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Rheumatoid Arthritis and Physical Therapy



  • Osteoarthritis and rheumatoid arthritis - Normal joint Osteoarthr -- Smart-Servier.jpg
    Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by inflammatory arthritis and extra-articular involvement. RA with symptom duration of fewer than six months is defined as early, and when the symptoms have been present for more than months, it is defined as established.
  • There is no laboratory test that is pathognomonic for rheumatoid arthritis. The treatment of patients with rheumatoid arthritis requires both pharmacological and non-pharmacological agents. Today, the standard of care is early treatment with disease-modifying anti-rheumatic drugs[1]
  • RA is a highly disabling disease associated with high morbidity. RA results in considerable direct costs eg health care expenses, and indirect costs, eg. loss of productivity due to morbidity and decreased life expectancy.[2] The increased mortality mainly associated with cardiovascular disease and accelerated atherosclerosis. Atherosclerotic disease is driven by inflammatory mechanisms similar to those in RA. Cardiovascular morbidity correlates with inflammatory activity in RA.

Clinically Relevant Anatomy

Diagram showing how Rheumatoid Arthritis affects a joint in the hand
  • The dense connective-tissue membrane that secretes synovial fluid
  • Lines the ligamentous surfaces of joint capsules, tendon sheaths where free movement is necessary, and bursae.
  • Normally the synovium consists of 2 – 3 layers of cells.
  • In patients with rheumatoid arthritis, the synovium is strongly thickened and inflamed.
  • The cause of this inflammation in rheumatoid arthritis is unknown.[3]

The synovium in rheumatoid arthritis is infiltrated by immune cells which include innate immune cells (monocytes, dendritic cells, mast cells) and adaptive immune cells, B cells, and plasma cells. Cytokines and chemokines stimulate factors that activate endothelial cells and attract immune cells within the synovial compartment. Fibroblast and inflammatory cells lead to osteoclast generation resulting in bone erosion the hallmark feature of rheumatoid arthritis, and loss of joint integrity what frequently leads to disability. [4] [1]

During the early phase of the disease, there is an influx of inflammatory cells into the synovial membrane. As the disease progresses, there is a proliferation of monocytes and thickening of the synovial membrane with small villous projections into the joint space.[1]


RA is found all around the world but does tend to be more prevalent in the Native American and white population.


  • 29 cases/100,000 in northern Europe,
  • 38/100,000 in North America
  • 16.5/100,000 in southern Europe. [1]


  • In North America and northern Europe, RA affects 0.4% to 1% of the population
  • In southern Europe, it affects 0.3% to 0.7% of the population.
  • Female to male ratio is 2-3:1
  • Increases with age. RA most commonly begins in: women between the ages of 30 and 60; later in life for men; in the pediatric population usually begins before the age of 16, known as Juvenile Idiopathic Arthritis (JIA)[5][6]


The cause of Rheumatoid Arthritis remains unknown and can therefore not be prevented. Simple disorganization of the immune system can be at the origin of the body attacking its own tissue. The evolution of the disease varies from person to person; sometimes the inflammation can become systemic, which means that it will expand and also affect multiple organs, systems, or tissues. [3]

Systemic inflammation and autoimmunity in RA begin long before the onset of detectable joint inflammation[7].

  • Emerging data suggest that RA-related autoimmunity may be initiated at a mucosal site years before the onset of joint symptoms.
  • The candidate sites of origin include the oral, lung, and gastrointestinal mucosa, as data consistent with this hypothesis have been generated for each location. eg Changes in the composition and function of the intestinal microbiome have been related to rheumatoid arthritis. The composition of the gut microbiome is altered in patients with rheumatoid arthritis (dysbiosis), rheumatoid arthritis patients have decreased gut microbiome diversity when compared with healthy individuals. Studies have linked inflammation in the oral cavity and specifically periodontitis to the preclinical period of RA.[8].
  • Individual patients may undergo initiation events at unique sites but still converge on similar joint findings as the disease process evolves.
  • RA is typically divided into two subtypes designated “seropositive” and “seronegative” disease, with seropositivity being defined as the presence of serum elevations of the autoantibodies rheumatoid factor (RF) and the more recently described antibodies to citrullinated protein/peptide antigens (ACPAs).
  • Multiple genetic and environmental factors[8] have been associated with an increased risk for rheumatoid arthritis (RA).
  • Cigarette smoking is the strongest environmental risk factor associated with rheumatoid arthritis.[1]

