Clinical Practice Guideline for Physical Therapist Management of People With Rheumatoid Arthritis

Abstract

Objective

This guideline revises the 2008 Royal Dutch Society for Physical Therapy guideline for physical therapy for patients with rheumatoid arthritis (RA).

Method

This revised guideline was developed according to the Appraisal of Guidelines for Research and Evaluation tool and the Guidelines International Network standards. A multidisciplinary guideline panel formulated clinical questions based on perceived barriers in current care. For every clinical question, a narrative or systematic literature review was undertaken, where appropriate. The guideline panel formulated recommendations based on the results of the literature reviews, the values and preferences of patients and clinicians, and the acceptability, feasibility, and costs, as described in the Grading of Recommendations Assessment, Development and Evaluation evidence-to-decision framework.

Results

The eventual guideline describes a comprehensive assessment based on the International Classification of Functioning, Disability and Health Core Set for RA. It also includes a description of yellow and red flags to support direct access. Based on the assessment, 3 treatment profiles are distinguished: (1) education and exercise instructions with limited supervision, (2) education and short-term supervised exercise therapy, and (3) education and intensified supervised exercise therapy. Education includes RA-related information, advice, and self-management support. Exercises are based on recommendations concerning the desired frequency, intensity, type, and time-related characteristics of the exercises (FITT factors). Their interpretation is compliant with the individual patient’s situation and with public health recommendations for health-enhancing physical activity. Recommended measurement instruments for monitoring and evaluation include the Patient-Specific Complaint instrument, Numeric Rating Scales for pain and fatigue, the Health Assessment Questionnaire Disability Index, and the 6-minute walk test.

Conclusion

An evidence-based physical therapy guideline was delivered, providing ready-to-use recommendations on the assessment and treatment of patients with RA. An active implementation strategy to enhance its use in daily practice is advised.

Impact

This evidence-based practice guideline guides the physical therapist in the treatment of patients with RA. The cornerstones of physical therapist treatment for patients with RA are active exercise therapy in combination with education. Passive interventions such as massage, electrotherapy, thermotherapy, low-level laser therapy, ultrasound, and medical taping play a subordinate role.

Guidelines, Physical Therapists, Rheumatoid Arthritis

Introduction

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease that most commonly affects the joints of the hands, wrists, shoulders, elbows, knees, and ankles and feet. Apart from the joints, RA can also affect other body systems, such as the cardiovascular or respiratory system. RA is a relatively common disease that affects approximately 0.3% to 1% of European and North American adults.¹ RA-related symptoms include joint pain, stiffness, swelling, limitation of joint range of motion, and general fatigue. These symptoms may lead to limitations in (1) daily activities, such as self-care or household activities; and (2) societal participation, including unpaid and paid work² and leisure activities.

There have been great advancements in the medical treatment of RA over the past decades. By now, various effective disease-modifying antirheumatic drugs (DMARDS) are available, including conventional synthetic DMARDs (eg, methotrexate), targeted synthetic DMARDs (eg, Janus Kinase inhibitors), and biological DMARDs (eg, anti-tumor necrosis factor [TNF] biologics or non-TNF biologics). Strategies to achieve the best possible effect include early and aggressive treatment, targeting remission (treat to target), and tight control.

Despite the availability of effective medication, there is a substantial proportion of patients with persisting or recurring disease activity, with or without joint damage. Moreover, the evidence for an increased cardiovascular risk in patients with inflammatory joint diseases is growing.³ As a result, many patients are in need of additional, nonpharmacological treatment, including physical therapy.⁴ The physical therapist is, apart from other nonmedical professionals such as a clinical nurse specialist, occupational therapist, psychologist, and social worker, an important member of the multidisciplinary team. It is of utmost importance that physical therapist treatment is provided according to the latest insights from research and clinical practice. Clinical practice guidelines can contribute to the achievement and maintenance of such high-quality care. For this purpose, the first version of the Royal Dutch Society for Physical Therapy (KNGF) Guideline for RA was developed in 2008.⁵ As the evidence for physical therapy increased, new insights from daily practice arose, and medical treatment of RA rapidly evolved—changing the clinical picture of RA continuously—a revision was deemed necessary.

The purpose of this paper is to describe the recommendations on the diagnostics and treatment of the revised clinical practice physical therapy guideline for patients with RA. The recommendations described in this guideline primarily apply to physical therapists.

Method of Guideline Development

The revision of the 2008 guideline was undertaken according to the guideline methodology developed by the KNGF.⁶ That methodology is based on the Appraisal of Guidelines for Research & Evaluation⁷ tool, the Guidelines International Network⁸ standards, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence-to-decision framework.⁹ The process consists of 4 phases: (1) preparation, (2) development, (3) review and authorization, and (4) dissemination and implementation. This paper focuses on the first 3 phases that were executed from October 2016 to March 2018.

Phase 1: Preparation

Between October and December 2016, 3 groups were formed: the author group, the guideline panel, and the review panel. The author group consisted of guideline experts and policy advisors with expertise in the field of guideline development methodology and research experience (E.H., N.S., G.M.), a postdoc researcher (W.P.), and a professor in the field of physical therapy and arthritis (T.V.V.). The task of the author group was to perform focus groups to formulate clinical questions, perform the literature search, prepare and guide the guideline panel discussions, guide the guideline development process, and prepare the manuscript. Both the guideline and review panels were comprised of physical therapists with clinical and/or research experience regarding the treatment of people with RA as well as representatives of a patient organization and professional organizations of rheumatologists, orthopedic surgeons, sports doctors, general practitioners, clinical nurse specialists, physical therapists, hand therapists, podiatrists, health insurers, and the Dutch National Health Care Institute (see Suppl. Appendix 1 for all stakeholders).

The tasks of the guideline panel were to formulate clinical questions and ensuing research questions, comment on the literature searches and draft texts produced by the author group, and formulate the recommendations. The task of the review panel was to critically review the draft guideline texts and recommendations. An independent expert in guideline development (P.v.d.W.) was appointed as chair of both the guideline panel and review panels.

Prior to the start of the guideline development, barriers regarding the assessment and treatment of patients with RA as perceived by physical therapists and patients were identified through focus groups with physical therapists (n = 19) and patients (n = 10). The guideline panel subsequently identified barriers that were then prioritized and formulated into clinical questions (Tab. 1).

