Physical Therapists Play a Key Role in the Comprehensive Management of Rheumatoid Arthritis.

Abstract

The medical management of rheumatoid arthritis (RA) has improved remarkably over the last 50 years. Today, disease-modifying antirheumatic drugs are staples of RA management and alone, or in combination with a plethora of biologic therapies, have reduced overall RA disease activity and related joint destruction. Under the treat-to-target approach, treatment is escalated until a target of remission or low disease activity is reached and promptly escalated when the target is no longer met (1, 2). These advances have greatly reduced disease activity, yet functional limitation, such as difficulty with housework, getting up from a chair, or walking, still impairs the quality of life of adults with RA, including those whose disease is in remission. Physical therapists are experts in improving and preserving physical function and optimizing quality of life for people with functional limitations, including those with RA. In this issue of Arthritis Care & Research, the 2022 American College of Rheumatology (ACR) Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis by England et al (3) presents the first systematic effort by the ACR to evaluate the contribution of physical therapy interventions to the comprehensive care of adults with RA. As physical therapists and researchers who are experts in rheumatology and who have played various roles on the guideline team, we see this guideline as a critical step toward meaningful progress in integrating physical therapy into routine care for adults with RA. To facilitate the use of this guideline by physical therapists in patient care, it is important to consider the context in which it will be used. In this editorial, we discuss the guideline's recommendations as they apply to physical therapy, challenges to implementation, and practical steps moving forward in advancing the integrative care for adults with RA. Exercise is a key component of physical therapy care. The single strong recommendation in this guideline was for consistent engagement in exercise. As in the 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee (4), there was insufficient evidence to strongly recommend any specific type of exercise (e.g., resistance, aerobic) or to provide dosage guidance. This broad, but strong, recommendation for exercise highlights the key role of physical therapy in helping people with RA adapt, implement, and maintain the most appropriate exercises and programming to achieve optimal outcomes tailored to individual needs and goals. Other components of physical therapy care, including comprehensive physical therapy and specific intervention types, received conditional recommendations. While this may seem counterintuitive, a discussion around the underlying interventions’ definitions that guided study inclusion in the literature review can add clarity to these conditional recommendations. For example, the guideline committee defined comprehensive physical therapy as examination and treatment provided by a physical therapist. The literature search yielded 6 eligible studies. These studies included exercise with substantial variety in type, intensity, frequency, and duration, as well as in other included interventions and outcome measures assessed. This heterogeneity likely contributed to mixed results and prevented meta-analyses. While the evidence suggested benefits of comprehensive physical therapy without evidence of harm, the evidence was inadequate to produce a strong recommendation. Despite the evidence limitations, the patient panel strongly advocated for the distinct contributions of physical therapy in the management of RA. Similar scenarios played out for other interventions commonly prescribed by physical therapists, including hand therapy exercises, splinting, assistive and adaptive equipment, work-site assessments and modifications, and thermal modalities. There were only a few eligible studies, often with heterogenous intervention details and a variety of outcome measures, again preventing strong recommendations. Importantly, all recommendations were based on the experience of the clinicians and the perspectives of the patients in the guideline panel, as well as the certainty of the evidence. The input from patients and clinicians favored conditional support for most interventions considering the limited evidence. An exception was the conditional recommendation against the use of electrotherapy, which was based on the burden and cost for the patient, in combination with the limited evidence of benefit. To integrate this new guideline in physical therapy practice, it is essential to appreciate the implications of the conditional recommendations. Recommendations are conditional because the certainty of the available evidence is low or very low and the balance of benefit or harm and burden are close. In this case, the choice to use or not use a treatment is preference-sensitive, meaning current evidence suggests no superior option and the choice depends on what matters most to the patient. The final decision should be made jointly between the patient and the provider. Notably, the conditional recommendations call for the practice of patient-centered care, and do not justify changes to payers’ policies. The recommendations only contribute to improving patient outcomes if they are fully integrated in clinical practice. However, their implementation can be hindered by challenges at the health professional, patient, and policy levels. Here, we highlight critical barriers and practical recommendations affecting key stakeholders. Rheumatology providers play a critical role in incorporating physical therapy in the routine management of RA. As was emphasized by the patient panel informing the guideline, adults with RA lean on their rheumatology provider to guide their care. This includes seeking guidance on topics outside of