FEATURED ARTICLE • RHEUMATOLOGY & PHYSIOTHERAPY

Rheumatoid Arthritis: Clinical Features, Assessment and Physiotherapy Management

Introduction

Rheumatoid arthritis (RA) is a chronic systemic autoimmune inflammatory disease that primarily affects synovial joints. Persistent inflammation can cause pain, stiffness, swelling, loss of function and, when inadequately controlled, structural joint damage and deformity. RA can also involve organs and systems beyond the joints.

Physiotherapy is part of comprehensive non-pharmacological management. Current ACR guidance strongly recommends consistent exercise over no exercise and conditionally recommends aerobic, aquatic and resistance exercise. It also conditionally recommends comprehensive physical therapy, occupational therapy, hand therapy and selected orthoses/splinting when indicated.

Risk Factors

• Genetic susceptibility.
• Female sex.
• Smoking.
• Periodontal and other environmental factors.
• Obesity/metabolic factors.
• Family history of RA.
• Other immune or environmental influences.

Common Clinical Features

• Symmetrical inflammatory joint pain and swelling, commonly involving the hands, wrists and feet.
• Morning stiffness that typically lasts longer than in non-inflammatory mechanical disorders.
• Warmth and tenderness of involved joints.
• Reduced grip and hand function.
• Fatigue and reduced exercise tolerance.
• Muscle weakness and deconditioning.
• Progressive deformity in established disease.
• Functional difficulty with dressing, gripping, walking, stairs and work tasks.

Extra-Articular Manifestations

RA can affect tissues beyond the joints. Possible manifestations include rheumatoid nodules, ocular inflammation, lung disease, cardiovascular disease, vasculitis, neuropathy and osteoporosis. The presence of systemic symptoms should be communicated to the medical team.

Disease Activity and Clinical Assessment

Physiotherapy Goals

• Reduce disability and improve function.
• Maintain or improve joint mobility.
• Improve muscle strength and aerobic capacity.
• Support participation and independence.
• Manage fatigue and activity pacing.
• Protect vulnerable joints during functional tasks.
• Support adherence to an individualized exercise program.
• Identify problems requiring rheumatology/medical referral.

Exercise and Physical Activity

Exercise is a core component of non-pharmacological RA management. The 2022 ACR guideline strongly recommends consistent exercise over no exercise and conditionally recommends aerobic, aquatic, resistance and mind-body exercise. EULAR updated its physical-activity recommendations in 2026, reinforcing physical activity as an important component of management of inflammatory arthritis.

1. Aerobic Exercise

Walking, cycling, swimming, aquatic exercise or other appropriate aerobic activities can improve cardiovascular fitness and physical function. Begin at a tolerable level and progress gradually according to symptoms, fitness and disease activity.

2. Resistance Exercise

Progressive strengthening can address muscle weakness and deconditioning. Exercises may include sit-to-stand, lower-limb strengthening, resistance-band exercises and appropriately selected hand/upper-limb strengthening.

3. Aquatic Exercise

Warm-water exercise may be useful for people who find land-based exercise difficult or uncomfortable. Buoyancy can reduce joint loading while allowing active movement.

4. Flexibility and Mobility

Gentle active ROM can help maintain movement. During painful, acutely inflamed joints, loading and exercise intensity should be modified rather than forcing range.

5. Balance and Functional Training

For patients with lower-limb involvement or deconditioning, balance, gait, stair and transfer training should be integrated into functional goals.

Exercise During a Flare

The exact response depends on disease activity, joint involvement, medication, fatigue and comorbidities. Exercise planning should therefore be individualized rather than based on one fixed protocol.

Hand and Wrist Rehabilitation

Hand involvement can significantly affect independence. A hand-therapy program may include gentle ROM, functional strengthening when appropriate, tendon-gliding or dexterity activities, joint-protection education, splinting/orthoses when indicated, and adaptive strategies for daily tasks.

Joint Protection

• Use larger joints when possible for demanding tasks.
• Avoid prolonged high-load gripping when symptoms are active.
• Use two hands for heavier objects when appropriate.
• Keep frequently used objects within easy reach.
• Use adaptive equipment when it reduces unnecessary joint stress.
• Alternate demanding tasks with lighter activities.

