PTJ: Physical Therapy & Rehabilitation Journal | Physical Therapy, 2021;101:1–16

https://doi.org/10.1093/ptj/pzab127
Advance access publication date May 17, 2021
Clinical Practice Guidelines

Clinical Practice Guideline for Physical Therapist

Management of People With Rheumatoid Arthritis

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Wilfred F. Peter, PhD1 ,2 ∗ , Nynke M. Swart, PhD3 , Guus A. Meerhoff, MsC3 ,4 ,
Thea P.M. Vliet Vlieland, PhD1 ,5
1 Department of Orthopaedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden, the Netherlands
2 Amsterdam Rehabilitation Research Center, Amsterdam, the Netherlands
3 Royal Dutch Society of Physical Therapy, Amersfoort, the Netherlands
4 Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, Nijmegen, the Netherlands
5 University of Applied Sciences Leiden, Leiden, the Netherlands

*Address all correspondence to Dr Peter at: w.f.h.peter@lumc.nl

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.
Keywords: Guidelines, Physical Therapists, Rheumatoid Arthritis

Received: June 15, 2020. Revised: February 2, 2021. Accepted: February 14, 2021
© The Author(s) 2021. Published by Oxford University Press on behalf of the American Physical Therapy Association. All rights reserved.
For permissions, please email: journals.permissions@oup.com
2 Physical Therapy Guideline in 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 thera-
pist is, apart from other nonmedical professionals such as a
clinical nurse specialist, occupational therapist, psychologist,
and social worker, an important member of the multidisci-
plinary 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 recommenda-
tions 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 accord-
ing to the guideline methodology developed by the KNGF.6
That methodology is based on the Appraisal of Guidelines
for Research & Evaluation7 tool, the Guidelines Interna-
tional Network8 standards, and the Grading of Recommen-
dations 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 phys-
ical therapy and arthritis (T.V.V.). The task of the author group
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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).
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
Peter et al
Table 1. Clinical Questions and Recommendations from the Physical Therapy Guideline for Patients With RAa
Clinical Question Methods and Indications
Which domains of the This question was answered using the ICF Core Set for
ICF should be assessed RA, which includes the most relevant aspects for people
during the diagnostic with RA and has been validated from the physical
process? 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.
Which measurement This question was answered by describing the
instruments are measurement instruments that are recommended for the
recommended during diagnostic process. The measurement instruments are
the diagnostic phase and selected based on the steps described in KNGF’s
evaluation? 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.
What is the indication This question was answered based on a number of key
for physical therapy or articles and information from (inter)national clinical
exercise therapy? 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.
What type of education On March 3, 2017, KNGF conducted a search on studies
and advice is that describe which information and advice physical
recommended? 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.
3
Recommendations
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
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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.
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.
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.
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)
(Continued)
4 Physical Therapy Guideline in Rheumatoid Arthritis

Table 1. Continued

Clinical Question Methods and Indications Recommendations

Is exercise therapy To answer this question, a systematic review was conducted with the The recommendation for exercise
recommended? following research question: What is the (cost) effectiveness of exercise therapy for patients with RA is divided
therapy (I) compared with no exercise therapy for the treatment of into the 3 defined indications:
patients with RA (P) to improve their quality of life, physical functioning, Recommendation 2 (Indication 1)
pain, fatigue, aerobic capacity, muscle strength, ROM, and work Consider offering exercise therapy for
productivity (O)? Possible harms of exercise therapist interventions are patients with indication 1 in the

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also determined, defined as increased pain, increased disease activity, and form of instructions for exercises to
damage on radiograph. be done primarily independently.
On March 3, 2017, KNGF conducted a search on systematic reviews and Ensure that exercises are aligned
RCTs on exercise therapy in patients with RA. The search terms for with the patient’s request for help,
exercise therapy are included in Suppl. Appendix 2. Five RCTs30–34 met and adhere to the principles
the selection criteria for indication 1, and 20 RCTs34–53 met the selection regarding the frequency, intensity,
criteria for indication 2. No studies were found for indication 3. type, and duration of the exercise
Conclusion from the literature study therapy. (Conditional
Indication 1 recommendation for the
The literature shows a moderate to large effect of exercise therapy with intervention, low level of evidence)
limited supervision on the (crucial) outcome measures—quality of life, Recommendation 3 (Indication 2)
physical functioning, and pain—compared with no exercise therapy Offer patients with indication 2
with limited supervision. The quality of evidence varies from very low exercise therapy that is aligned with
to low. The literature also shows a small effect of exercise therapy their need for assistance, and adhere
with limited supervision on the outcome measure of muscle strength to the principles regarding the
compared with no exercise therapy with limited supervision, with the frequency, intensity, type, and
quality of evidence being moderate. The effectiveness of exercise duration of the exercise therapy.
therapy with limited supervision on fatigue, ROM, and work (Strong recommendation for the
productivity is unknown. There were no undesirable effects of intervention, low-to-moderate level
exercise therapy for indication 1. of evidence)
Indication 2 Recommendation 4 (Indication 3)
The literature shows that the effect of supervised exercise therapy on the Consider offering exercise therapy for
(crucial) outcome measures of quality of life, physical functioning, patients with indication 3. Ensure
and pain are large, moderate, and small, respectively, compared with that the exercise therapy is aligned
no treatment. The quality of evidence for these outcomes is low, with the patient’s need for assistance,
moderate, and very low, respectively. The literature also shows a large and adhere to the principles
effect of supervised exercise therapy on muscle strength and ROM regarding the frequency, intensity,
and a moderate effect on aerobic capacity, compared with no type, and duration of the exercise
supervised exercise therapy; however, the quality of evidence is low to therapy. (Conditional
moderate. The effect of supervised exercise therapy on fatigue and recommendation for the
work productivity is unknown. There were no undesirable effects of intervention, no level of evidence)
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.