medical management, such as what exercise is safe and how to complete daily activities. However, patients sometimes feel uncertain that providers are knowledgeable about exercise guidance, and rheumatology providers often lack time and training to comprehensively address exercise and functional limitations (5-7). Physical therapists can help address these challenges, as they are trained in modifying exercise to ensure safety and target functional limitations. To be clear, it is not feasible to expect rheumatology providers to be experts in addressing all facets of their patients’ health needs; rather, this guideline highlights the need for an interprofessional approach. The critical role of the rheumatology provider is to understand how physical therapists can address patients’ needs, provide a clear and consistent message on the benefits of exercise and physical therapy, advocate for these options with their patients, and refer them to physical therapy services when appropriate (8). Rheumatology providers may be unclear why, when, and how to incorporate physical therapy into the management of RA, and the guideline does not address these details. In contemporary practice, physical therapists work autonomously and collaborate with members of an interprofessional team. They conduct comprehensive evaluations to identify functional limitations and contributors to these limitations and to educate patients on interventions to address these limitations. While adults with RA can often pursue physical therapy independently, a referral from a rheumatology provider is likely a potent facilitator. The referral can be straightforward and at a top level; e.g., it could evaluate and treat to improve pain management, range of motion, and physical function. While the best time to incorporate physical therapy into RA management is unclear, the guideline shares that many members of the patient panel wished they learned about physical therapy earlier after diagnosis so they were aware of their therapeutic options as challenges and needs arose in the disease course. Evidence-based guidance on the use of physical therapy and exercise in the integrative care of patients with RA is only useful if patients are aware of these options. Multiple studies using various methodologies demonstrate consistently low utilization of physical therapy among adults with RA, with estimates ranging from 10% to 15% in the prior 6 to 12 months (9-11). Indeed, utilization of formal physical therapy services are not necessary for all patients at all times. Yet, our collective experiences speaking with persons with RA, including patient advisory board members for organizations, patient panel participants, and individuals, consistently reflect a general lack of awareness of physical therapy and an absence of physical therapy in the therapeutic options presented by their rheumatology provider to address common and persistent functional limitations. These anecdotal experiences are supported by the finding that 50% of a US cohort of older adults with longstanding RA (median 10 years since diagnosis) reported they had never used physical therapy or occupational therapy (9). The guideline makes a strong recommendation for consistent engagement in exercise. Yet, individuals with RA consistently report key challenges limiting their participation in physical activity and exercise, including fear of disease exacerbation and uncertainty on how to exercise safely (7). To overcome these challenges, they seek guidance from experts on how to exercise safely (5-8). A range of options exist for those with RA to receive tailored guidance to adopt exercise. Self-guided programs have been developed for adults with RA, such as one provided by the Arthritis Foundation (https://www.arthritis.org/health-wellness/healthy-living/physical-activity/other-activities/best-exercises-for-rheumatoid-arthritis). Community programs may offer group exercise classes designed for adults with arthritis. Social connection provided by group programs can be a strong facilitator to exercise (7), however, such offerings vary based on location and may not be widely accessible. A referral to physical therapy to initiate exercise and physical activity participation should be considered in instances where the patient is unsure, or perhaps fearful, of activity and would benefit from a personalized prescription and progression of an exercise program. Moreover, physical therapists with rheumatology expertise can provide education as to which symptoms are expected after starting to exercise and which symptoms signal doing too much. Matching a patient's preference and clinical needs to these options should take place through shared decision-making and with the acknowledgment that it may take several tries to find the best fit. This guideline should serve to empower and mobilize physical therapists to work with patients with RA early after their diagnosis. First, physical therapists are emboldened by the strong recommendation for exercise as a safe and essential component of the management of RA. Similarly, the guideline supports most interventions in the physical therapists’ toolbox, providing options to tailor a treatment plan that meets the individual's needs, preferences, and values. The guideline recognizes that the treatment decisions should be shared between the provider and the patient, based on values and preferences, which aligns with patient-centered care. Indeed, conversations about continuous engagement in exercise can be challenging as they require that the physical therapist is equipped with the knowledge, skill, and confidence to motivate a change and ongoing maintenance of patients’ behaviors. Ideally, physical therapists and patients develop a working relationship soon after diagnosis so physical therapists can provide education on the role of physical therapy in optimizing quality of life throughout the disease course. This guideline should also