid arthritis. Prothero (2018) found that psychological interventions resulted in small to moderate improvements in biopsychosocial outcomes in patients with RA in addition to standard care.
Social worker: A social worker can help you find practical solutions to some of the problems you may encounter in living with rheumatoid arthritis, such as helping you navigate health insurance issues.
Orthopedic surgeons: These professionals manage the surgical aspect of rheumatoid arthritis and its complications. Fortunately advances in medical treatments have eliminated many of these complications (tendon ruptures, joint damage causing nerve compressions, fractures that don’t heal, etc.) but there are still problems requiring surgical expertise in some patients.

Rheumatoid Arthritis Treatment

Treatment is multifaceted, with the aforementioned treatment team. Medication often plays a vital role in RA treatment and pain management.

Below are the common medications in rheumatoid arthritis from Healthline.com:

Disease-modifying antirheumatic drugs (DMARDs)

Disease-modifying antirheumatic drugs (DMARDs) are used to decrease inflammation. Unlike other medications that temporarily ease pain and inflammation, DMARDs can slow the progression of rheumatoid arthritis. This means that you may have fewer symptoms and less damage over time.

The most common DMARDs used to treat rheumatoid arthritis include:

hydroxychloroquine (Plaquenil)
leflunomide (Arava)
methotrexate (Trexall)
sulfasalazine (Azulfidine)
minocycline (Minocin)

Biologics are injectable drugs.

They work by blocking specific inflammatory pathways made by immune cells. This reduces inflammation caused by rheumatoid arthritis. Doctors prescribe biologics when DMARDs alone aren’t enough to treat rheumatoid arthritis symptoms. Biologics aren’t recommended for people with compromised immune systems or an infection. This is because they can raise your risk of serious infections.

The most common biologics include:

abatacept (Orencia)
rituximab (Rituxan)
tocilizumab (Actemra)
anakinra (Kineret)
adalimumab (Humira)
etanercept (Enbrel)
infliximab (Remicade)
certolizumab pegol (Cimzia)
golimumab (Simponi)

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are among the most commonly used rheumatoid arthritis treatment drugs. Unlike other pain relievers, NSAIDs seem to be more effective in treating symptoms of rheumatoid arthritis. This is because they prevent inflammation.

Some people use OTC NSAIDs. However, stronger NSAIDs are available with a prescription.

ibuprofen/hydrocodone (Vicoprofen)
ibuprofen/oxycodone (Combunox)
Naproxen
Aspirin
celecoxib (Celebrex)
ibuprofen (prescription-strength)
nabumetone (Relafen)
naproxen sodium (Anaprox)
naproxen (Naprosyn)
piroxicam (Feldene)

Other NSAIDs include

diclofenac (Voltaren, Diclofenac Sodium XR, Cataflam, Cambia)
diflunisal
indomethacin (Indocin)
ketoprofen (Orudis, Ketoprofen ER, Oruvail, Actron)
etodolac (Lodine)
fenoprofen (Nalfon)
flurbiprofen
ketorolac (Toradol)
meclofenamate
mefenamic acid (Ponstel)
meloxicam (Mobic)
oxaprozin (Daypro)
sulindac (Clinoril)
salsalate (Disalcid, Amigesic, Marthritic, Salflex, Mono-Gesic, Anaflex, Salsitab)
tolmetin (Tolectin)
Diclofenac/misoprostol (Arthrotec)
Topical capsaicin (Capsin, Zostrix, Dolorac)
Diclofenac sodium topical gel (Voltaren 1%)
Diclofenac sodium topical solution (Pennsaid 2%)

Opioids

People with RA who take opioids should also use other treatments. This is because opioids only change the way you experience pain. They don’t slow the disease down or prevent inflammation.

Opioids include:

codeine
acetaminophen/codeine
fentanyl
hydrocodone (Vicodin)
hydromorphone
morphine
meperidine (Demerol)
oxycodone (Oxycontin)
tramadol (Ultram)

Corticosteroids

Corticosteroids are also called steroids. They come as oral and injectable drugs. These drugs can help reduce inflammation in rheumatoid arthritis. They may also help reduce the pain and damage caused by inflammation. These drugs aren’t recommended for long-term use.

Side effects can include:

high blood sugar
stomach ulcers
high blood pressure
emotional side effects, such as irritability and excitability
cataracts, or clouding of the lens in your eye
osteoporosis

Steroids used for RA include:

betamethasone
prednisone (Deltasone, Sterapred, Liquid Pred)
dexamethasone (Dexpak Taperpak, Decadron, Hexadrol)
cortisone
hydrocortisone (Cortef, A-Hydrocort)
methylprednisolone (Medrol, Methacort, Depopred, Predacorten)
prednisolone

Immunosuppressants

These drugs fight off the damage caused by autoimmune diseases such as rheumatoid arthritis. However, these drugs can also make you more prone to illness and infection. If your doctor gives you one of these drugs, they’ll watch you closely during treatment.