Genetic and Familial Risk Factors for RA

There is a generally increased prevalence of RA within families resulting from the interaction between patients’ genotype and environment.

  • Twin studies have shown a concordance rate of 15% to 30% among monozygotic twins and 5% among dizygotic twins. The heritability of rheumatoid arthritis is approximately 40% to 65% for seropositive rheumatoid arthritis and 20% for seronegative rheumatoid arthritis[1].
  • Genetic factors in RA are suggested by an increased prevalence of disease within certain racial groups such as North American natives, who exhibit prevalence rates of RA of 5–7%[8]. Although there may be non-genetic familial or cohort factors that play a role in the family or racial/ethnic group risk, multiple specific genetic loci have been identified that are associated with increased risk for RA and in some cases decreased risk.
  • The strongest of the genetic risk factors are a set of alleles within the major histocompatibility complex (MHC) that encode amino acid sequences that predict structural similarities in the human leukocyte antigen (HLA) peptide-binding groove and are termed in the aggregate “shared epitope,”(SE). SE alleles are believed to contribute up to ∼40% of the genetic risk for RA, although other studies suggest less contribution[8].

Environmental Factors

Multiple environmental, dietary, and lifestyle factors have been associated with RA[8]

  • Increases risk Female sex; exposure to tobacco; occupational dust (silica); air pollution; high sodium red and iron consumption; obesity; low vitamin D intake and levels.
  • Deceased risk: fish and omega 3 fatty acid consumption; moderate alcohol intake; healthy diet; oral contraceptive/HRT; statin use.

Mucosal Processes Influencing RA Development

The initial inflammation and autoimmunity in RA begin outside of the joints[7]. RA-related autoimmunity may originate at a mucosal site. The general model[8] underlying a hypothesis that mucosal surfaces (and potentially microbes) play a role in the pathogenesis of RA is as follows.

  • At some point in preclinical RA, at a mucosal surface (e.g., the oral cavity, lung, gut) interactions between microbes potentially other environmental factors (e.g., tobacco smoke), and host factors lead to mucosal inflammation and initial breaks in RA-related immune tolerance.
  • This mucosal inflammation then facilitates local, and then systemic, propagation of autoimmunity through mechanisms that include molecular mimicry or facilitation of the development of direct autoimmunity to self-antigens.

Gender and Rheumatoid Arthritis

Female-specific factors influence risk for RA. (many controversies still exist[9]).

  • The post-menopause stage, early age at menopause, the post-partum period, and the use of anti-estrogen agents are associated with RA onset.
  • All these phenomena have in common an acute decline in ovarian function and/or in estrogen bioavailability. 
  • There are controversies regarding other female hormonal factors.
  • The influence of systemic hormonal treatments, including contraceptive and HRT, on RA onset, remains unclear.
  • The effect of other factors related to diverse hormonal changes (such as parity, breastfeeding, or PCO) is also controversial.
  • The timing of estrogen exposure plays a role in RA onset, female hormonal factors having varying effects during premenopause and post-menopause.
  • The effect of sex hormones on the immune system and their interaction with environmental and genetic factors could explain the higher prevalence of RA in women.
  • Some female hormonal factors are potentially modifiable, understanding their precise role is key for future preventive interventions focusing on women at high risk[8].