Table 1

Clinical Questions and Recommendations from the Physical Therapy Guideline for Patients With RA^a

Clinical Question	Methods and Indications	Recommendations
Which domains of the ICF should be assessed during the diagnostic process?	This question was answered using the ICF Core Set for RA, which includes the most relevant aspects for people with RA and has been validated from the physical therapist’s perspective.12 The ICF Core Set for RA forms the basis in the guideline for history taking and physical examination. The core set is supplemented with clinically relevant factors based on expert opinion.	Best Practice Recommendation 1 The physical therapist should perform a comprehensive inventory of the patient’s health status and the impact of the disease on the patient’s life during history taking. In addition, be aware of the course of the disease and previous and current medical treatment. Best Practice Recommendation 2 The physical therapist should examine and document current disease activity (extent and severity of joint pain, swelling, and limited joint ROM), the presence of structural joint damage and deformities, general exercise tolerance, and muscle function during physical examination, including examination of the cervical spine and the jaw joints.
Which measurement instruments are recommended during the diagnostic phase and evaluation?	This question was answered by describing the measurement instruments that are recommended for the diagnostic process. The measurement instruments are selected based on the steps described in KNGF’s Measurement Instruments Framework for evidence-based products.71 The first step contains the selection of the relevant ICF domains that should be measured. Thereafter, the available measurement instruments for the relevant domains are identified and compared based on the feasibility and the clinometric properties. Finally, the measurement instrument that best fits the ICF domain is recommended by the guideline panel.	Best Practice Recommendation 3 The physical therapist should use the following measurement instruments for supporting the diagnostic process and evaluating treatment in RA: • NRS for fatigue • NPRS • Borg RPE scale 6–20 • HAQ-DI • PSC • 6MWT When assessing the various aspects of physical functioning, preference is given to a combined application of a self-reported questionnaire and a performance-based test.
What is the indication for physical therapy or exercise therapy?	This question was answered based on a number of key articles and information from (inter)national clinical guidelines.22,23,30 The available evidence was combined with clinical expertise, and patient preferences conform to the principles of evidence-based medicine. No evidence could be identified on the indication for physical and exercise therapy in patients with RA. In practice, therapy can be used to meet various needs for assistance. A distinction is made among needs for assistance relating to education (information and advice) about the condition; the progression of RA and the treatment, particularly the role of self-management; and specific exercises aimed at increasing muscle strength and aerobic capacity and achieving and maintaining adequate levels of general physical activity. In general, the panel agreed that there is an indication for physical therapy or exercise therapy if: • There is a need for assistance related to limitations in activities of daily living and/or social participation by the patient based on the functional movement; and/or • The patient is unable to achieve or maintain an adequate level of physical functioning independently. An adequate level is determined by the need for assistance, meets the Dutch physical activity guidelines, and assumes an effective coping strategy. Depending on health status and the extent to which patients are capable of self-management, the panel distinguished 3 types of indications.	Best Practice Recommendation 4 Physical therapists should classify patients with RA into 1 of 3 treatment profiles based on the initial assessment: • Treatment profile 1: A short period of education, advice, and exercise/movement instruction • Treatment profile 2: A short period of guidance and supervision in addition to 1, eg, due to the complexity or severity of problems or limited self-management skills • Treatment profile 3: Intensified guidance and supervision in addition to 1, eg, due to the presence of serious comorbidity or complications of the disease or its treatment.
What type of education and advice is recommended?	On March 3, 2017, KNGF conducted a search on studies that describe which information and advice physical therapists should offer patients with RA to facilitate self-management. A total of 755 references were found. Ultimately, the international guideline for providing information and advice to patients with inflammatory rheumatic disorders by the European League Against Rheumatism (EULAR)23 was selected to answer the clinical question.	Recommendation 1 Consider offering patients with RA customized information and advice for supporting effective self-management and optimizing health and well-being. The therapist provides information and advice about the disorder and the possible consequences of RA, the importance of exercise and a healthy lifestyle (including decreasing stress and fatigue and the way this lifestyle can be achieved and maintained), and the treatment options. (Conditional recommendation for the intervention, moderate level of evidence)
Is exercise therapy recommended?	To answer this question, a systematic review was conducted with the following research question: What is the (cost) effectiveness of exercise therapy (I) compared with no exercise therapy for the treatment of patients with RA (P) to improve their quality of life, physical functioning, pain, fatigue, aerobic capacity, muscle strength, ROM, and work productivity (O)? Possible harms of exercise therapist interventions are also determined, defined as increased pain, increased disease activity, and damage on radiograph. On March 3, 2017, KNGF conducted a search on systematic reviews and RCTs on exercise therapy in patients with RA. The search terms for exercise therapy are included in Suppl. Appendix 2. Five RCTs30–34 met the selection criteria for indication 1, and 20 RCTs34–53 met the selection criteria for indication 2. No studies were found for indication 3. Conclusion from the literature study Indication 1 The literature shows a moderate to large effect of exercise therapy with limited supervision on the (crucial) outcome measures—quality of life, physical functioning, and pain—compared with no exercise therapy with limited supervision. The quality of evidence varies from very low to low. The literature also shows a small effect of exercise therapy with limited supervision on the outcome measure of muscle strength compared with no exercise therapy with limited supervision, with the quality of evidence being moderate. The effectiveness of exercise therapy with limited supervision on fatigue, ROM, and work productivity is unknown. There were no undesirable effects of exercise therapy for indication 1. Indication 2 The literature shows that the effect of supervised exercise therapy on the (crucial) outcome measures of quality of life, physical functioning, and pain are large, moderate, and small, respectively, compared with no treatment. The quality of evidence for these outcomes is low, moderate, and very low, respectively. The literature also shows a large effect of supervised exercise therapy on muscle strength and ROM and a moderate effect on aerobic capacity, compared with no supervised exercise therapy; however, the quality of evidence is low to moderate. The effect of supervised exercise therapy on fatigue and work productivity is unknown. There were no undesirable effects of exercise therapy for indication 2. Indication 3 No studies were found in which the effectiveness of exercise therapy was evaluated in patients with complex problems (multimorbidity). Evidence to decision Indication 1 The beneficial effects (improvement of quality of life, degree of physical activity, and fatigue) of exercise therapy are present, whereas the harmful effects (increased pain, disease activity, and/or damage on radiograph) were in favor of the exercise therapy. Even though the estimated effects are of limited magnitude and there is uncertainty about the probability of the estimated effects, the panel believes that the desired effects outweigh the undesirable effects. Also, based on the probability of cost-effectiveness and the high degree of acceptability and feasibility of exercise therapy for indication 1, the panel believes that exercise therapy can be considered for indication 1. Indication 2 Based on the many desired effects of exercise therapy for indication 2 (with a reasonable quality of evidence) and the lack of undesirable effects, the expectation that patients will view exercise therapy in a positive light due to the desired effects and the high degree of acceptability and feasibility of exercise therapy for indication 2, the panel believes that exercise therapy can be strongly recommended for indication 2. Indication 3 The panel deems it probable that the desired effects of exercise therapy for indication 3 outweigh the undesirable effects based on practical experience. In addition, exercise therapy for indication 3 is considered acceptable and feasible by the panel. Based on this, the panel believes that exercise therapy can be considered for indication 3.	The recommendation for exercise therapy for patients with RA is divided into the 3 defined indications: Recommendation 2 (Indication 1) Consider offering exercise therapy for patients with indication 1 in the form of instructions for exercises to be done primarily independently. Ensure that exercises are aligned with the patient’s request for help, and adhere to the principles regarding the frequency, intensity, type, and duration of the exercise therapy. (Conditional recommendation for the intervention, low level of evidence) Recommendation 3 (Indication 2) Offer patients with indication 2 exercise therapy that is aligned with their need for assistance, and adhere to the principles regarding the frequency, intensity, type, and duration of the exercise therapy. (Strong recommendation for the intervention, low-to-moderate level of evidence) Recommendation 4 (Indication 3) Consider offering exercise therapy for patients with indication 3. Ensure that the exercise therapy is aligned with the patient’s need for assistance, and adhere to the principles regarding the frequency, intensity, type, and duration of the exercise therapy. (Conditional recommendation for the intervention, no level of evidence)
Are the following non-exercise therapeutic interventions recommended? • Electrostimulation (including TENS) • Low-level laser therapy (LLLT) • Ultrasound • Massage • Thermotherapy • Medical taping • Dry needling	To answer this question, a systematic review was conducted with the following research question: What is the (cost) effectiveness of non-exercise therapeutic interventions—either as an addition to the exercise therapy intervention or stand-alone (I)—compared with no exercise therapy (C) for patients with RA (P) to improve their quality of life, physical functioning, pain, fatigue, aerobic capacity, muscle strength, ROM, disease activity, damage on radiograph, and work productivity (O)? Possible harms of exercise therapy interventions are also determined, defined as increased pain, increased disease activity, and damage on radiograph. On March 3, 2017, KNGF conducted a search on systematic reviews and RCTs on exercise therapy in patients with RA. (The search terms for exercise therapy are included in Suppl. Appendix 2). After screening of the title and abstract, 1 article for electrostimulation,59 1 article for TENS,60 6 articles for LLLT,61–66 and 1 article for ultrasound67 were included. Based on the selection criteria, no articles could be included that investigated the effectiveness of massage, thermotherapy, medical taping, or dry needling. The size of the effect in the included studies about LLLT, electrostimulation (including TENS), and ultrasound was often unknown, because the effect size was not reported. The quality of the available evidence was very low. Evidence to decision Based on the lack of scientific evidence for non-exercise therapeutic interventions in patients with RA, the lack of scientific evidence for non-exercise therapeutic interventions for other disorders, and the general tendency within the field of physical therapy to focus on an active approach, the panel strongly discourages low-power laser therapy, electrostimulation (including TENS), ultrasound, massage, thermotherapy, medical taping, and dry needling. The panel is of the opinion that passive mobilization should preferably not be offered; however, passive mobilization can be considered to support exercise therapy, exclusively as a short-term intervention for increasing joint mobility in patients without active inflammation.	Recommendation 5 Consider not offering the following interventions to patients with RA (Conditional recommendation against interventions, lack of evidence): • LLLT • Electrostimulation (including TENS) • Ultrasound • Massage • Thermotherapy • Medical taping • Dry needling Passive mobilization of joints and muscles should preferably not be offered to patients with RA. Consider short-term passive mobilization of an affected joint to support exercise therapy only to patients without active inflammation to increase joint mobility. (Conditional recommendation—neither in favor nor against the intervention, lack of evidence) Passive mobilizations are contraindicated for cervical problems. (Strong recommendation against intervention, lack of evidence)

