By Auckland Physiotherapy | Evidence-Based RA Management
Rheumatoid arthritis (RA) is more than just joint pain—it's a complex autoimmune condition that can significantly impact your quality of life, daily activities, and overall health. If you've recently been diagnosed with RA, or have been living with it for years, you're likely navigating a maze of treatment options, from medications and injections to physiotherapy and lifestyle changes.
At Auckland Physiotherapy, we work alongside rheumatologists and other healthcare providers to deliver comprehensive, evidence-based care for people with rheumatoid arthritis. While we can't cure RA, modern treatment approaches have transformed what's possible. Many people with RA now live active, fulfilling lives with well-controlled symptoms. Understanding your treatment options and how they work together is the first step toward optimal management.
Rheumatoid arthritis is an autoimmune condition where your immune system mistakenly attacks the lining of your joints (the synovium), causing inflammation, pain, and eventually joint damage if left untreated. Unlike osteoarthritis, which is primarily a wear-and-tear condition, RA is driven by immune system dysfunction.
RA typically affects joints symmetrically—meaning both hands, both knees, or both feet rather than just one side. Common affected joints include hands and wrists, feet and ankles, knees, shoulders, and elbows. However, RA is a systemic disease that can affect other body systems including the heart and blood vessels, lungs, eyes, and skin. This is why comprehensive treatment addressing the whole condition, not just joint symptoms, is essential.
Early Diagnosis and Treatment: Critical for Long-Term Outcomes
One of the most important advances in RA care is the recognition that early, aggressive treatment significantly improves long-term outcomes. Research consistently shows that starting disease-modifying treatment within the first few months of symptom onset prevents irreversible joint damage, reduces long-term disability, and improves quality of life. If you suspect you have RA but haven't been diagnosed, seeking prompt evaluation from a rheumatologist is crucial.
Modern RA treatment aims for several interconnected goals. The primary objective is achieving remission or low disease activity, meaning minimal or no symptoms and no active inflammation. Research shows this is achievable for many people with current treatments.
Additional goals include preventing joint damage and deformity, maintaining physical function and independence, managing pain and stiffness effectively, reducing systemic inflammation and associated health risks, and optimizing quality of life and participation in valued activities. Achieving these goals requires a multifaceted approach combining medications, physiotherapy, lifestyle modifications, and regular monitoring.
While physiotherapy and exercise are crucial components of RA management, medications form the foundation of disease control by targeting the underlying immune dysfunction.
Disease-Modifying Anti-Rheumatic Drugs (DMARDs)
DMARDs are the cornerstone of RA treatment. Unlike pain medications that only address symptoms, DMARDs actually slow or stop disease progression by modifying the immune response. The most commonly prescribed DMARD is methotrexate, which has decades of research supporting its effectiveness and safety when properly monitored.
Methotrexate works by suppressing the overactive immune response driving RA inflammation. Studies show it reduces joint pain and swelling, prevents joint damage when started early, and is generally well-tolerated with regular monitoring. Most people take methotrexate once weekly, along with folic acid supplementation to reduce side effects. Regular blood tests monitor for potential side effects on the liver and blood cells.
Other conventional DMARDs include hydroxychloroquine (Plaquenil), sulfasalazine, and leflunomide. Sometimes these are used in combination with methotrexate for better disease control.
Biologic DMARDs
Biologic medications represent a major advance in RA treatment. These are engineered proteins that target specific components of the immune system driving RA inflammation. Biologics are typically used when conventional DMARDs like methotrexate don't provide adequate disease control, or sometimes as first-line treatment in severe RA.
Common biologic classes include TNF inhibitors such as adalimumab (Humira), etanercept (Enbrel), and infliximab (Remicade), which block tumor necrosis factor, a key inflammatory protein. Other biologics target different immune pathways, including rituximab which depletes B cells, tocilizumab which blocks interleukin-6, and abatacept which modulates T cell activation.
Research shows biologics are highly effective, often achieving remission when conventional DMARDs haven't worked. They're generally well-tolerated, though they do increase infection risk by suppressing immune function. In New Zealand, access to biologic medications often requires meeting specific criteria and approval through Pharmac.
JAK Inhibitors
Janus kinase (JAK) inhibitors are a newer class of RA medications taken as pills rather than injections. They work by blocking enzymes involved in the inflammatory process. Examples include tofacitinib (Xeljanz), baricitinib (Olumiant), and upadacitinib (Rinvoq). Studies show JAK inhibitors are as effective as biologics for many people, with the advantage of oral administration rather than injections.