(Continued)
Peter et al 5

Table 1. Continued

Clinical Question Methods and Indications Recommendations

Are the following non-exercise
therapeutic interventions
recommended?
• Electrostimulation (including
TENS)
• Low-level laser therapy
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
Recommendation 5
Consider not offering the following
interventions to patients with RA
(Conditional recommendation against
interventions, lack of evidence):
• LLLT

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(LLLT) improve their quality of life, physical functioning, pain, • Electrostimulation (including TENS)
• Ultrasound fatigue, aerobic capacity, muscle strength, ROM, disease • Ultrasound
• Massage activity, damage on radiograph, and work productivity • Massage
• Thermotherapy (O)? Possible harms of exercise therapy interventions are • Thermotherapy
• Medical taping also determined, defined as increased pain, increased • Medical taping
• Dry needling disease activity, and damage on radiograph. • Dry needling
On March 3, 2017, KNGF conducted a search on
systematic reviews and RCTs on exercise therapy in Passive mobilization of joints and muscles should
patients with RA. (The search terms for exercise therapy preferably not be offered to patients with RA.
are included in Suppl. Appendix 2). After screening of the Consider short-term passive mobilization of
title and abstract, 1 article for electrostimulation,59 1 an affected joint to support exercise therapy
article for TENS,60 6 articles for LLLT,61–66 and 1 article only to patients without active inflammation
for ultrasound67 were included. Based on the selection to increase joint mobility. (Conditional
criteria, no articles could be included that investigated the recommendation—neither in favor nor against
effectiveness of massage, thermotherapy, medical taping, the intervention, lack of evidence) Passive
or dry needling. The size of the effect in the included mobilizations are contraindicated for cervical
studies about LLLT, electrostimulation (including TENS), problems. (Strong recommendation against
and ultrasound was often unknown, because the effect intervention, lack of evidence)
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.
a
6MWT = 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.

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 inter-
ventions based on systematic literature reviews were com-
bined 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
6 Physical Therapy Guideline in Rheumatoid Arthritis
Table 2. Formulation of Recommendations Based on Literature Review Combined With Expert Opinion (Based on GRADE9 )a
Type of Recommendation
Strong recommendation against the intervention
Conditional recommendation against the intervention
Conditional recommendation for the intervention
Strong recommendation for the intervention
a
Recommendations 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.
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 out-
weigh 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 desir-
able effects probably outweigh the undesirable effects (con-
ditional 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.
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 com-
ments, 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 guide-
line, 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/reu
matoide-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 summa-
rized 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
Formulation
Do not offer the intervention
Consider not offering the intervention
Consider offering the intervention
Offer the intervention
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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 cate-
gories: 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 inven-
tory 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.
Yellow and Red Flags
An inventory of yellow and red flags is part of the his-
tory 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 complica-
tions, such as signs of myeloma compression, are red flags
necessitating immediate referral (Suppl. Appendix 4).
Peter et al 7

Table 3. Relevant Questions for History Taking in Patients With RAa

History-Taking
Relevant Questions
Items
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 Is there pain in 1 or more joints? (NPRS)
anatomical What is the location of the pain (which joints)? Is the pain related to exertion?

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characteristics 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?

(Continued)
8 Physical Therapy Guideline in Rheumatoid Arthritis

Table 3. Continued

History-Taking
Relevant Questions
Items
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?

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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?
a
Table 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.

Best Practice Recommendation 2: evidence-based pharmacological and non-pharmacological

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 exer-
cise tolerance, and muscle function during physical examina-
tion, 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.
Best Practice Recommendation 3:
Measurement Instruments
The physical therapist should use the following measurement
instruments for supporting the diagnostic process and eval-
uating 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, valid-
ity, and feasibility were conditional for this selection. When
assessing the various aspects of physical functioning, pref-
erence is given to a combined application of a self-reported
questionnaire and a performance-based test.
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 exer-
cise 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 educa-
tion, 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.