^a6MWT = Six-Minute Walk Test; Borg RPE scale = Borg Rating of Perceived Exertion Scale; EULAR = European League Against Rheumatism; HAQ-DI = Dutch Consensus Health Assessment Questionnaire Disability Index; ICF = International Classification of Functioning, Disability, and Health; KNGF = Koninklijk Nederlands Genootschap voor Fysiotherapie; NPRS = Numeric Pain Rating Scale; NRS = Numeric Rating Scale; PSC = patient-specific complaints; RA = rheumatoid arthritis; RCTs = randomized controlled trials; ROM = range of motion; TENS = transcutaneous electrical nerve stimulation.

Phase 2: Development

The development process was based on the principles of evidence-based practice, including a description of the best available evidence combined with clinical expertise and patient preferences.¹⁰ As a first step, the barriers identified in the focus groups were discussed and prioritized and translated into clinical questions by the guideline panel (Tab. 1). The clinical questions were then translated into research questions, which were answered using systematic reviews for the questions about therapeutic interventions and narrative reviews for all other questions.

Regarding the therapeutic interventions, a systematic search of the literature was conducted on March 3, 2017, in PubMed, Embase, Central, Cochrane, PeDRO, and EMCARE (Suppl. Appendix 2). Randomized controlled trials (RCTs) in adults diagnosed with RA according to the American College of Rheumatology/European League Against Rheumatism classification criteria,⁸ describing the posttreatment effect of the intervention of interest compared with usual care, were included. Outcomes of interest were defined in advance by the guideline panel and rated as critical (quality of life, physical function, pain, and fatigue) or important (aerobic capacity, muscle strength, range of motion, disease activity, radiographic joint damage, and absenteeism) based on their importance for decision making. The evidence was synthesized by providing the estimates of the effects and the quality of the evidence for each outcome. Using GRADE group methods,⁹ RCTs were classified as high-quality evidence and downgraded to moderate, low, or very low based on the risk of bias (assessed in accordance to the Cochrane risk of bias tool),¹⁰ inconsistency of results (studies showing clinical or statistical heterogeneity), indirectness of the evidence (the study population differs from the target population of the guideline), imprecision (low amount of studies or included patients, eg, <300 patients or events), and publication bias.

For the clinical questions to be answered by narrative reviews (eg, questions on the diagnosis of RA; the desired assessment; or the optimal type, frequency, intensity, and time-related factors of exercises [FITT factors]), a search of key articles, landmark papers, (inter)national clinical guidelines, clinical protocols, and textbooks was conducted.

During a period in which 4 face-to-face meetings were organized, the author group and the guideline panel produced draft texts. For every part of the draft text that was finished, the review panel was consulted by email. The final draft of the complete guideline was discussed with the review panel in 1 face-to-face meeting. Recommendations based on a narrative review and expert opinion were designated as Best Practice Recommendations, with imperative wording, ``The physical therapist should…''. Recommendations for therapeutic interventions based on systematic literature reviews were combined with expert opinion. Their formulation was based on the GRADE evidence-to-decision framework,¹¹ including a discussion on the balance between benefits and harms; the quality of the evidence; the values and preferences of patients and clinicians; and the feasibility, equity, and acceptability. The discussion was structured by the use of an evidence-to-decision form (Suppl. Appendix 3),¹¹ leading to strong (offer or do not offer) or conditional (consider or consider not to) recommendations in favor of or against the intervention or to a neutral recommendation.¹¹ The GRADE methodology specifies 2 categories of the strength of a recommendation.¹² A strong recommendation is one for which the guideline panel is confident that the desirable effects of an intervention outweigh its undesirable effects (strong recommendation for an intervention) or that the undesirable effects of an intervention outweigh its desirable effects (strong recommendation against an intervention). A strong recommendation implies that most or all individuals will be best served by the recommended course of action.

A conditional recommendation is one for which the desirable effects probably outweigh the undesirable effects (conditional recommendation for an intervention) or undesirable effects probably outweigh the desirable effects (conditional recommendation against an intervention), but appreciable uncertainty exists. A conditional recommendation implies that not all individuals will be best served by the recommended course of action. There is a need to consider more carefully than usual the individual patient’s circumstances, preferences, and values. The formulation of the recommendations based on expert opinion only and on systematic literature review combined with expert opinion is described in Table 2.

Table 2

Formulation of Recommendations Based on Literature Review Combined With Expert Opinion (Based on GRADE⁹)^a

Type of Recommendation	Formulation
Strong recommendation against the intervention	Do not offer the intervention
Conditional recommendation against the intervention	Consider not offering the intervention
Conditional recommendation for the intervention	Consider offering the intervention
Strong recommendation for the intervention	Offer the intervention

^aRecommendations based on a narrative review and expert opinion are designated as “best practice recommendations” and formulated in terms of “The physical therapist should….”. GRADE = Grading of Recommendations Assessment, Development and Evaluation.