Corticosteroids
Steroids like prednisone rapidly reduce inflammation and can provide quick symptom relief. However, long-term steroid use carries significant risks including bone loss, weight gain, diabetes, and increased infection risk. Current RA treatment approaches use steroids as a "bridge" therapy—providing symptom control while waiting for DMARDs to take effect (which can take weeks or months), or during disease flares for short-term symptom management.
The goal is to use the lowest effective steroid dose for the shortest time possible, while DMARDs provide long-term disease control.
Pain and Anti-Inflammatory Medications
Non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen, or celecoxib help manage pain and reduce inflammation but don't modify disease progression. They're useful for symptom management alongside DMARDs. Paracetamol can help with pain relief though it doesn't address inflammation.
These medications treat symptoms but don't prevent joint damage, which is why DMARDs remain the treatment priority.
While medications control the underlying disease process, physiotherapy addresses the physical impacts of RA on joints, muscles, and functional abilities. Research consistently demonstrates that physiotherapy is an essential component of comprehensive RA care.
Exercise Therapy: Essential Despite Inflammation
One of the most important shifts in RA management is the recognition that exercise is beneficial, not harmful, even during active disease. For years, people with RA were told to rest their joints, but current evidence shows that appropriate exercise reduces pain and fatigue, improves joint function and range of motion, maintains and builds muscle strength, enhances cardiovascular health, and improves mood and quality of life.
Importantly, research shows that exercise does not increase disease activity or accelerate joint damage in RA. In fact, people with RA who exercise regularly often have better long-term outcomes than those who remain sedentary.
Types of Exercise for Rheumatoid Arthritis
Evidence supports several exercise modalities for RA:
Strengthening exercises are particularly important because RA causes muscle weakness around affected joints. Research shows that strength training performed 2-3 times weekly significantly improves muscle strength, reduces pain, and enhances physical function. At Auckland Physiotherapy, we design progressive strength programs that respect joint limitations while building supporting musculature.
Aerobic exercise such as walking, cycling, or swimming improves cardiovascular fitness, helps manage fatigue (a major RA symptom), supports weight management, and reduces cardiovascular disease risk (which is elevated in RA). Studies show that moderate-intensity aerobic exercise 3-5 times weekly is safe and beneficial for people with RA.
Flexibility and range of motion exercises help maintain joint mobility and prevent contractures (permanent joint tightening). These are particularly important for hands, wrists, and shoulders commonly affected by RA. Gentle stretching and range of motion work should be performed daily.
Balance and proprioception training reduces fall risk, which is important as RA affects foot and ankle joints that are crucial for balance. Exercises improving balance help maintain independence and reduce injury risk.
Exercising During Flares
During RA flares when joints are particularly inflamed and painful, exercise requires modification but shouldn't be abandoned entirely. Research suggests that during flares, reduce exercise intensity and duration, focus on gentle range of motion exercises to prevent stiffness, consider water-based exercise which reduces joint stress, and avoid high-impact activities. Once the flare subsides, gradually return to your regular exercise program.
Manual Therapy and Joint Protection
Physiotherapists provide hands-on treatment techniques that complement exercise. Research shows that joint mobilization can reduce pain and improve mobility in affected joints, soft tissue massage decreases muscle tension and improves circulation, and therapeutic taping provides temporary pain relief and joint support.
We also teach joint protection principles—techniques to reduce joint stress during daily activities. These include using larger, stronger joints for tasks when possible, avoiding positions that strain small finger joints, using assistive devices and adaptive equipment, and balancing activity with rest to prevent overuse.
Hand Therapy for RA
Hand and wrist involvement is extremely common in RA, often causing significant functional limitations. Specialized hand therapy includes exercises to maintain finger and wrist mobility and strength, splinting to support joints and prevent deformity, activity modification to protect hand joints, and recommendations for adaptive equipment that reduces hand strain.
Research shows that early hand therapy intervention can prevent or minimize hand deformities that were once considered inevitable in RA.
Fatigue is one of the most challenging and underappreciated symptoms of RA. Unlike normal tiredness, RA fatigue is overwhelming exhaustion that doesn't improve with rest. Studies show that up to 80% of people with RA experience significant fatigue that impacts daily activities.
Evidence-Based Fatigue Management Strategies
Research identifies several effective approaches to managing RA fatigue:
Regular exercise, paradoxically, is one of the most effective fatigue management strategies. Studies consistently show that people with RA who exercise regularly experience less fatigue than those who are sedentary. Start with gentle activities and gradually increase as tolerated.