Characteristics/Clinical Presentation

In rheumatoid arthritis, joint complaints are in the foreground. The most common clinical presentation of RA is

  • Polyarthritis of small joints of hands: proximal interphalangeal (PIP), metacarpophalangeal (MCP) joints, and wrist. Some patients may present with monoarticular joint involvement.
    RA Hand 1.png
  • Commonly joint involvement occurs insidiously over a period of months, however, in some cases, joint involvement may occur over weeks or overnight. 
  • Other commonly affected joints include wrist, elbows, shoulders, hips, knees, ankles, and metatarsophalangeal (MTP) joints.
  • Stiffness in the joints in the morning may last up to several hours, usually greater than an hour. The patient may have a “trigger finger” due to flexor tenosynovitis.

On examination,

  • May be swelling, stiffness, deformity, and tenderness of the PIP, MCP wrist, knee joints, referred to as synovitis, and there may be a decreased range of motion.
  • Deformity, pain, weakness, and restricted mobility resulting in loss of function.[10]
  • Rheumatoid nodules may be present in 20% of patients with rheumatoid arthritis; these occur over extensor surfaces at elbows, heels, and toes.
  • Late in the course of the disease patient may present with “boutonniere (flexion at PIP and extension at DIP), swan neck (flexion at DIP and extension at PIP) deformities, subluxation of MCP joints and ulnar deviation.
  • Other features may include the presence of carpal tunnel syndrome, tenosynovitis, and finger deformities.
  • Examine the joints on swelling, pain due to palpation, pain due to movement, decreased range of motion, deformation, and instability. 
  • Hallmark symptoms such as symmetrical joint swelling and tenderness, morning stiffness, positive rheumatoid factor (RF), elevated acute phase reactants, and radiographic evidence of erosive bone loss.
  • Significant predictors of functional decline among persons with RA are slow gait and a weak grip. [3][11]

Rheumatoid arthritis can affect almost every organ in the body

  • The three most important complaints are pain, morning stiffness, and fatigue.
  • Muscular strength, muscular endurance, and aerobic endurance are typically reduced in patients with rheumatoid arthritis in comparison with healthy patients.
  • In 80-90% of the patients with rheumatoid arthritis, the cervical spine is involved, which can lead to instability, caused by the ligamentous laxity (between the first and second cervical vertebrae most commonly) This instability can lead to pain and neurological symptoms, eg headache and tingling in the fingers. [3]
  • Individuals with RA are 8 times more likely to have a functional disability compared with adults in the general population from the same community.

Signs and Symptoms of RA

  • Joint Pain: warmth, redness, tenderness, swelling
  • Joint Stiffness: increased in the mornings
  • Fatigue throughout the body
  • Fever
  • Weight Loss
  • Rheumatoid Nodules: small lumps of tissue felt under the skin
  • Symmetrical Patterns of affected joints
  • Most common joints: wrist, hand, fingers, cervical spine, shoulder, elbow, knee, hip, foot, and ankle
  • Prolong symptoms
  • Anemia
  • Neck Pain
  • Dry Eyes
  • Dry Mouth


RA stages.png
Disease progression:

Stage 1: No destructive changes on x-rays

Stage 2: Presence of x-ray evidence of periarticular osteoporosis, subchondral bone destruction but no joint deformity

Stage 3: X-ray evidence of cartilage and bone destruction in addition to joint deformity and periarticular osteoporosis.

Stage 4: Presence of bony or fibrous ankylosis along with stage 3 features.[1]

Differential Diagnosis


RA has many effects on individuals including mortality, hospitalization, work disability, increase in medical cost/expenses, decreases in quality of life, and chronic pain. On average, the chronic RA patient has two or more comorbid conditions.[12] This is significant because of the comorbidities effects on quality of life, functional status, prognosis, and outcome. Associated Complications include:[13]

  • Infections
  • Chronic anemia
  • Gastrointestinal cancers
  • Pleural effusions
  • Osteoporosis
  • Heart disease
  • Sicca syndrome
  • Felty syndrome
  • Lymphoma[1]
  • Damage to the lung tissue (rheumatoid lung)
  • Side effects from treatment and medication. 
  • General deconditioning
  • Neurological complications
  • Ocular complications