Phase 3: Review and Authorization

The recommendations and underlying descriptions formed the base of a draft guideline, which was field-tested by 16 physical therapists working in clinical care with special attention to credibility and feasibility in daily practice. Based on their comments, revisions were made to the draft guideline, resulting in the final document. All participating stakeholders were then requested to authorize this final version of the guideline, resulting in authorization by all relevant professional associations and patient organizations (Suppl. Appendix 1). The guideline and its supporting documents were published in Dutch at the KNGF website in open access on November 14, 2018 (https://www.kngf.nl/kennisplatform/richtlijnen/reumatoide-artritis).¹³

Organization of the Guideline

As background information on RA in the guideline, the pathology, physiology, prevalence, diagnostics, and general treatment were described based on narrative reviews.

The main recommendations for assessment and treatment resulting from the guideline development process are summarized in Table 1. These recommendations, and a summary of additional recommendations and underlying descriptions as included in the guideline,¹³ are presented below.

Assessment Recommendations

For the examination/assessment part of the guideline, there is and will be no evidence from clinical trials to support or refute specific elements. Therefore, this part of the guideline was based on textbooks, overview papers, and publications on general core sets for the assessment of people with RA. The recommendations are considered to be “best practice” recommendations, that is, expert opinion.

In particular, the ICF Core Set for RA was used as the basis for a comprehensive assessment.¹⁴ The ICF Core Set for RA represents the typical spectrum of problems in the functioning of patients with RA and was validated in a 3-round Delphi survey from the perspective of physical therapists. As such, it was considered as a solid base for the history taking and physical examination by the guideline panel. The Core Set was further supplemented with a few factors relevant for physical therapist practice, which were based on expert opinion as discussed during the guideline panel meetings. It includes the aspects most relevant for people with RA in the following categories: body structures and functions, activities, participation, external factors, and personal factors. The assessment consists of history taking including the identification of red and yellow flags and physical examination.

Best Practice Recommendation 1: History Taking

The physical therapist should perform a comprehensive inventory of the patient’s health status and the impact of the disease on the patient’s life during history taking. In addition, the physical therapist should be aware of the course of the disease and previous and current medical treatment.

A comprehensive inventory of the patient’s health status and the impact of the disease on the patient’s life should be based on the ICF Core Set for RA.¹⁴ In addition, the guideline panel concluded that documenting the course of the disease and previous and current medical treatment (response to medication and surgery such as joint replacement surgery) is important. Examples of relevant questions for history taking can be found in Table 3.

Table 3

Relevant Questions for History Taking in Patients With RA^a

History-Taking Items	Relevant Questions
General	What is the patient’s need for assistance? (PSC) What are the expectations regarding physical or exercise therapy? What are the expectations regarding the progression of the symptoms?
Functions and  anatomical  characteristics	Is there pain in 1 or more joints? (NPRS) What is the location of the pain (which joints)? Is the pain related to exertion? What is the progression of the pain in the morning, afternoon, evening, or nighttime? Is there inexplicable, persistent severe pain and/or inflammatory symptoms in 1 or more joints? (potential red flag) Is there morning stiffness and/or start-up stiffness? If so, for how long? Is there swelling of 1 or more joints? If so, which joints? Is there limited range of motion and/or stiffness in 1 or more joints? If so, which joints? Is there fatigue? (NRS) Is there reduced muscle strength? If so, where and during which activities? Is there decreased endurance? Are there skin problems (ulcers) or nail fold infarcts that may be associated with RA? Are there problems when chewing or swallowing? Is there dry mouth and/or dry eyes, for example as a result of Sjögren’s syndrome? Is there high blood pressure? (cardiovascular risk factor) Is there high cholesterol? (cardiovascular risk factor) Is there neck pain and/or pain in the back of the head, in combination with paresthesia and/or dysesthesia, motor deficit, “twitching” legs, and/or a sandy feeling in the hands? (neurological symptoms that could indicate a red flag) Are there sensory disorders? (potential red flags) Are there balance problems? (potential red flags) Are there sleep problems? Is there a sudden increase of symptoms or an acute RA flare-up? (potential red flag) Is there severe back pain, possibly after a fall? [potential red flag with osteoporosis and (long-term) corticosteroid use] Are there signs of infection somewhere other than in the joints, possibly accompanied by fever and/or general malaise? (potential red flag with the use of biologicals)
Activities (PSC)	Are there limitations to performing activities of daily living and/or functions such as: • changing posture (eg, turning around in bed, getting up from bed, sitting down) • self-care, such as getting dressed and undressed, showering, combing hair (optional measurement instrument for arm and hand function; Quick-DASH) • walking (at home or outside), climbing stairs • picking up items from the ground • writing or other fine motor activities • eating and/or drinking • cycling, driving a car, or using public transportation • sexual activities Does the patient meet the “Dutch Physical Activity Guidelines”? (see section A.5.2) If so, with which activities and for how many minutes per week? If not, what is the most important impeding factor? Which degree of physical activity is achieved? With which activities and for how many minutes per week? (optional measurement instrument: accelerometer/pedometer or the MET method)
Participation	What is the family situation? (to assess the daily exertion compared to the capacity) Are there limitations resulting from the symptoms in: • relationships and/or social contacts? • paid or volunteer work? (optional measurement instrument: WPAI) • free time, eg, when playing sports or engaging in hobbies? • quality of life (optional measurement instrument: RAQol)
External factors	Is there a family history of RA? Is there a family history of cardiovascular disease? How do the people surrounding the patient (partner, family, friends, co-workers) respond to the symptoms? What is the patient’s living situation? Are there stairs in the house and how does the patient do climbing these stairs? Does the patient use medication? If so, which ones? What is the effect of the medication? Are there side effects? If so, which ones? Has the patient previously undergone physical or exercise therapy for RA? If so, what was the result? Other than the rheumatologist, is there another medical specialist or other health care provider involved with the patient for treating the RA or related comorbidity? Does the patient use modifications, aids, or facilities for activities of daily living or household tasks? How about at work or during sport or leisure activities? Does the patient use a walking aid? If so, what is the effect? Does the patient use an aid to perform activities? (standing support, stand-up chair, wheeled stool, knee support)? If so, what is the effect? Has any surgery been performed in the past (for example, joint replacement surgery or tendon surgery)? If so, how long ago did this take place and how did the recovery progress?
Personal factors	What are the patient’s views regarding exercise? How does the patient handle the complaints in his/her daily life? Among other things, measures the patient has undertaken to influence his/her complaints, such as resting/exercise, and are these helping? Presence of the following conditions: Comorbidity? If so, which ones? Does this influence the patient’s functional movement and/or exercise capacity? Overweight? (cardiovascular risk factor) Smoking? If so, how much does the patient smoke? (cardiovascular risk factor) Facilitating or inhibiting factors towards exercise? If so, which ones? A need for information about RA and the treatment? Fear, for example of falling?

^aTable 3 represents examples of relevant questions when taking a patient’s history. The questions can be adapted to suit the therapist’s communication style and the patient’s communication level. Possible contraindications, yellow and red flags, risk factors, prognostic factors, and measurement instruments are listed in parentheses. MET = frequency, intensity, type, and time frame; NPRS = Numeric Pain Rating Scale; NRS fatigue = Numeric Rating Scale for fatigue; PSC = patient-specific complaints; RA = rheumatoid arthritis; RAQol = RA Quality of Life Questionnaire; WPAI = Work Productivity and Activity Impairment Questionnaire.

Yellow and Red Flags

An inventory of yellow and red flags is part of the history taking. Yellow flags are indications of psychosocial and behavioral risk factors for maintaining and/or exacerbating health problems in RA. Red flags are patterns of symptoms, or warning signs, that may indicate severe pathology and may require additional medical evaluation.