These drugs come in oral and injectable forms. They include:

cyclophosphamide (Cytoxan)
cyclosporine (Gengraf, Neoral, Sandimmune)
azathioprine (Azasan, Imuran)
hydroxychloroquine (Plaquenil)

Researched Non-Pharmacological Treatment

Andersson (2017) performed a survey of physical therapists and noted 91% of physical therapists reported more confidence with treating osteoarthritis compared to rheumatoid arthritis, although physical therapy and exercise are the most effective pain management strategies in patients with rheumatoid arthritis (Park 2016). I felt the same way until recently, but now know physical therapists and personal trainers play a vital role in rheumatoid arthritis.

Nutrition

Mediterranean diet: Forsyth (2018) identified beneficial effects of the Mediterranean diet in reducing pain and increasing function in patients with rheumatoid arthritis.
More research on various diets should be assessed, especially since gut microbiome disruption is a risk factor.

Acupuncture

Lee (2008) performed a systematic review of acupuncture for rheumatoid arthritis and concluded: “penetrating or non-penetrating sham-controlled RCTs failed to show specific effects of acupuncture for pain control in patients with RA.”

Splinting

Hand/wrist splinting is commonly performed in patients with rheumatoid arthritis to help stabilize their wrist and hand. However, the effectiveness of splinting is mixed:

Adams (2008) found no significant differences between a standardized occupational therapy group and hand exercises and static resting splints.
Veehof (2008) found pain relief and grip/functional strength improvement with prefabricated wrist working splint compared to the usual care group.

Hand Exercises

Specific hand strengthening and range of motion exercises appear to have a positive effect on function.

Bergstra (2014) performed a systematic review on hand exercises in patients with RA and noted: “[m]ost studies showed improvements in power grip strength as a result of the exercise intervention …The improvement in power grip ranged between 1 and 4.5 kg.”

Modalities

Electrical Stimulation, electromagnetic energy, mechanical energy, thermotherapy, massage, manual therapy, balneotherapy.

Hurkmans (2011) created a practice guidelines for physical therapist and concluded all these forms of treatment can be neither recommended nor discouraged due to minimal research.
Cryotherapy is a possible treatment modality. One randomized study conclude cryotherapy for 2 weeks in combination of regular RA treatment (pharmacotherapy, kinesitherapy, and physical modalities) resulted in similar functional results as another group receiving the regular RA treatment and RA modalities (magnetotherapy, electrotherapy, ultrasound therapy, and laser therapy). The cryotherapy group underwent the following procedures:
- They passed through prechambers (−10°C and −60°C) into the therapy-chamber (−110°C), where they stayed for 3 min, walking in a circles and performing energetic movements by the upper limbs.

In a systematic review, Nelson (2017) concluded: “his review found seven randomized controlled trials representing 352 participants who satisfied the inclusion criteria. Risk of bias ranged from four to seven. Our results found low- to moderate-quality evidence that massage therapy is superior to non-active therapies in reducing pain and improving certain functional outcomes. It is unclear whether massage therapy is more effective than other forms of treatment.”

Exercise-based Intervention:

The benefits of strength training on those with RA cannot be overstated. One study in sweden found that long-term aerobic fitness programs paired with muscle strengthening of moderate to high intensity “reduces activity limitations and improves both oxygen uptake and muscle strength” (Swärdh, 2016). Similar studies report “..improved cardiorespiratory fitness and cardiovascular health, increased muscle mass, reduced adiposity, improved strength, and physical functioning, all without exacerbation of disease activity or joint damage” (Cooney, 2011).

All this is to say that while exercise does not impact the immunological effects of the disease, it provides numerous benefits without adding any more negative consequences than to the general population.

Rheumatoid Cachexia

On top of RA’s detrimental effects on a person’s joints and immune system, two-thirds of all RA patients exhibit a form of muscle wasting called rheumatoid cachexia. This loss of muscle contributes to changes in muscle/tendon morphology, loss of strength and muscle contraction speed, as well as eventual coordination and balance deficiencies.The loss of weight due to muscle wasting is masked by an increase of adipose tissue from inactivity, creating a vicious circle. Fitness programs designed to increase muscle hypertrophy can greatly reduce these effects by increasing the size and strength of muscle tissue, while simultaneously reducing body fat.

Recommendations

If the client is deconditioned or new to exercise, begin with lightweight exercises, easy aerobics, and plenty of stretching. As the client progresses in strength, continue to increase resistance to promote muscular adaptation. Aim for 3 sets of 10-15 reps of each exercise, adjusting the weight accordingly. Choosing the correct resistance is paramount, as too little won’t encourage muscular growth, and too much will place excessive pressure on the joints, causing discomfort (Lourenzi, 2017).

Pain

Monitor pain both during and post-workout and adjust accordingly. Remember, everyone’s RA is different and responds to exercise in different ways. Lastly, as joint stiffness and inflammation can be worse in the mornings, schedule training sessions later in the day to allow the client to stretch and release accumulated fluid from the joints.

