The Role of Physical Therapy in Management of Patients with Osteoarthritis and Rheumatoid Arthritis

Brenda Greene, PT, PhD, OCS
Division of Physical Therapy
Emory University School of Medicine
Atlanta, GA

S. Sam Lim, MD
Division of Rheumatology
Emory University School of Medicine
Atlanta, GA

Therapeutic Exercise

Therapeutic exercise is the systematic implementation of planned physical movements, postures, or activities designed to: 1) remediate or prevent impairments; 2) enhance function; and 3) enhance fitness and well-being (12). In both RA  and osteoarthritis (OA) patients, common impairments to be addressed by therapeutic exercise are decreased strength, range of motion, and cardiovascular endurance (13).

By understanding the pathophysiologic process of arthritis and the biomechanics of joint function, physical therapists develop exercise programs that not only address specific patient impairments and goals, but they also develop exercise programs that protect vulnerable joints in an attempt to prevent anticipated sequelae of the disease process. For example, if a patient with OA of the knee presents with a varus deformity and Grade I laxity of the lateral collateral knee ligament, the therapist would expect increased compression and muscle shortening on the medial side of the joint and increased tension on the lateral side of the joint. To protect the vulnerable lateral collateral ligament when strengthening exercises for the hip abductor muscles are performed, resistance will be applied above the knee rather than at the ankle. To prevent or improve shortening in muscles and tendons, stretching exercises will be emphasized for the hip adductor and hamstring muscles. In addition to appropriate exercise program planning, the physical therapist monitors the patient's response to exercise, re-assesses initial findings, and modifies the exercise program when necessary.

The therapeutic exercise program must be designed with the specific stage of the disease process in mind, the number of joints involved, and the degree of inflammation. RA is characterized by a variable course of exacerbations and remissions, and OA may present with acute intra-articular or extra-articular swelling. Conventional wisdom dictates that during an acute flare the goals of therapeutic exercise are to decrease pain and inflammation and to maintain range of motion and strength without aggravating the inflamed joints (14,15). Appropriate exercises at this stage are isometric exercises at multiple joint angles to slow the atrophy associated with rest and or active range-of-motion (ROM) exercises to prevent contractures and maintain nutrition to the cartilage. Although the described exercises represent the current standard of care, some have suggested that even in the acute stage of RA a more intensive, dynamic exercise program has greater benefit than the current standard without deleterious effects (16). 

During the subacute and chronic stages of the disease process, the goals of therapeutic exercise are to progressively increase muscle strength, range of motion, and function (14,15). Appropriate exercises at these stages are aquatic exercises, dynamic isotonic exercises, and passive range of motion. Once the joints symptoms have subsided, aerobic exercises are a necessity.

The research evidence supporting the effectiveness of aerobic and strengthening exercises in people with OA and RA is moderately strong. A systematic review of 6 randomized clinical trials using aerobic conditioning exercises, such as stationary bicycling, walking, or aquatic exercise, in people with RA was conducted by the Cochrane Group (17). The conclusions were that conditioning exercises were effective in improving aerobic capacity, muscle strength, and joint mobility. In people with knee OA, aerobic exercise has been shown in an 18-month randomized clinical trial to decrease pain and self-reported disability and improve objectively assessed functional performance (18). Strengthening exercises in people with OA have also been shown to have the same beneficial effects of decreased pain and disability and improved function (18). Improvements in joint range of motion also have been reported following conditioning exercises (19).

The evidence suggests that supervised exercises of moderate to high intensity properly performed do not exacerbate joint pain or disease progression (17,19). Some patients may be safer and more likely to initiate an exercise program if they first receive individualized exercise instruction from a health care professional. Two of the factors that have been shown to consistently influence exercise behavior are the confidence one feels for being able to exercise (self-efficacy) and the belief that exercise results in positive benefits (20,21). The physician is in a unique position to positively influence a patient's beliefs about exercise.

Physical activity is defined as "any bodily movement produced by skeletal muscles that results in energy expenditure" (22). Low levels of physical activity are associated with increased mortality rates from a variety of causes (23,24). The Centers for Disease Control and Prevention and the American College of Sports Medicine recommend every U.S. adult, including those with disabilities, should have at least 30 minutes or more of moderate-intensity physical activity on most days of the week (25). The 30 minutes can be accumulated from shorter multiple bouts of physical activity dispersed throughout the day. The level of physical activity in the population of people with arthritis is not known. Based on physical impairments common in this population, it is probable that physical activity is lower in people with arthritis than in the general population.