Energy conservation and pacing involves balancing activity with rest, prioritizing important activities, breaking tasks into smaller segments, and planning rest periods before becoming exhausted. Occupational therapists and physiotherapists can teach specific energy conservation techniques.
Sleep optimization is crucial, as poor sleep worsens RA fatigue. This includes establishing regular sleep schedules, creating a comfortable sleep environment, managing pain that disrupts sleep, and addressing sleep disorders if present.
Addressing disease activity with appropriate medication management is fundamental, as uncontrolled inflammation is a major contributor to fatigue. Working with your rheumatologist to optimize disease control often significantly improves energy levels.
Managing stress and mental health is important because depression and anxiety, which are more common in people with RA, worsen fatigue. Psychological support, stress management techniques, and treatment for mood disorders when present all help reduce fatigue.
Beyond medical treatment and physiotherapy, several lifestyle factors significantly impact RA outcomes.
Diet and Nutrition
While no diet cures RA, research shows that nutrition influences inflammation and overall health. The Mediterranean diet, rich in fish, olive oil, fruits, vegetables, and whole grains, has the strongest evidence for reducing inflammation in RA. Studies show that following a Mediterranean-style diet may reduce disease activity and improve symptoms.
Omega-3 fatty acids from fish or supplements have anti-inflammatory properties and research shows they may reduce RA pain and morning stiffness. Maintaining a healthy weight is important, as excess weight increases stress on weight-bearing joints and obesity is associated with increased inflammation.
Some people with RA report that specific foods trigger symptoms, though this varies individually. Common reported triggers include processed foods, refined sugars, and nightshade vegetables (though scientific evidence for nightshades is limited). An elimination diet supervised by a dietitian can help identify personal triggers.
Smoking Cessation
If you smoke and have RA, quitting is one of the most important things you can do. Research shows that smoking worsens RA disease activity and severity, reduces the effectiveness of RA medications (particularly methotrexate), increases joint damage, and elevates the risk of RA-related complications. Studies demonstrate that people with RA who quit smoking experience improved disease control and better treatment responses.
Stress Management
Stress doesn't cause RA, but research shows it can trigger flares and worsen symptoms. The relationship is bidirectional—RA causes stress, and stress worsens RA. Effective stress management techniques supported by research include mindfulness meditation, which has been shown to reduce pain and improve quality of life in RA, gentle yoga incorporating breathing and relaxation, cognitive-behavioral therapy for managing chronic illness challenges, and regular physical activity, which reduces both stress and RA symptoms.
Sleep Quality
Poor sleep is common in RA due to pain, stiffness, and the inflammatory process itself. However, inadequate sleep worsens pain perception, increases fatigue, and may worsen inflammation. Improving sleep quality through good sleep hygiene, appropriate pain management at night, and treating sleep disorders when present is an important component of RA management.
RA treatment isn't a one-time prescription—it requires ongoing monitoring and adjustment. Modern RA care involves regular assessment of disease activity using validated measures, periodic blood tests monitoring inflammation markers and medication side effects, and imaging studies (X-rays, ultrasound, or MRI) to assess joint damage.
The treat-to-target approach, supported by strong research evidence, involves setting specific treatment goals (usually remission or low disease activity), regularly assessing whether goals are being met, and adjusting treatment if targets aren't achieved within 3-6 months. This proactive approach leads to better long-term outcomes than simply treating symptoms as they arise.
At Auckland Physiotherapy, we work collaboratively with your rheumatologist to monitor your physical function and adjust your exercise and physiotherapy program based on disease activity and treatment changes.
Pregnancy and Rheumatoid Arthritis
Many women with RA can have successful pregnancies, though planning is important. Some RA medications must be stopped before conception due to potential fetal harm (particularly methotrexate), while others are safe during pregnancy. Interestingly, many women experience reduced RA symptoms during pregnancy, though flares often occur after delivery.
If you have RA and are considering pregnancy, discuss this with your rheumatologist well in advance to optimize your treatment plan.
RA in Older Adults
Managing RA in older adults requires special considerations including increased risk of medication side effects, higher risk of infections with immunosuppressive medications, greater impact of RA on mobility and independence, and presence of other health conditions complicating treatment. However, research shows that older adults with RA benefit substantially from appropriate treatment, including exercise programs tailored to their abilities.
Work and Rheumatoid Arthritis
Many people with well-controlled RA continue working successfully. Strategies that help include open communication with employers about accommodation needs, workplace modifications such as ergonomic equipment, flexible scheduling to accommodate medical appointments and fatigue, and pacing strategies to balance work demands with energy levels. In New Zealand, employment protections exist for people with disabilities including RA. If work is becoming difficult, occupational therapy assessment can identify helpful modifications.