Goals

With the client’s limitations in mind, developing a training protocol should be centered around their goals as well as quality of life. Examples of goals can range from gaining 8 pounds of muscle mass or being able to touch their toes, to goals such as being able to walk down a staircase without help, having the mobility to brush their own teeth, or pick up a grandchild. Each of these goals requires a very specific training protocol to address them. The importance of specificity in programming requires a trainer that has extensive knowledge of biomechanics and physiology. This article would take hours to read if we covered exercises for every goal, so we chose two representative examples from opposite ends of the spectrum to showcase.

3 Major Types of Exercises

Flexibility – 7 Days/Week
- Stretches: hamstring, quad, calf, forearm, SMR upper/lower back
- Range of motion: All major and minor joints
- Activities: Yoga, Tai-Chi, Pilates
- Goals: increase range/mobility
- Avoid: excessive ROM on compromised joints
Aerobic – 3 Days/Week
- cycling, swimming, walking, rowing
- Goals: cardiovascular health
- Avoid: high impact
Strengthening – 2-3 Days/Week
- DB (foam handle), KB, Bands, HIIT, Calisthenic
- Goals: Hypertrophy, ADL (activities of daily living)
- Avoid: low reps, high weight, joint pain

Example Training Program 1:

40 year old female, deconditioned, no relevant exercise history.
Reports stiffness and pain of wrists and fingers, low overall muscle mass.
Goals: reduce morning stiffness, increase muscle mass.

Homework – Daily

Perform each exercise slowly for :60, repeat for two rounds

Wrist Flexion/Extensions
Wrist Supination/Pronations
Hand Spread to Fist (lay hands on table, spread fingers as far as possible, make a firm fist, repeat)
Press thumb to each finger (:15 each)

Day 1 – 30-40 Minutes

3 Sets

1a. DB Squat x 12

1b. Barbell [elevated] Push-Ups x 10

1c. DB Incline Row x 12

1d. DB Wrist Rotations (supination/pronation) x 15

3 Sets

2a. HOH Curl-Up x 15

2b. DB Bridge x 15

2c. Stationary Bicycle :90

Day 2 – 30-40 Minutes

3 Sets

1a. DB Reverse Lunge + Press x 6e

1b. DB Incline Reverse Fly x 12

1c. DB Bench Row x 12

1d. Forearm Roller x 2

3 Sets

2a. Rowing Machine x :90

2b. Elbow Plank x :30

2c. Band Side-Step + Band Pull :60

Example Training Program 2:

49 year old female, deconditioned, limited overall ROM, walker required for movement
Reports significant joint involvement (>10 joints), fused PIPs, knee/shoulder replacements
Goals: brush teeth (mobility, grip strength), walk without aid, take stairs.

Homework – Daily

Perform each exercise slowly for :60, repeat for two rounds

Wrist Flexion/Extensions
Wrist Supination/Pronations
Hand Spread to Fist (lay hands on table, spread fingers as far as possible, make a firm fist, repeat)
Press thumb to each finger (:15 each)
Band Pull, Wall-Slides, Arm Swings
Supine Gate Openers

Day 1 – 60 Minutes

3 Sets

1a. Band Seated Anti-Rotations x :30e

1b. Band Seated Hip Abduction x :60

1c. Band Pull (ext. rotation) x :60

1d. Band High Row x :60

3 Sets

2a. Alt. Elevated Step-Downs x :60

2b. Dynadisc Balance (2 legs) x :60

2c. Stationary Bicycle :90

3 Sets

2a. Band Bicep Curl x :60

2b. Office Chair Hamstring Walks x 2 Laps

2c. Seated Band Quad Kicks x 15e

Day 2 – 60 Minutes

3 Sets

1a. DB Bridge w/ Band x 15

1b. Band Supine Quad Extension x 15e

1c. DB Chest Press x 15

1d. Forearm Roller x 2

3 Sets

2a. Rowing Machine x :90

2b. Assisted Band Monster Walk x :60

2c. Assisted Elevated Lateral Step-Ups x :60

3 Sets

2a. Assisted Band Side-Steps x :60

2b. DB Forearm Rotations x :60

2c. DB [Elbow 90 degree] Lateral Raise x 10

Rheumatoid Arthritis Treatment Conclusion

Although it is the responsibility of rheumatologists to correctly diagnose patients with RA, the role of experienced physical therapists and trainers is paramount in the lives of the diagnosed. The rehabilitation techniques and manual therapy done by a physical therapist may greatly reduce the pain, swelling, and stiffness associated with the disease, leading to a greater quality of life. Well-educated and experienced trainers apply goal-oriented programming along with safe and progressive training to combat many of the deficiencies associated with RA. Both therapist and trainer together can recognize the signs and symptoms of RA early on and refer the client to a rheumatologist for further testing.

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Dr. John Mullen, DPT, CSCS and Michael Vaandering, CPT, ACSM.