In the Netherlands, checking the presence of red flags is important in the decision-making process in patients who consult the physical therapist via direct access. Before starting and during treatment, particular signs of infection (probably related to the use of DMARDs) and neurological complications, such as signs of myeloma compression, are red flags necessitating immediate referral (Suppl. Appendix 4).

Best Practice Recommendation 2: Physical Examination

The physical therapist should examine and document the patient’s current disease activity (extent and severity of joint pain, swelling, and limited joint range of motion), the presence of structural joint damage and deformities, general exercise tolerance, and muscle function during physical examination, including examination of the cervical spine and the jaw joints.

All the joints and peri-articular structures that can be affected by RA, and not only the ones that are symptomatic, must be assessed during the physical examination.^15,16 There may be joints in which the symptoms are latent, such as subtle swelling or limited joint range of motion. It should be noted that apart from peripheral joints, the cervical spine and the jaw joints should be examined as well. By means of physical examination, the physical therapist gains insight into current disease activity (extent and severity of joint pain, swelling, and limited joint range of motion), the presence of structural joint damage and deformities, and general exercise tolerance and muscle function. Relevant points of attention during the physical examination are presented in Table 4.

Table 4

Relevant Points of Attention During the Physical Examination of Patients With RA^a

Examination Area	Examination Component	Points of Attention
Functions and  anatomical  characteristics	Inspection	Where is the pain reported (which joints)? During which movement(s) does the pain occur in the respective joints? Is there any swelling of the respective joints? If so, which joint(s) and to which degree (slight, moderate, or severe). Is the swelling diffuse or localized? Are there changes in position or deformities of the joint(s), in particular the hands, wrists, or feet? (see section A.3).
	Palpation	Is there any swelling of the joints or surrounding structures (eg, tendons, bursae)? Is there any temperature increase of the joint(s)? Is palpation painful? Are there changes in position or deformities of the joint(s), in particular the hands, wrists, or feet? (see section A.3).
	Functional examination	Active movement examination: • determination of the range of motion of all joints of the upper and lower extremities and of the cervical spine in all directions; • assessment of the combined shoulder and elbow function by having the patient perform several combined movements (eg, the hair combing movement). Passive movement examination of the joints with limited range of motion that was determined during the active movement examination. Assessment: • the muscle weakness and muscle endurance of the upper and lower extremities; • the active and passive stability, muscle length and proprioception; • the static and dynamic balance; • the sensitivity of primarily the upper extremities (potential red flag); • the hand function (movement examination), but also coordination, gripping function, and the functioning of the flexor and extensor tendons in the hand (including tendon gliding); • the physical functioning ([6MWT] is a supporting functional test to estimate the physical functioning and to use as a baseline measurement for the treatment); • The aerobic capacity (eg, with the help of the Borg scale [6–20] or the heart rate)
Activities	Inspection	Assessment of: • the gait pattern; such as heel strike, ankle function, knee function (is there a flexion contracture, eg?) and hip function (is there a Trendelenburg, eg?), trunk rotation, and arm function; • the quality of movement during functional activities, such as standing, getting up and sitting down, bending, transfers, getting (un)dressed, walking up/down stairs, reaching and gripping, picking something up from the floor, and writing; • specific activities that are restricted during work, sports, or other leisure activities; • use of aids; • performance of other specific activities where symptoms are reported.

^a6MWT = Six-Minute Walk Test; RA = rheumatoid arthritis.

Best Practice Recommendation 3: Measurement Instruments

The physical therapist should use the following measurement instruments for supporting the diagnostic process and evaluating the treatment in RA: the Patient-Specific Complaint instrument,¹⁷ numeric rating scales for pain and fatigue,¹⁸ the Dutch version of the Health Assessment Questionnaire Disability Index,¹⁹ and the 6-Minute Walk Test²⁰ (Suppl. Figure).

A limited number of measurement instruments for initial assessment and subsequent monitoring and evaluation were selected based on the ICF core set for RA. Reliability, validity, and feasibility were conditional for this selection. When assessing the various aspects of physical functioning, preference is given to a combined application of a self-reported questionnaire and a performance-based test.

Indications and Contraindications for Treatment

In the international literature, 2 practice recommendations emphasize the importance of access to physical therapy for patients with RA: (1) “People with RA should have access to evidence-based pharmacological and non-pharmacological treatment,” and (2) “People with RA should understand the benefit of exercises and physical activity and should be advised to exercise appropriately.”²¹ In the absence of literature describing specific indications for physical therapy in RA, the guideline panel formulated that there is an indication for physical therapy if (1) the patient has a need for support regarding their RA-related problems and the ensuing limitations in daily activities and/or social participation; and/or (2) the patient is, related to RA, unable to achieve or maintain an adequate level of exercise and/or physical activity.^22–24

When the physical therapist suspects a diagnosis other than RA or lacks relevant information on the severity of the disease, when generic or specific red flags are identified during history taking or physical examination, or there is present possible absolute contraindications for physical exercise or a grounded expectation that exercise may worsen the symptoms, the patient’s referring physician or, in case of self-referral, treating rheumatologist or general practitioner should be contacted. Another reason to contact a physician is, in case of self-referral, a suspected diagnosis of RA. The early identification of (probable) RA with appropriate referral is an important task of the physical therapist, who can thus play a role in the earliest possible medical treatment of this condition.

Best Practice Recommendation 4: Treatment Profiles

1. Physical therapists should classify patients with RA into 1 of 3 treatment profiles based on the initial assessment (see Tab. 5 for more details): a short period of education, advice, and exercise/movement instruction; a short period of guidance and supervision in addition to (1), for example, due to the complexity or severity of problems or limited self-management skills; intensified guidance and supervision in addition to (1), for example, due to the presence of serious comorbidity or complications of the disease or its treatment.

Table 5

Patient Profiles for Physical Therapy in Patients With RA^a

Patient Profile	Description	Criteria
1	Need for information, advice, and instructions for mainly independently performed exercises	A need for information, advice, instruction and practical tools when exercising and (again) moving and/or; A need for more insight into the disease, the symptoms and course of RA, and the consequences for physical functioning and social participation and/or; A need for information about the physical therapists or remedial therapeutic treatment options and the own role in them and/or; A need for information about the possible health effects of appropriate exercises and an active lifestyle and the own role therein and/or; A need for information about the practical possibilities of participating independently or with the help of others (eg, informal carers, care providers other than physical therapists or remedial therapists, sports/fitness instructors, etc) in the regular or adapted range of sports and exercise activities to obtain and maintain sufficient physical activity and/or; A request for help that relates to aspects such as: limitations in self-regulation skills related to physical activity, or the availability of exercise options and social support.
2	Need for information, advice, instruction, and exercise therapy with brief physical therapy guidance	A request for help in the area of RA-related complaints, and related disorders and limitations in daily activities and/or social participation, which cannot be solved by short-term information, advice, and instruction alone and/or; A need for more and longer guidance to be able to carry out an exercise program independently and to obtain and maintain sufficient physical activity.
3	Need for information, advice, instruction, and exercise therapy with intensive and/or long-term supervision of a physical therapist	Restriction(s) in basic daily activities and social participation as a result of which the patient is not able to independently obtain or maintain an adequate level of functioning and/or; A high disease activity based on the clinical picture that cannot be regulated adequately with medication and/or; Serious joint damage and/or; Serious joint deformations and/or; Presence of risk factors for delayed recovery that hinder the implementation of remedial therapy (eg, comorbidity) and/or; Presence of psychosocial factors (yellow flags) in combination with inadequate pain coping.