Energy Conservation and Fatigue Management

• Plan demanding activities for times of better energy.
• Break tasks into manageable periods.
• Alternate activity and rest.
• Prioritize essential activities.
• Use efficient body mechanics and adaptive equipment.
• Maintain regular physical activity within tolerance rather than prolonged inactivity.

Cervical Spine Precautions

RA can involve the upper cervical spine, including atlantoaxial instability. This is clinically important because instability can be associated with neurological or spinal cord complications. A patient with known cervical instability, neurological symptoms, unexplained upper-neck pain, or a relevant surgical/medical history requires appropriate medical assessment and individualized precautions before cervical manual techniques or high-load activities.

Orthoses and Splinting

For hand/wrist involvement or deformity, selected splints, orthoses or compression strategies may be considered as part of comprehensive rehabilitation. ACR conditionally recommends these options in appropriate patients. They should be fitted and monitored for comfort, skin problems, function and changing joint status.

Foot and Ankle Management

Foot and ankle involvement can affect standing and gait. Assessment should include pain, swelling, ROM, alignment, footwear, balance and walking tolerance. Bracing, orthoses or taping may be considered when clinically indicated, with referral for podiatry/orthotic or medical input when needed.

Medical Management Awareness

Disease-modifying antirheumatic drugs (DMARDs), biologic therapies and targeted synthetic DMARDs are used to control inflammatory disease. Physiotherapists do not prescribe these medications, but should understand that disease activity and medication changes can alter symptoms, exercise tolerance and infection risk. Current EULAR recommendations for RA pharmacological management were updated in 2025.

Outcome Measures

• Pain and stiffness scales.
• Patient-reported functional measures such as the HAQ Disability Index when used by the care team.
• Timed functional tests where appropriate.
• Grip strength for hand involvement.
• Range-of-motion measurements.
• Aerobic capacity or walking tests when clinically appropriate.
• Disease-activity measures coordinated with the rheumatology team.

Assessment Findings

• Tenderness and reduced ROM at selected wrist joints.
• Reduced grip strength compared with functional requirements.
• Reduced aerobic conditioning.
• Fatigue after prolonged activity.
• Difficulty with demanding hand tasks.

Rehabilitation Plan

• Individualized aerobic exercise at a tolerable intensity.
• Progressive lower-limb and upper-limb strengthening.
• Gentle wrist/hand mobility exercises.
• Joint-protection education and adaptive strategies.
• Pacing and energy-conservation education.
• Functional practice related to household and work tasks.
• Regular reassessment and communication with the rheumatology team if symptoms change.

Prognosis

RA outcomes vary with disease activity, early treatment, structural damage, comorbidities, physical activity and adherence to medical and rehabilitation management. Modern treat-to-target approaches and effective disease-modifying therapies can reduce inflammation and disability, but long-term monitoring remains important.

Key Takeaways

• RA is a systemic autoimmune inflammatory disease, not simply a wear-and-tear arthritis.
• Exercise is a core part of non-pharmacological management.
• Aerobic, resistance and aquatic exercise can be incorporated according to individual needs.
• Hand therapy, splinting and joint-protection strategies may be useful for hand involvement.
• Cervical spine involvement requires particular caution because atlantoaxial instability can occur.
• Exercise should be modified according to disease activity, symptoms, fatigue and medical status.
• Close communication with rheumatology is important in patients with changing or severe symptoms.

References

• Fraenkel L, et al. 2021 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care & Research.
• ACR. 2022 American College of Rheumatology Guideline for Exercise, Rehabilitation, Diet, and Additional Integrative Interventions for Rheumatoid Arthritis. Arthritis & Rheumatology.
• EULAR. Recommendations for physical activity in people with inflammatory arthritis and osteoarthritis: 2025 update. Annals of the Rheumatic Diseases, published online 26 April 2026.
• EULAR. Recommendations for the management of rheumatoid arthritis with synthetic and biological DMARDs: 2025 update. Annals of the Rheumatic Diseases, published online 12 March 2026.