Treatment Planning for Rheumatoid Arthritis

 By Julie Goodwin, November 1, 2023

For as long as we’ve been recording history, people have been diagnosed with arthritis. Eventually, almost everyone will be affected by one or more forms of arthritis during their lifetime. As massage therapists, we are in a unique position to help clients with arthritis better manage some of the most troublesome symptoms of the condition, like joint pain and fatigue.

To do the most effective work, however, we need to have a good understanding of the condition. Here, we’ll talk about how massage therapists can plan effective massage sessions for clients with rheumatoid arthritis (RA).

Rheumatoid Arthritis: Understanding the History and Where We Are Today

When considering how RA affects our clients and planning how best to serve them, understanding some basic terminology is helpful:

• Arthritis: the prefix “arth-” refers to joints; the suffix “-itis” refers to inflammation; the term “arthritis,” therefore, refers to inflammation of the joints, usually synovial joints.
• Rheumatoid: the prefix “rheuma-” is from ancient Greek, meaning “that which flows as a river or stream;” the suffix “-toid” signifies “resembling.” By the mid-1800s, “rheuma-” had evolved to indicate “a discharge from the body,” and when combined with “-toid” became applied to a disease of the joints—arthritis—characterized by inflammation and degenerative changes to joints and other structures. In earlier times, RA was also called rheumatism. RA is only one of multiple health conditions designated as rheumatoid in nature: rheumatic fever, also autoimmune and inflammatory, can follow a group A streptococcal infection and cause heart damage (designated as rheumatic heart disease).

The earliest traces of arthritis date back to prehistoric times, detected in the fossils of dinosaurs. The first signs of arthritis in humans were found in the skeletal remains of indigenous peoples going back as far as 4500 BCE, and ever since then, arthritis has been found across the world.

Several schools of thought have developed about the history of rheumatoid arthritis. One school of thought is that RA is a disease of the modern era, a result of an environmental or genetic stimulus that did not exist in ancient times (a caveat to this school of thought is that early humans did not live long enough to develop many diseases common today).

A second theory suggests that RA existed amongst our ancient ancestors but was never definitively characterized. Most recently, a hybrid theory has arisen that postulates RA originally developed in indigenous populations in North America and spread to European populations through the travel of persons and/or goods. These theories are known as the Recent Origin, Ancient Origin and New World-to-Old World views of RA’s origins, and some degree of evidence exists to defend each view.

Throughout the 19th century, symptoms of RA were routinely designated as gout (another form of inflammatory arthritis) until the finding of excess uric acid in the blood of gout patients but absent in patients with somewhat similar symptoms was established, opening the door for accurate diagnosis of RA.

Today, “arthritis” is an umbrella term used to describe a number of conditions that cause joint pain and stiffness and, in some types, inflammation-related joint deterioration. The Arthritis Foundation estimates that there are more than 100 types of arthritis, and that one in four adult Americans is affected by it. By 2040, estimates also predict that:

• The number of adults in the U.S. with doctor-diagnosed arthritis will increase by nearly 50 percent to just over 78 million (almost 30 percent of all adults).
• The number of adults reporting activity limitations due to arthritis will increase to nearly 35 million (more than 11 percent of all adults).

The Demographics and Costs of RA

Woman have a greatly increased risk for developing an autoimmune disease when compared to men, possibly due to differences in sex hormones, the X chromosome or environmental factors, among other potential causes.

The role of autoimmunity in both RA and PsA means that women are two-to-three times more likely to be affected by either condition: one in 12 women and one in 20 men will develop an inflammatory autoimmune rheumatic disease in their lifetime.

The societal costs of RA are enormous. According to 2005 U.S. Medicare/Medicaid data (the most recent detailed tally available), the total annual societal costs of RA (direct, indirect and intangible) totaled $39.2 billion. Of that number, 33 percent of the total cost was allocated to employers, 28 percent to patients, 20 percent to the government and 19 percent to caregivers.

Additionally, the direct ($8.4 billion) and indirect ($10.9 billion) costs to RA patients translate to a total annual cost of $19.3 billion.

That’s not even to mention the intangible costs that people with RA face, including quality-of-life deterioration ($10.3 billion) and premature mortality ($9.6 billion). The social and personal costs of RA can be significant.