^aRA = rheumatoid arthritis.

Treatment Recommendations

Systematic reviews related to the research questions on exercise therapy and non-exercise therapeutic interventions were conducted to formulate recommendations. Narrative reviews were conducted to describe the content of exercise therapy and patient education.

Recommendation 1: Patient Education

Consider offering RA patients customized information and advice to support their effective self-management and optimize their health and well-being. The therapist provides information and advice about the disorder and the possible consequences of RA, the importance of exercise and a healthy lifestyle (including decreasing stress and fatigue and the way this lifestyle can be achieved and maintained), and the treatment options (conditional recommendation for the intervention, moderate level of evidence).

The recommendation on patient education was based on the recommendations of the European League Against Rheumatism²⁵ that was substantiated by 11 systematic reviews or meta-analyses, 36 RCTs, 7 controlled trials, 9 pre-post-test studies, 23 cross-sectional studies, and 21 qualitative studies. A synthesis of the literature concluded a small but positive effect of patient education on self-reported pain, fatigue, activity limitations, and physical activity in a 4- to 18-month follow-up.²⁵ With education, the physical therapist provides information about the condition and strategies to reduce disability within the boundaries of his or her professional expertise. Advice and instructions may be related to the performance of specific activities, for example, ways to distribute the load over multiple joints during heavy activities or the use of assistive devices.²⁵ Moreover, the guideline panel concluded that education provided by the physical therapist should include instructions and advice for the execution of patient-specific exercises and an active lifestyle. To this end, supporting the patient in how best to be physically active yet distribute their energy over the day and/or week is an important point of attention. In patients with RA, it should be particularly acknowledged that there may be barriers for exercise and physical activity, such as lack of knowledge, lack of social support, pain, fatigue, or fear that exercise may damage joints.²⁵

Aspects that need to be addressed are:

• The beneficial effect of individually adjusted and appropriately dosed exercises and/or physical activities on muscle strength, aerobic capacity, daily functioning, disease activity, and mental functioning

• Preventive effects of a sufficient amount of physical activity^22–24 and limitation of sedentary behavior that apply to the whole population are particularly important for people with RA who are at an increased cardiovascular risk.

To promote an individualized plan for specific exercises and overall physical activity for patients with RA, sustained integration into their daily lives is essential. To this end, the principles of behavioral change^26–31 should be used during the education (Suppl. Appendix 4).

Recommendations for Exercise Therapy

Recommendations on exercise therapy in patients with RA are based on a systematic review of RCTs and are divided into recommendations for unsupervised and supervised exercise. To improve the feasibility for daily physical therapist practice, recommendations were specifically defined regarding their FITT factors (Tab. 6). That translation was based on general knowledge on physical activity^22,23 and a physical activity guideline on arthritis.²⁴

Table 6

FITT Factors for Exercise Therapy in Patient With RA^a

Factors for Exercise Therapy	Patient Goals
Frequency	Aim that the patient preferably performs daily, but at least 2 d/wk (for muscle strengthening/functional exercises) to at least 5 d/wk at least 30 min at a time (for aerobic exercises) (which also complies with the Dutch Health Council exercise recommendations16 and international guidelines for arthritis17,18). Start with 1 to 2× weekly guided exercise therapy, supplemented with independently performed exercises and complete the guidance during the treatment period.
Intensity	Aim for the following minimum intensity for muscle strength and aerobic training: Muscle strength training: 60%–80% of 1 repetition maximum (1RM) (≈ Borg score 14–17) (or 50%–60% of 1RM (≈ Borg score 12–13) for people not accustomed to strength training) with 2 to 4 sets of 8 to 15 repetitions with 30–60 s. rest between sets. Aerobic training: >60% of maximum heart rate (≈ Borg score 14–17) [or 40%–60% of maximum heart rate (≈ Borg score 12–13) for people not used to aerobic training]. Ensure a gradual build-up in intensity during the program and follow the training principles.
Type	Offer exercise therapy in a combination of: Muscle strength training:   Choose exercises primarily aimed at the large muscle groups around the knee and hip joint (especially knee extensors, hip abductors, and knee flexors). Have these exercises performed on both legs (for hip and knee osteoarthritis, both for unilateral and bilateral osteoarthritis). Choose both functional exercises with your own body weight and exercises with devices. Exercises with high mechanical knee load (eg, “leg extension device”) should preferably be avoided in case of knee osteoarthritis and after joint replacement surgery of the knee. Aerobic training:   Choose activities with relatively low joint load, such as walking, cycling, swimming, rowing, or cross-trainer. Functional training: Choose (parts of) activities that are hindered in the patient’s daily life (eg, walking, climbing stairs, sitting down and getting up from a chair, lifting or packing large or small objects) by exercising (parts of) these activities. Consider offering specific balance and/or coordination/neuromuscular training in addition to exercise therapy if there are disturbances in balance and/or coordination/neuromuscular control that interfere with the patient’s functioning. Consider offering (active) range-of-motion or muscle stretching exercises in addition to the exercise therapy if there are muscle shortening and/or reversible mobility limitations of the joint that interfere with the patient’s functioning.
Time	Aim for a treatment period between 3 and 6 months, supplemented by 1 or more follow-up sessions after completion of this treatment period to encourage compliance. Encourage the patient to continue practicing independently after the treatment period.
General points of attention	Offer exercise therapy in combination with instructions for independently performed exercises or activities to promote physical activity. Observe the Health Council of the Netherlands Movement Guidelines. In the case of RA, accompany and motivate the patient when moving with specific barriers such as pain, stiffness, fatigue, and fear of worsening the disease. In patients with hand problems, consider a specific exercise program for the hand. The patient can be referred to a physical therapist or remedial therapist or occupational therapist with specific expertise in the field of the (rheumatic) hand. Consider water-based exercise therapy in the initial phase of treatment if there are serious pain symptoms during exercise. Consider using the MET method (see measuring instruments) when estimating exercise capacity. Consider the use of e-health applications to support the patient in performing or continuing to perform exercises independently and/or to reduce the level of supervision. Consider offering group exercise therapy if little individual support is required.
Training principles for  people with RA	Precede the workout with a warm-up and finish with a cooling-down. Determine the starting intensity of the strength training and monitor the intensity during the treatment using the 1RM submaximal test. Determine the starting intensity of the aerobic training and monitor the intensity during treatment using heart rate and/or Borg score. Gradually increase the intensity of training to the maximum level possible for the patient. Reduce the intensity of the next workout if joint pain increases after the workout and persists for more than 2 h. Start with a short period of 10 min (or less if necessary) in aerobic exercises, in patients who are untrained and/or limited by joint pain and mobility. Offer alternative exercises using the same muscle groups and energy systems if the exercise leads to an increase in joint pain. When adjusting training intensity, use variation in sets and repetitions (in strength), intensity, duration of session or exercise, type of exercise, and rest rests and determine the adjustment in consultation with the patient.

^aFITT = frequency, intensity, type, and time frame; MET = metabolic equivalent of tasks; RA = rheumatoid arthritis; 1RM = 1 repetition maximum.