Diagnostic Procedures

  1. Lab evaluation of patients with rheumatoid arthritis consists of obtaining
  • Rheumatoid factor (antibody against the Fc portion of IgG). About 45% to 75% of patients with RA test positive for rheumatoid factor. However, the presence of the rheumatoid factor is not diagnostic of rheumatoid arthritis. It may be present in connective tissue disease, chronic infections, and healthy individuals, mostly in low titers.
  • Anti-citrullinated protein antibodies (ACPA) are found in about 50% of patients with early arthritis, which subsequently are diagnosed with RA.
  • Acute-phase reactants, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) may be elevated in the active phase of arthritis.

2. X-ray of both hands and feet are usually obtained for the presence of erosions, the pathognomonic feature of rheumatoid arthritis (plain radiograph does not show early changes of the disease).

3. Magnetic resonance imaging (MRI) and ultrasound of joints detect erosions earlier than an x-ray. MRI and US are more sensitive than clinical examination in identifying synovitis and joint effusion.[1]


Rheumatoid arthritis has no cure and is a progressive disease. All individuals have multiple exacerbations and remissions. Close to 50% of patients with the disease become disabled within 10 years. Besides the joint disease, the individuals can suffer from many extra joint-related problems which significantly alters the quality of life. The progression of disease does vary from individual to individual. The following factors determine a worse prognosis:

  • Elevated serum titer of autoantibodies
  • Presence of HLA-DRB1*04 genotype
  • Involvement of many joints
  • Extra-articular features
  • Female gender
  • Age of less than 30
  • Insidious onset
  • Presence of systemic symptoms

Rheumatoid arthritis is also associated with cardiovascular risk factors, infection, respiratory disease, and the development of malignancies. Patients with rheumatoid arthritis have 2-3 times higher risk of death compared to the general population.[1]

Medical Management

A strategic approach is followed when managing rheumatoid arthritis, disease activity is assessed at regular intervals, and treatment is changed as per the disease activity.

  1. Disease-modifying, anti-rheumatic drugs (DMARDs) are initiated as soon as the diagnosis of rheumatoid arthritis is made.
  • Traditional or conventional DMARD include methotrexate, leflunomide, sulfasalazine, hydroxychloroquine.
  • Biological DMARDs (BDMARDs) (drug treatment). For optimal outcome in RA is early clinical remission to delay joint damage. Severe RA patients with inadequate response to conventional disease-modifying anti-rheumatic drugs (cDMARDs) need high-potency drugs as BDMARDs [14] BMARDs include TNF (tumor necrosis factor): Adalimumab, Etanercept, Infliximab, Golilumab, Certolizumab. And non-TNF inhibitors: Tocilizumab (Interleukin-6 inhibitor), Abatacept (inhibits T-cell costimulation), Rituximab (anti-B cell)

2. HMG-CoA reductase inhibitors (also known as statins) are widely used as lipid-lowering agents in patients with rheumatoid arthritis (RA) to reduce their cardiovascular risk. The Statin therapy also

  • significantly reduced tender joint counts, swollen joint counts, erythrocyte sedimentation rate (ESR), compared with placebo groups.[15]
  • influences immune regulation, potentially facilitating autoimmunity, eventually resulting in autoimmune diseases such as rheumatoid arthritis (RA)[16].

3. Radiosynovectomy, an intra-articular injection of small radioactive particles to treat synovitis.

  • The treatment can be repeated 3-time in an interval of 3 months if the first treatment showed an insufficient effect.
  • Repeated treatments are more effective than single treatments with higher activity.
  • The therapy is well-tolerated with a low rate of side effects.

4. Surgical treatment aimed at the inflammatory focus elimination and reduction of pain syndrome severity, function loss, and joint deformity. The most used operative interventions are tenonectomy, synovectomy, arthrodesis, total endoprosthesis.[17]

Nutritional Guidelines

Dietary interventions demonstrate substantial benefits in reducing disease symptoms such as pain, joint stiffness, swelling, tenderness, and associated disability with disease progression. There is still uncertainty about the therapeutic benefits of dietary manipulations for RA[18]. Dietary modification helps in staying in the remission phase of the inflammatory condition.