Related: Massage As A Nonpharmocological Intervention for Arthritis

RA can notably threaten longevity: hazards to mortality are 60 to 70 percent higher in people with RA when compared with those in the general population. And despite medical advances on many fronts, the overall survival gap between people with RA and those without RA has not been closing over the past decades.

Many autoimmune conditions, including RA, are characterized by temporary periods of relative wellness called remissions or subacute phases, when symptoms are at a decreased level or are even absent, and other periods when symptoms suddenly reemerge or worsen and may cause organic and systemic damage, called recurrences, exacerbations or flares.

For people with such an autoimmune condition, there is never a day off: constant, focused self-awareness and vigilance are required to perhaps sense the onset of a flare and take steps that may remediate its effects.

Treatment Planning: How Massage Can Be Safe and Effective for Clients With RA

Planning therapeutic massage treatment for a client with RA can be challenging, call on a wide range of practitioner skills, and involve a heightened degree of sensitivity to the client’s needs.

The start of any massage therapy session should include a thorough intake, but this is especially true when you’re working with people who are dealing with chronic diseases like RA. All clients who have been doctor-diagnosed with RA and are seeking massage therapy should be clear on what the potential effects of massage are, as well as the benefits they might expect to see. If you’re seeing a client with RA for the first time, you may even consider asking for a physician referral or confirmation that they’ve discussed the use of massage therapy with their care provider.

Massage therapists are also going to need RA-specific health information so they can be sure to tailor the massage session accordingly. This information should include:

• A comprehensive client health history.
• Identification of the client’s RA complications and health conditions that coexist with RA.
• Discussion of the client’s current prescribed and over-the-counter medications, including vitamins and nutritional supplements, along with side effects experienced.
• Description of recent medical and surgical procedures necessitated by the client’s RA.
• Assessment of the effects of RA on the client’s structures and functioning, such as pain.

Related: Free Client Intake Form

After initial health information is confirmed and assessment done, massage therapists need to get specific about what will occur during the massage, making sure the client fully understands what they can expect and is realistic about outcomes and be empowered to make decisions around pressure throughout the session.

You should be prepared to cover the following:

1. Therapeutic intentions. Make sure that you and the client agree on the goals for the massage session. Be realistic. Do not overpromise results and realign client expectation if they are unrealistic about what can be achieved with massage therapy. You do not want to set a client up for disappointment.
2. Cautions and contraindications. Carefully review both the cautions and contraindications associated with the massage session, and be sure your client understands. For example, if your client is experiencing a flare, rescheduling the session may be appropriate. Be aware of joints that are inflamed or swollen and work around those areas if necessary.
3. Modality choices, including those appropriate during a period of flare. Discuss the techniques you are planning to use during a massage session and make sure your client feels secure enough to provide accurate feedback regarding pressure and comfort. Be prepared to check in and adjust as needed.
4. Recommended positioning and draping. Talk frankly with your client about positioning and draping, as well as what is most comfortable for them. Again, during a flare and if massage is appropriate, a client might prefer staying partially or fully clothed, and they may not be able to easily get on and off your massage table.
5. Additional therapeutic measures that may be desirable and provide comfort. Especially if pressure is not comfortable during a massage session, talk to your clients with RA about other therapeutic measures available that may bring them some relief and help them manage stress.

Regular massage therapy can be a valuable adjunct to medical treatments for RA, and providing nurturing touch can be gratifying for any massage therapist who chooses to acquire the necessary information and skills for a client with this complex medication condition.

4 Common Types of Arthritis

By overall prevalence, the most common types of arthritis include:

1. Osteoarthritis (OA) currently affects more than 30 million Americans and is, by far, the most prevalent form. Although the overall incidence of arthritis has decreased in the 21st century, high rates of obesity remain a significant risk for developing OA.
2. Gout is a form of inflammatory arthritis that affects more than 8 million Americans. In people with gout, high blood levels of uric acid cause sharp, needle-like crystals to form at certain joints, most often in the feet and ankles but sometimes in the hands and wrists as well.
3. Rheumatoid arthritis (RA) affects around 1.5 million Americans. RA’s onset is caused by an autoimmune response in which the immune system attacks the synovial membrane tissue lining joints, creating inflammation that eventually destroys the tissue.
4. Psoriatic arthritis (PsA) affects about 1 million Americans. PsA is also autoimmune, and accompanies (or can precede) psoriasis, an autoimmune skin condition in which epidermal skin cells proliferate uncontrollably, forming hard, swollen plaques.