RA research continues to advance, with several promising areas:
Biosimilar Medications
Biosimilars are highly similar versions of existing biologic medications, typically available at lower cost. Research shows they're as effective and safe as original biologics, and increasing availability in New Zealand improves access to these important treatments.
Targeted Synthetic DMARDs
Newer medications that precisely target specific inflammatory pathways are being developed and tested. These may offer benefits similar to biologics with different administration routes or side effect profiles.
Personalized Medicine
Research is working toward predicting which patients will respond best to which medications, potentially avoiding the current trial-and-error approach to finding the right treatment. Genetic testing and biomarkers may eventually guide treatment selection.
Understanding Remission
Researchers are studying what happens during sustained remission to understand if some people might eventually discontinue medication. Current evidence suggests some patients in prolonged remission can reduce medication doses, but this requires careful monitoring and should only be done under rheumatologist supervision.
Living with a chronic condition like RA significantly impacts mental health. Research shows that people with RA have higher rates of depression and anxiety compared to the general population. This isn't surprising given the challenges of chronic pain, fatigue, functional limitations, medication side effects, and uncertainty about the future.
Importantly, mental health and RA symptoms influence each other—depression worsens pain perception and fatigue, while poorly controlled RA increases depression and anxiety risk. This is why addressing mental health is an essential component of comprehensive RA care.
Effective strategies include psychological therapy, particularly cognitive-behavioral therapy which helps develop coping skills, peer support through RA support groups where you can connect with others facing similar challenges, stress reduction techniques including mindfulness and relaxation practices, and appropriate treatment for depression or anxiety when present, which may include therapy, medication, or both.
At Auckland Physiotherapy, we recognize the emotional challenges of living with RA and can connect you with appropriate mental health resources when needed.
With modern medication management, many people with RA never require surgery. However, surgery may be considered when joint damage causes severe pain or functional limitation despite optimal medical treatment, joint instability creates safety concerns, or severe deformity significantly impacts quality of life.
Common surgical procedures for RA include joint replacement (hip, knee, shoulder), synovectomy (removing inflamed joint lining), tendon repair or reconstruction, and hand and wrist procedures to improve function.
Importantly, even when surgery is necessary, research shows that prehabilitation—physiotherapy and exercise before surgery—improves surgical outcomes. Postoperative physiotherapy is also crucial for optimal recovery and function.
Effective RA management requires coordination among multiple healthcare providers. Your team typically includes a rheumatologist managing medications and overall disease control, a physiotherapist addressing physical function and exercise, your general practitioner for overall health management, and potentially occupational therapists for workplace and daily activity adaptations, dietitians for nutritional guidance, and mental health professionals for psychological support.
At Auckland Physiotherapy, we function as part of your RA care team, communicating with your rheumatologist and other providers to ensure coordinated, comprehensive care.
Your RA management plan should include:
While receiving an RA diagnosis can be frightening, it's important to know that treatment has advanced dramatically in recent decades. With early, appropriate treatment, most people with RA can achieve good disease control, maintain physical function, continue working and enjoying activities, and live full, active lives.
The key is taking an active role in your care—adhering to medications, participating in physiotherapy and exercise, making lifestyle modifications, attending regular appointments, and communicating openly with your healthcare team about symptoms and concerns.
If you've been diagnosed with rheumatoid arthritis or are struggling to manage your symptoms, Auckland Physiotherapy can help. We specialize in evidence-based RA management, working alongside your rheumatologist to optimize your physical function and quality of life.
We provide:
Don't let rheumatoid arthritis limit your life. With the right treatment approach combining medication management, physiotherapy, and lifestyle modifications, you can achieve good disease control and maintain your quality of life.
Contact Auckland Physiotherapy today:
Visit www.aucklandphysiotherapy.co.nz or call to book your comprehensive rheumatoid arthritis assessment. Let us help you develop a personalized management plan that addresses your specific needs and goals.
Remember: rheumatoid arthritis is a manageable condition. With early diagnosis, appropriate treatment, and your active participation in care, you can live well with RA. Take the first step toward better management today.
The information provided in this blog is for educational purposes and should not replace professional medical advice. Rheumatoid arthritis requires medical management by a rheumatologist. Always consult with your healthcare providers regarding your specific treatment needs. If you experience severe joint swelling, fever, or signs of infection, seek immediate medical attention.
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