  • Eating certain foods can help you manage their symptoms.
  • Avoiding food which causes inflammation like processed food, high salt, oils, butter, sugar, and animal products.
  • Supplements: Research suggests that there are vitamins and minerals which may have an effect on RA[18]eg. vitamin D, cod liver oil, and multivitamins. These may help eg reduce joint inflammation, improve bone health. It is recommended to consult your primary care physician.

Physical Therapy Management

Rheumatoid arthritis is a chronic disorder that has no cure. All the currently available treatments are geared towards improving the symptoms and offering a better quality of life.[1] Treatments that achieve pain relief and the slowdown of the activity of RA to prevent disability and increase functional capacity.[19]

Hydrotherapy Pool Exercises.jpg

The benefits of physical therapy interventions have been well documented. 

  • Physical therapists play an integral role in the nonpharmacologic management of RA.
  • Physiotherapy help clients cope with chronic pain and disability through the design of programs that address flexibility, endurance, aerobic condition, a range of motion (ROM), strength, bone integrity, coordination, balance, and risk of falls. 
  • All current UK clinical guidelines for the management of RA recommend the use of physiotherapy (PT) and occupational therapy (OT) as an adjunct to drug treatment.
Resting wrist hand brace.jpeg

The four most common components of PT/OT for RA hands are

  1. Exercise therapy,
  2. Joint protection advice and provision of functional splinting and assistive devices
  3. Massage therapy, and
  4. Patient education. 

The therapy goals in most cases are: [20] 

  • Improvement in disease management knowledge
  • Pain control
  • Improvement in activities of daily living
  • Improvement in Joint stiffness (~ Range of motion)
  • Prevent or control joint damage
  • Improve strength
  • Improve fatigue levels
  • Improve the quality of life 
  • Improve aerobic condition
  • Improve stability and coordination

Patient questionnaires, not joint counts, radiographic scores, or laboratory tests, provide the most significant predictors of severe 5-year outcomes in patients with RA, including functional status, work disability, costs, joint replacement surgery, and premature death. 

Treatment techniques

Cold/Hot Applications: cold for acute phase; heat for chronic phase and used before exercise. [21]

Transcutaneous electrical nerve stimulation (TENS) is used to relieve pain. [22]

Hydrotherapy-Balneotherapy: exercise with minimal load on the joints.[23]

Joint Protection

  • Rest & Splinting: Orthosis and splinting prevent the development of deformities and support joints
  • Therapy Gloves: to control and manage hand pain, to maintain or restore the patient’s hand function and increase grip strength. Psychologically help to relax or calm the wearer. worn during the day or at night. Made of various materials: nylon, wool, and elastane fibers. [24]
  • Compression Gloves: moderate joint swelling and consequently reduce the pain
  • Assistive and adaptive devices eg easy pour kettle, ergonomic good grip preparation knives, sock donner,

Massage Therapy: Massage and the manual trigger of an articular movement focused on the improvement of function, pain reduction, reduction of disease activity improve flexibility and welfare (dimension of depression, anxiety, mood, and pain) [25]

Therapeutic Exercise

  • Physical exercise helps to increase the physical capacity of the patient [19].
  • Exercise improves general muscular endurance and strength without detrimental effects on disease activity or pain in RA
  • Before beginning an exercise program performs a global evaluation of the situation: joint-inflammation local or systemic, state of the disease, age of the patient, and grade of collaboration.[19]
  • Exercise therapy is aimed at improving daily functioning and social participation by means of improvement of the strength, aerobic condition, the range of motion, stabilization, and coordination.