The intensity of muscle-strengthening exercises should be built up from 50% to 60% of the 1-repetition maximum to 60% to 80% of the 1-repetition maximum, while the intensity of aerobic exercise should be built up from 40% to 60% of the maximum heart rate to more than 60% of the maximum heart rate, all according to the guidelines of the American College of Sports Medicine for patients with arthritis.²³ Depending on capacity of the patient, the exercises can be varied by means of the frequency, duration, and rest between exercises. Based on evaluations, the treatment plan must be adjusted regularly. The duration of the supervised treatment is determined in consultation with the patient. It is important that the frequency of exercising does not decrease; the emphasis shifts from supervised to non-supervised exercising. At the end of the treatment, the patient should be guided to regular exercise and physical activities to maintain achieved treatment goals.

Recommendation 2: Education, Advice, and Instruction (Treatment Profile 1)

Consider exercise therapy for patients with Treatment Profile 1 in the form of instructions for exercises to be done primarily independently. Ensure that exercises are aligned with the patient’s request for help and adhere to public health recommendations for health-enhancing physical activity regarding the frequency, intensity, type, and duration (conditional recommendation for the intervention, low level of evidence).

For Treatment Profile 1, an individually tailored exercise and physical activity plan should be developed, with limited supervision to monitor the appropriate performance.^32–36 With appropriate advice and instruction, patients can do the exercises and be physically active on their own. The recommendation is based on a moderate effect of unsupervised exercise therapy on quality of life (2 RCTs; standardized mean difference [SMD = 0.44; 95% CI = −0.34 to 1.22] and physical functioning [3 RCTs; SMD = 0.32; 95% CI = 0.02 to 0.62] and a large effect on pain [4 RCTs; SMD = 0.54; 95% CI = 0.22 to 0.87]) in patients with RA, with the evidence being of low quality.^32–36 Furthermore, there was a small effect on muscle strength (2 RCTs; SMD = 0.24; 95% CI = −0.09 to 0.57; low level of evidence), a small (positive) effect on disease activity (2 RCTs; SMD = 0.60; 95% CI = −0.56 to 1.77; low level of evidence), and a moderate positive effect on radiological damage (2 RCTs; SMD = 0.32; 95% CI = −0.43 to 1.07; very low level of evidence). The physical therapist aims for a maximum of 3 to 6 sessions over a treatment period of 3 to 6 months. The treatments can take place shortly after each other or are spread over a certain period of time with appropriate evaluation every 8 weeks. During the evaluations, the treatment plan must be adapted from time to time. Taking into account the physiological principles of exercise, adjustments to the tailored exercise and physical activity plan are made with regard to intensity (Tab. 4), frequency, duration, and rest between exercises.

Recommendation 3: Short-Term or Intermittent Supervised Exercise Therapy (Treatment Profile 2)

Offer exercise therapy for patients with Treatment Profile 2 in the form of instructions for exercises to be done primarily independently and a concise period of supervision. Ensure that exercises are aligned with the patient’s request for help and adhere to public health recommendations for health-enhancing physical activity regarding the frequency, intensity, type, and duration (strong recommendation for the intervention, low to moderate level of evidence).

For Treatment Profile 2, based on an individualized exercise and physical activity plan, supervised exercise therapy twice a week is provided in the initial phase supplemented by independently performed home exercises and physical activities.^24,37–57 This recommendation is based on research demonstrating that in patients with RA supervised exercise therapy has a large effect on quality of life (3 RCTs; SMD = 0.70; 95% CI = 0.14 to 1.25; low quality of evidence), a moderate effect on physical functioning (17 RCTs; SMD = 0.43; 95% CI = 0.18 to 0.68; moderate quality of evidence), and a moderate effect on pain (3 RCTs; SMD = 0.49; 95% CI = −0.33 to 1.11; very low quality of evidence). Furthermore, there was a moderate effect on aerobic capacity (11 RCTs; SMD = 0.49; 95% CI = 0.33 to 0.65; high level of evidence), a large effect on muscle strength (12 RCTs; SMD = 0.63; 95% CI = 0.21 to 1.05; low level of evidence), a large effect on range of motion (2 RCTs; SMD = 0.59; 95% CI = 0.17 to 1.01; moderate level of evidence), a small (positive) effect on disease activity (7 RCTs; SMD = 0.23; 95% CI = 0.16 to 0.62; moderate level of evidence), and a small (positive) effect on radiological damage (2 RCTs; SMD = 0.09; 95% CI = −0.14 to 0.31; moderate level of evidence).^37–57

Recommendation 4: Intensified Supervised Exercise Therapy (Treatment Profile 3)

Consider exercise therapy for patients with Treatment Profile 3 in the form of longstanding, supervised exercise therapy. Ensure that exercises are aligned with the patient’s request for help and, if possible, adhere to public health recommendations for health-enhancing physical activity, with adjustments regarding the frequency, intensity, type, and duration (conditional recommendation for intervention, no level of evidence).

Patients with an indication for Treatment Profile 3 have serious and/or progressive functional disability, for example, due to severe comorbidity or complications. The literature on the effectiveness of exercise therapy in patients with RA with severe functional disability is absent because all studies, except for 1 study in patients with active disease,⁵⁷ have been performed on patients with relatively stable disease and/or little or no comorbidities, radiological damage, and/ or joint arthroplasties. The recommendation is therefore based on expert opinion of the multidisciplinary guideline panel. Based on a process of clinical reasoning and a treatment strategy proven effective in earlier research,^58,59 it is recommended to adjust the desired frequency, intensity, and duration of the exercise therapy depending on the patient’s health status. For adjusting the exercise therapy, the i3-S model⁶⁰ can be used. I3-S stands for a 3-step inventory of (1) relevant comorbid diseases, (2) contraindications and restrictions for exercise treatment with selected comorbidities, and (3) potential adaptations to exercise therapy. Maintaining and, if possible, improving daily functioning and social participation are always the most important treatment goals regardless of the underlying cause. Given the varying nature and severity of the problem, treatment goals are regularly adjusted or new treatment goals set. The design of the treatment can also change.

Recommendation 5: Non–Exercise Therapeutic Interventions and Passive Mobilizations

Consider not offering the following interventions to patients with RA: low-level laser therapy, electrostimulation (including transcutaneous electrical nerve stimulation), ultrasound, massage, thermotherapy, medical taping, or dry needling. Passive mobilization of joints and muscles should preferably not be offered to patients with RA (conditional recommendation against interventions, lack of evidence).

Consider short-term passive mobilization of an affected joint only as an exception to support exercise therapy in patients without active inflammation to increase joint mobility (conditional recommendation, neither in favor nor against the intervention; lack of evidence).

Do not offer passive mobilizations in case of cervical problems; this intervention is contra-indicated (strong recommendation against intervention, lack of evidence).

Based on systematic literature searches, the following non-active exercise interventions are not recommended: electrotherapy (including transcutaneous electrical nerve stimulation),^61,62 low-level laser therapy,^63–68 ultrasound,⁶⁹ massage (evidence absent), thermotherapy (evidence absent), medical taping (evidence absent), and dry needling (evidence absent). As an exception, the expert panels agreed on the short-term use of passive mobilizations to support exercise therapy. They can be considered only in patients without active inflammation to increase joint mobility when they cannot achieve maximum range of motion. These recommendations align with the use of treatment modalities in the Choose Wisely campaign of the American Physical Therapy Association.⁷⁰ Passive cervical spine mobilizations are contraindicated in any case.

