Rheumatoid Arthritis: Physical Therapy Considerations & Interventions

Background

As a first-year physical therapy student, I completed my first clinical rotation at Select Physical Therapy, an outpatient orthopedic clinic. I was exposed to a wide range of diagnoses, such as complex regional pain syndrome, post-TKA, bankart lesions, and many more. One day, I saw a patient with rheumatoid arthritis. She had been coming to see my clinical instructor for a few years for different complaints, and her most recent complaint that she was being seen for at that time was low back pain. I realized that while my understanding of osteoarthritis was quite comprehensive, my knowledge about RA was almost non-existent. I didn’t know what I could and couldn’t do with this patient, and I realized that I was not well informed on the PT implications of the presence of this disease. When it came time for me to choose elective classes for my third year of PT school, I decided to work on research with Dr. Louise Thoma. Louise is currently working on a survey-based study that is examining PT utilization, physical function, physical activity, and other measures among individuals with RA. I’ve learned so much about RA and how physical therapy can help this population by being involved in this research, so I wanted to use my capstone as a way to share this knowledge with fellow students and clinicians. 

 

Statement of Need

In today’s entry-level DPT curriculums, student clinicians are educated extensively on osteoarthritis and its implications for our patients. However, there is very little content included that teaches on other forms of arthritis, specifically rheumatoid arthritis. This is partially due to the fact that research evidence supporting physical therapy interventions for rheumatoid arthritis pain, fatigue, and other symptoms, is severely lacking. RA can be managed well today with pharmacologic interventions such as DMARDs and anti-rheumatic drugs. 1,2,3 However, physical therapy has the potential to play an important role in the management, prevention, and treatment of RA disease symptoms, provision of activity modifications, and delivery of patient education.4,5 Personally, as an almost entry-level clinician, I felt very unprepared to treat patients with RA before learning more about the disease throughout the fall semester while doing research work with Dr. Thoma. Since patients can access physical therapy services without a referral from a physician in many states, we not only need to know how to identify symptoms of RA for referral purposes, but we also need to know any absolute or relative contraindications to certain interventions and how to effectively evaluate and treat this specific patient population. 

 

Purpose

The purpose of this recorded lecture is to prepare physical therapists and students on how to effectively evaluate and treat rheumatoid arthritis patients, specifically in the outpatient orthopedic setting. My hope is that this module serves as a helpful resource for clinicians and students to learn from and use as a reference for their clinical practice. 

 

Products

My products include a narrated google slides presentation with integrated audio, a pre- and post-presentation evaluation, and a medication guide. The medication guide is a handout that includes many of the commonly prescribed RA pharmaceutical drugs, with information about their action, administration, side effects, and common names. The presentation includes information about RA as a diagnosis, the difference between RA and OA, suggestions for evaluation and treatment for RA-related and RA-unrelated chief complaints in this population, and additional resources, such as the Rheumatoid Arthritis Management in Adults CPG and links to youtube videos where real RA patients share their experiences. 

Presentation: 

https://docs.google.com/presentation/d/17sAbN22EKRExRfUfmPQLT2W_fJ-wY9IDzOnSQCi-zg0/edit?usp=sharing 

RA Medication Guide:

https://docs.google.com/document/d/14wx11GsFLvALje2QAwFSVLu5p-FLNi0DSc-UhhKIbA0/edit 

 

Evaluation Component

A google forms pre- and post-presentation evaluation have been created for viewers to take prior to and after going through the narrated lecture. This evaluation gives me insight into the effectiveness of the presentation to teach the concepts outlined by the learning objectives. It also gives me feedback from the audience on how the presentation could be improved in the future. 

Pre-Presentation Evaluation:

https://docs.google.com/forms/d/e/1FAIpQLSccKg03s_VakiDPCzVPazLQlagtJPJ_JuzEFcuw6oMxNhdljQ/viewform?usp=share_link 

Post-Presentation Evaluation:

https://docs.google.com/forms/d/e/1FAIpQLSfh5szWJjnyVZfAI2hC6-Sn25WJkwXpVeNikd_Ik3z64EXudw/viewform?usp=share_link 

 

Self-Assessment/Reflection

My personal objectives for this capstone project are listed below: 

 

• Find and synthesize the most up-to-date literature available on PT interventions for RA 
• Understand the underlying disease processes of RA for better clinical decision-making when treating patients with the disease 
• Gain hands-on experience in creating teaching materials for PT students and clinicians to share knowledge in an area of expertise 
• Work with a team of advising committee members to gain feedback and refine my created materials 

 

I believe that all of these objectives were met. I’ve seen progress in my teaching skills and in my overall understanding of the RA disease processes, as well as the most recent evidence surrounding this diagnosis. My confidence and ability in reading, evaluating, and writing research articles has improved dramatically. I also now feel much more prepared to evaluate and treat rheumatoid arthritis patients, and I’m proud of my capstone products that will hopefully reach people who are looking to improve their clinical skills for treating this population as well. 

 

Acknowledgements

First, I would like to thank my Capstone committee, which included Dr. Joshua Torrey, PT, DPT, Dr. Adam Stickley, PT, MSPT, and my advisor, Dr. Louise Thoma, PT, DPT, PhD. Thanks to all of you for your feedback, patience, and support as I created this learning module. Louise, thank you for all of your guidance throughout this entire year, and your willingness to meet with me often in order to discuss every tiny detail of my project. To the RA/OA research team (Megna Mishra, SPT, Sarah Novroski, SPT, Ashley Hodge, SPT, Dr. Joshua Torrey, PT, DPT, Dr. Chris Lane, PT, DPT, and Dr. Louise Thoma, PT, DPT), thank you for all of your feedback and suggestions as I created and refined this recorded lecture. All of your time and input is greatly appreciated and helped me create a product that will help physical therapists and students better understand how to treat rheumatoid arthritis.  

References:

1. Moreland LW, Russell AS, Paulus HE. Management of rheumatoid arthritis: the historical context. J Rheumatol. 2001;28(6):1431-1452.
2. Caldwell JR, Furst DE. The efficacy and safety of low-dose corticosteroids for rheumatoid arthritis. Semin Arthritis Rheum. 1991;21(1):1-11. doi:10.1016/0049-0172(91)90051-Z
3. De Andrade, J. R., McCormick, J. N., & Hill, A. G. S. (1964). Small doses of prednisolone in the management of rheumatoid arthritis. Annals of the Rheumatic Diseases, 23(2), 158.
4. Lourenzi FM, Jones A, Pereira DF, Santos JHCAD, Furtado RNV, Natour J. Effectiveness of an overall progressive resistance strength program for improving the functional capacity of patients with rheumatoid arthritis: a randomized controlled trial. Clin Rehabil. 2017;31(11):1482-1491. doi:10.1177/0269215517698732
5. Tai-Seale M, McGuire TG, Zhang W. Time allocation in primary care office visits. Health Serv Res. 2007;42(5):1871-1894. doi:10.1111/j.1475-6773.2006.00689.x