Programs for Patients with RA

  • Includes; ROM-exercises; aerobic exercise: stabilization/coordination exercises.
  • Start with a moderate-intensive exercise program [26][27]
  • Progress to a high-intensive exercise program if possible aimed at improving aerobic capacity, strength, and endurance.
  • The duration and intensity of the exercises should be based on the individual patient and their assessment[19].


  • When the patient experiences an exacerbation and the joints are acutely inflamed then isometric exercises should be done
  • Avoid stretching in acute cases.
  • Revise the exercise program if pain persists 2 hours after the activity or there is an increase in joint swelling
  • Patients with active RA in their knees should avoid climbing stairs or weight lifting as it could lead to intra-articular pressure in the knee joint
  • Avoid excessive stress over the tendons with stretches and avoid ballistic movements

Exercises examples

  1. In acute phase: isometric/static exercises -> be held for 6 seconds and repeated 5–10 times each day ; load = 40% 1RM. Chronic phase -> minimum 4 repetitions for each joint in 2 to 3 days These exercises increase the mobility of the joint, but the concerned joint will not be loaded during these exercises.[28] Contractures can be held for 6seconds and repeated 5-10 times daily[19].
  2. Stretching: Avoid in acute cases.
  3. Strengthening: Moderate-intensive exercise therapy where a minimum of 8-10 exercises is necessary for the major muscle groups. Each exercise has to be repeated 8-10 times and a minimal start intensity of 30-50 percent of 1 repetition maximum (RM). [27] [28] Use light weights important for stabilization of the joint and prevention of traumatic injuries.
  4. Aerobic condition exercises: There are two types of exercises to improve the aerobic condition: Intensive exercises and moderate-intensive exercises. The intensive exercise therapy has a minimum duration of 20 minutes per session and this 3 times a week with an intensity of 65 to 90 percent of the maximal heart rate. The moderate-intensive exercise therapy has a minimum duration of 30 minutes per session and this 5 times a week with an intensity of 55 to 64 percent of the maximal heart rate. The aim of this exercise is to improve muscle endurance and aerobic capacity. eg: swimming, walking, cycling
  5. Stabilizing and coordinating exercises: The improvement of stabilization and coordination of a certain joint will be achieved by doing exercises that stimulate the sensorimotor system. For example, standing on a balance board. Important aspects of this exercise are motion control, balance, and coordination.
  6. Conditioning exercises in people with chronic inactive RA: swimming walking, cycling (include adequate rest periods)[19].
  7. Routine daily activities: SARAH (Strengthening and stretching for rheumatoid arthritis of the hand) exercise program see below table: The SARAH trial tests an intervention against the usual hand care. The main aim of the exercise program is increased hand function, which is suggested to be mediated by increases in strength, dexterity, and range-of-movement. The exercise program consists of the usual care plus a hand and wrist exercise program which includes seven mobility exercises and four strength exercises against resistance (i.e. therapy putty, theraband, or hand exerciser balls).[10]
  • Use a modified Borg scale to set the load (resistance) for the strength exercises based on self-perception of effort.
  • The level of resistance is determined by the patients’ rating of perceived effort using the weaker hand for each strength exercise.
  • Exercise therapy in patients with RA is used to improve the daily functioning and social participation through improving muscle strength, aerobic endurance, joint mobility, and stability, and/or coordination.
  • Preference is given to an active policy, especially where the physiotherapist has a supporting role.
  • In individual cases, passive treatments, such as manual operations, can be part of the treatment.

5. Patient Education: information about their condition and the different therapies disposed to improve their quality of life. eg Patients are taught how to protect the joints during routine daily life; adjusting their movement-behavior; behavioral change by your patient (a process with 3 phases: the motivation-phase, the initial-behavioral change phase, and the phase where the intended behavior is continued).

• Formulate achievable goals with the patient.

• Give proper instructions and be sure that the patient understands.

• Enough variation in the exercises is important to prevent boredom.