Discussion

A clinical practice guideline for physical therapy in patients with RA is developed according the Appraisal of Guidelines for Research & Evaluation⁷ and GRADE methodology.⁹ This practical guideline provides the physical therapist with a process of clinical reasoning, including initial assessment, treatment, and evaluation, to give the patient the best evidence-based treatment available.

To the best of our knowledge, comprehensive recommendations for physical therapy regarding initial assessment, treatment, and evaluation in patients with RA have not been previously described in a discipline-specific guideline, other than the KNGF guideline.⁵ On the international level, recommendations for treatment of patients with RA are described in various European League Against Rheumatism recommendations,^3,4,25 but these do not give specific guidance for a practicing physical therapist.

The required competences for physical therapists to treat patients with RA are addressed in professional physical therapist education. This newly updated guideline provides more detail regarding the disease as well as specifics of the cornerstones of physical therapist management: education and exercise. Regarding the latter, the desired FITT ²³ of exercise is presented according to 3 treatment profiles.

A strength of the methodology used to develop this guideline includes the involvement of many stakeholders (see Suppl. Appendix 1). Moreover, the clinical questions were formulated based on bottlenecks in clinical care as perceived by physical therapists and patients. Their questions are answered in the guideline, thereby fostering the implementation in physical therapist practice. In addition to the evidence from the literature and textbooks, the important considerations from practice and the opinions of experts and patients were taken into account in all phases of the development process. This was explicitly done with the eventual formation of the recommendations by the use of evidence-to-decision forms. Currently, a field test is being executed, which may, in and of itself, contribute to promoting the use of the guideline in daily clinical practice.

A limitation of the methodology is that for the physical therapist interventions, we limited evidence to published systematic reviews or meta-analyses and RCTs. If these were not available, we did not systematically search for other, non-controlled trials or observational studies. For answering the non-therapeutic clinical questions, we used textbooks and key articles provided by all experts in the panels. A more extensive literature search might have provided more information and evidence on the content of initial assessment and evaluation of treatment.

In the developmental process, several knowledge gaps with regard to physical therapist treatment in RA were identified. In this updated version of the guideline, the required FITT factors of the exercises were more clearly defined than in previous versions of the guideline. It has been clearly demonstrated that exercise and physical activity meeting public health recommendations for health-enhancing physical activity are effective and safe in patients with various rheumatic conditions, including RA.²⁴ Yet, the question remains of how exercise and physical activity plans should best be tailored to the individual patient when comorbidities are present. Comorbidity occurs relatively frequently in patients with RA because of (complications of) the disease and/or medication use and/or independently of RA. In addition to knowledge and skills regarding RA, this modified exercise therapy also requires specific knowledge and skills relating to the individual patient’s co-morbidities.⁶⁰ The general rule of “unskilled is unauthorized” applies here. If the treating therapist has insufficient knowledge and skills regarding the patient’s comorbidity, then the patient is referred to a therapist who does have sufficient knowledge of this subject.

With regard to phase 4 of the method of guideline development, dissemination and implementation, it is known that recommendations from guidelines are often insufficiently put into practice.⁷¹ Enhanced implementation strategies are needed to improve daily evidence-based practice strategies, such as improving attitudes and increasing awareness regarding guidelines as well as improving knowledge, skills, and confidence in evidence-based practice.¹² To start with, the clinical practice guideline on physical therapy for patients with RA is published on the website of the national physical therapy organization (KNGF)¹³ and is accessible to all physical therapists; the KNGF has sent an announcement with a reference to the guideline to its 19,000 physical therapist members. Also, the revised guideline is presented during the annual congress of the KNGF, and articles about the guideline were published in international journals, magazines, and websites for professionals working with patients with RA and in magazines and websites for patients with RA. To make the guideline accessible and useful to all physical therapists, an English version of the guideline will be made available on the website of the KNGF (https://www.kngf.nl/kennisplatform/richtlijnen/reumatoide-artritis) following the publication of this article in an issue of PTJ. In addition, interactive lectures and an e-learning module were developed and provided by the national professional organization (KNGF) to primary care physical therapists. Physical therapists are encouraged to follow the interactive lectures and e-learning by rewarding them with 3 Continuing Medical Education points, which they need to stay registered in the quality register. In October 2020, 7 interactive lectures about the Dutch physical therapy guideline were given and attended by more than 280 physical therapists, and the e-learning was completed by 1106 physical therapists. In the future, the KNGF will continue to encourage more physical therapists to attend interactive lectures and the e-learning about the revised guideline to improve the uptake of the guideline.

To evaluate the success of its implementation, quality indicators will be derived from the updated guideline. Quality indicators are tools that specify the minimum acceptable standard of practice⁷² and can be used to measure health care processes, organizational structures, and outcomes that relate to aspects of high-quality care of patients.⁷² The KNGF started to develop a strategy for the formulation of quality indicators of specific recommendations.⁷³ The KNGF guidelines on physical therapist treatment of hip and knee osteoarthritis⁷⁴ and RA will be the first subjects of quality indicator development.

The guideline has a modular structure and can therefore be revised modularly. A module consists of the elaboration of 1 clinical question. The guideline will be updated when bottlenecks arise in practice when applying the guideline or if scientific publications appear that necessitate the revision of a module or the entire guideline. The appearance of bottlenecks in practice and scientific publications are monitored conscientiously by the KNGF policy advisors, guideline experts, and scientific researchers.

In conclusion, an up-to-date physical therapy guideline for the assessment and treatment of patients with RA has been developed based on scientific evidence and expert consensus.

The cornerstones of physical therapist treatment for people with RA are active exercise therapy in combination with education, whereas passive interventions play a subordinate role. To improve the quality of care for patients with RA, adequate dissemination and implementation of the guideline—as well as timely updates, and the development of quality indicators to specify what is the minimal standard of practice to be used—are needed.

Author Contributions

Concept/idea/research design: W.F. Peter, N.M. Swart, G.A. Meerhoff, T.P.M. Vliet Vlieland

Writing: W.F. Peter, N.M. Swart, G.A. Meerhoff, T.P.M. Vliet Vlieland

Data collection: W.F. Peter, G.A. Meerhoff

Data analysis: W.F. Peter, G.A. Meerhoff, T.P.M. Vliet Vlieland

Project management: W.F. Peter, N.M. Swart, G.A. Meerhoff, T.P.M. Vliet Vlieland

Fund procurement: W.F. Peter, G.A. Meerhoff, T.P.M. Vliet Vlieland

Providing participants: W.F. Peter

Providing facilities/equipment: W.F. Peter, G.A. Meerhoff, T.P.M. Vliet Vlieland

Providing institutional liaisons: W.F. Peter, G.A. Meerhoff

Providing secretarial/clerical support: W.F. Peter

Consultation (including review of manuscript before submitting): W.F. Peter, N.M. Swart, G.A. Meerhoff, T.P.M. Vliet Vlieland

Acknowledgments

The authors acknowledge Dr Emalie Hurkmans for her role in the literature review; Prof Dr Philip van der Wees for chairing the guideline and review panel meetings; members of the guideline panel and review panel; and participants in the focus groups for their active collaboration.

Funding

This study was funded by the Dutch Society of Physical Therapy. N.A.S. and G.A.M. are employed by the funding source. The funder as an organization played no role in the study’s design, conduct, and reporting. N.A.S. and G.A.M. were involved because of their substantive expertise in the field of guideline development.

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest. P. van der Wees, who chaired the guideline and review panel meetings, is a PTJ Editorial Board member.