serve as a call to action for physical therapists. Patients want exercise and rehabilitation recommendations from trusted experts who understand RA (12). For example, adults with RA often experience recurrent periods of active and quiescent disease, gradual muscle wasting that begins early in disease, and risk of disease-related joint destruction. However, not all physical therapists are familiar with the unique needs of adults with RA. Indeed, physical therapists are experts in optimizing physical function and adapting exercise. However, rheumatology training for physical therapists is uncommon in the US. In Canada, some physical therapists work as multiskilled primary therapists in RA care and provide services that cross the traditional physical therapy and occupational therapy boundaries (13-15). Fewer than 1% of physical therapists have also received advanced practice training to perform tasks such as conducting musculoskeletal examinations, ordering investigative tests, and providing referrals to specialists or other health professionals (16). While developing a larger physical therapy workforce with rheumatology expertise is important, we also acknowledge that community practicing physical therapists are most accessible to patients. Thus, we must also build resources to better assist community-based physical therapists without specific rheumatology training to appropriately address patient concerns, functional limitations, and help patients engage in consistent physical activity to preserve function long-term. Currently episodic models of physical therapy care fall short in preserving function and promoting consistent engagement in exercise over the lifespan of people with RA. The World Health Organization defines rehabilitation as interventions aimed to optimize functioning and reduce disabilities in people with health conditions living within their environment (17). These interventions, including those delivered by physical therapists, usually end when patients’ goals are reached (18). Within this current concept of rehabilitation, patients are discharged from physical therapy when they reach treatment goals. Visits resume only when they experience the next health episode. This episodic model leaves no room for physical therapists to monitor patients’ physical function, exercise, and physical activity in order to refine the plan over time; hence, it limits the benefits to patients. The new ACR guideline signals an opportunity to reimagine rehabilitation for patients with RA. With the ubiquitous use of apps and wearable devices, patients can monitor and share information about their RA disease activity, symptoms, and physical activities with health care providers. These tools enable patients and physical therapists to work together and identify needs for a clinic visit before such needs become a major health episode. Other considerations to augment a reimagined model of rehabilitation include booster sessions or periodic check-ups to prevent disability and promote exercise engagement and routine inclusion of telehealth to extend patient access to physical therapists with rheumatology expertise. A new model of rehabilitation could empower patients to be active partners in their disease management to preserve their function and quality of life. The lack of high-quality studies evaluating comprehensive physical therapy and exercise interventions in adults with RA severely limited the strength and certainty of the recommendations in this guideline. While continuous engagement in exercise was strongly recommended, each specific type of exercise only received a conditional recommendation. Studies are needed to further clarify the optimal types and dosages of exercise needed for adults with RA, as well as investigate patient preferences for exercise and successful models of care delivery that can aid the long-term management of RA. Interventions are only effective if they are delivered and practiced as intended. It is plausible that the strong or conditionally recommended interventions may work in different ways because of individual factors (e.g., physical therapists’ knowledge about RA and patients’ preferences), clinical factors (e.g., the current model of care), or organizational contexts (e.g., human resource, leadership buy-in). Implementation of the guideline recommendations may also be influenced by the different perspectives of patients and their care teams. To this end, behavior change techniques, including goal setting, action planning, and self-monitoring using wearable devices, can play a prominent role in physical therapy practice (19, 20). To maximize its benefits to patients, we believe there is a critical need to invest in studying strategies that support patients’ consistent engagement in exercise and how they can be delivered by physical therapists in different clinical settings. In conclusion, physical therapists play a key role in the comprehensive management of RA. The 2022 American College of Rheumatology (ACR) Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis reflects an important step in actualizing the role of physical therapy in the routine care for those with RA. The existing evidence to support physical therapy was systematically evaluated. The multidisciplinary voting panel considered the evidence, alongside the emphatic advocacy from the patient panel, in voting to support physical therapy and its components in the management of RA. Yet, many challenges impede implementation. The recommendations in this editorial serve to highlight actionable steps to advance the role of physical therapy toward meeting the health needs of adults with RA. All authors drafted the article, revised it critically for important intellectual content, approved the final version to be published, and take responsibility for the integrity of the data and the accuracy of the data analysis. Disclosure Form Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.