Indications and Contraindications for Treatment Treatment Recommendations

In the international literature, 2 practice recommendations Systematic reviews related to the research questions on exer-
emphasize the importance of access to physical therapy for cise therapy and non-exercise therapeutic interventions were
patients with RA: (1) “People with RA should have access to conducted to formulate recommendations. Narrative reviews
Peter et al 9

Table 4. Relevant Points of Attention During the Physical Examination of Patients With RAa

Examination Area Examination Component Points of Attention

Functions and Inspection Where is the pain reported (which joints)? During which movement(s) does the pain occur in
anatomical the respective joints?
characteristics 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).

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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.
a
6MWT = Six-Minute Walk Test; RA = rheumatoid arthritis.

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 opti-
mize their health and well-being. The therapist provides infor-
mation and advice about the disorder and the possible con-
sequences 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 treat-
ment options (conditional recommendation for the interven-
tion, 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 appro-
priately dosed exercises and/or physical activities on
muscle strength, aerobic capacity, daily functioning,
disease activity, and mental functioning
10
Table 5. Patient Profiles for Physical Therapy in Patients With RAa
Patient
Description
Profile
1 Need for information, advice, and instructions
for mainly independently performed exercises
2 Need for information, advice, instruction, and
exercise therapy with brief physical therapy
guidance
3 Need for information, advice, instruction, and
exercise therapy with intensive and/or
long-term supervision of a physical therapist
a
RA = rheumatoid arthritis.
• Preventive effects of a sufficient amount of physical activ-
ity22–24 and limitation of sedentary behavior that apply to
the whole population are particularly important for peo-
ple 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 change26–31 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 activity22,23 and a physical activity
guideline on arthritis.24
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
Physical Therapy Guideline in Rheumatoid Arthritis
Criteria
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;
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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.
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.
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.
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 deter-
mined 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 Pro-
file 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 activ-
ity regarding the frequency, intensity, type, and duration (con-
ditional recommendation for the intervention, low level of
evidence).
Peter et al 11

Table 6. FITT Factors for Exercise Therapy in Patient With RAa

Factors for Exercise Therapy Patient Goals

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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.

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12 Physical Therapy Guideline in Rheumatoid Arthritis

Table 6. FITT Factors for Exercise Therapy in Patient With RAa

Factors for Exercise Therapy Patient Goals

Training principles for Precede the workout with a warm-up and finish with a cooling-down.
people with RA 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.

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

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 recom-
mendation is based on a moderate effect of unsupervised exer-
cise therapy on quality of life (2 RCTs; standardized mean dif-
ference [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 evi-
dence), 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 tai-
lored 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 interven-
tion, 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 evi-
dence), 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 recommenda-
tions for health-enhancing physical activity, with adjustments
regarding the frequency, intensity, type, and duration (condi-
tional 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 per-
formed on patients with relatively stable disease and/or little
or no comorbidities, radiological damage, and/ or joint arthro-
plasties. 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,
Peter et al
(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, mas-
sage, 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 mobil-
ity (conditional recommendation, neither in favor nor against
the intervention; lack of evidence).
Do not offer passive mobilizations in case of cervical prob-
lems; this intervention is contra-indicated (strong recommen-
dation 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 pro-
cess of clinical reasoning, including initial assessment, treat-
ment, and evaluation, to give the patient the best evidence-
based treatment available.
To the best of our knowledge, comprehensive recommenda-
tions for physical therapy regarding initial assessment, treat-
ment, 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, recom-
mendations for treatment of patients with RA are described
in various European League Against Rheumatism recommen-
dations,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
13
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 guide-
line includes the involvement of many stakeholders (see Suppl.
Appendix 1). Moreover, the clinical questions were formu-
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lated 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 phys-
ical 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 rec-
ommendations by the use of evidence-to-decision forms. Cur-
rently, 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 sys-
tematic 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 demon-
strated that exercise and physical activity meeting public
health recommendations for health-enhancing physical activ-
ity 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 individ-
ual patient’s co-morbidities.60 The general rule of “unskilled is
unauthorized” applies here. If the treating therapist has insuf-
ficient knowledge and skills regarding the patient’s comorbid-
ity, 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
14
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 indi-
cators will be derived from the updated guideline. Qual-
ity indicators are tools that specify the minimum accept-
able 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 consci-
entiously 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 edu-
cation, 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
Physical Therapy Guideline in Rheumatoid Arthritis
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):
Downloaded from https://academic.oup.com/ptj/article/101/8/pzab127/6277051 by Colegio Mayor Universidad del Rosario user on 25 April 2022
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 orga-
nization 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.
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