• The therapist has to involve the partner and other important people in the process because they have an important motivation-role. Also, the therapist himself has to motivate the patient.
• Keep in touch with the patient to be sure that the treatment was effective. [29]

Management of flare-ups

People who are diagnosed with RA also may experience a phenomenon that is called a “flare-up”. Usually happen after eg experiencing a secondary illness, being involved in a high-stress situation, overexerting oneself, What triggers flare-ups is currently still unknown. Strategies that can help someone who is experiencing a flare-up

  • Balance is key, schedule plenty of downtime to reduce the likelihood of affected joints from becoming flared up
  • Educate family, the staff at work, and other people who you interact with, they can help you during flare-ups
  • Have a backup plan, be prepared in case of a flare-up, and become familiar with warning signs of a flare-up
  • Practice relaxation and self-calming strategies: Research suggests that regularly practicing these relaxation techniques can reduce stress and lead to a reduction in pain.
  • Use modalities such as a cold pack or hot pack: Both of these have various effects on tissues which research suggests can be beneficial in reducing inflammation and pain during a flare-up
  • Lastly, corticosteroid injections can be used to reduce inflammation and reduce pain in a flared up joint

Outcome Measures

  • Simplified disease activity (SDAI) index: tender joint count, swollen joint count, patient global assessment, physician global assessment, and c reactive protein in mg/dl
  • Clinical disease activity index (CDAI): tender joint count, swollen joint count, patient global assessment, physician global assessment
  • DAS28-ESR (disease activity score): tender joint count, swollen joint count, patient global assessment, and erythrocyte sedimentation rate in mm
  • DAS-Crp (disease activity score): tender joint count, swollen joint count, patient global assessment, and c reactive protein in mg/dl.[1]
  • Rheumatoid Arthritis Disease Activity Index (RADAI-5): A self-reported outcome measure that consists of 5 questions in a Likert scale format that briefly surveys the patient regarding their views of their condition (both over the past 6 months and current status).
  • Disabilities of the Arm, Shoulder, and Hand (DASH): The DASH is a patient-reported outcome measure that evaluates the function of the upper extremities, and can be used to examine change over time.
  • Short Form-36 (SF36): A patient-reported outcome measure that is designed to evaluate the quality of life through measures such as physical functioning, role limitations due to physical or emotional problems, and general mental health.
  • Fatigue Severity Scale: A 9-item questionnaire that rates the patient’s fatigue and how it interferes with activities such as work or social life.


Classification of Functional Status

The American College of Rheumatology classified functional status in Rheumatoid Arthritis as:

  • Class I: Completely able to perform usual activities of daily living (self-care, vocational, and avocational)
  • Class II: Able to perform usual self-care and vocational activities, but limited in avocational activities
  • Class III: Able to perform usual self-care activities, but limited in vocational and avocational activities
  • Class IV: Limited ability to perform usual self-care, vocational, and avocational activities


  1. Rheumatoid Arthritis: Help to understand Rheumatoid Arthritis
  2. Rheumatoid Arthritis: Frequently asked Questions
  3. Rheumatology Check List Visit
  4. The RA Symptom Tracker Sheet
  5. The Arthritis Organization
  6. American College of Rheumatology Patient Education
  7. Self-help (Aids for Arthritis)
  8. RA Treatments
  9. American College of Rheumatology

Clinical Bottom Line

The outcome of most patients with Rheumatoid arthritis is guarded.

  • The disorder has frequent relapses and remissions, and at least 40% of patients will become disabled within ten years.
  • Some patients have mild disease, others may have a severe disease that severely affects the quality of life.
  • Worse outcomes are usually seen in patients with a high titer of autoantibodies, HLA-DRB1 genotypes, age younger than 30, multiple joint involvement, female gender, and extra-articular involvement.
  • The drugs used to treat rheumatoid arthritis also have potent side effects which often are not well tolerated. As the disease progresses, many patients will develop adverse cardiac events leading to death.
  • The overall mortality in patients with rheumatoid arthritis is three times higher than in the general population.
  • Despite advances in care, mortality from infection, cancer, and ongoing vasculitis remains unchanged[1]

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