This document is designed to provide health professionals, educators, and potential employers of health care providers with guidelines for competent physical therapy practice for persons with rheumatologic disorders. These guidelines were revised from and based upon "Discipline-Specific Standards of Care: Physical Therapy Competencies" by Carolee Moncur, PT, PhD published in Physical Therapy Management of Arthritis. New York: Churchill Livingston, 1988:29-41.

Items contained within this document are considered to be those an entry levelphysical therapist must have mastered to treat patients with rheumatic diseases. Items considered necessary but not entry level (may need to be acquired with experience, education, and with supervision by persons experienced in rheumatology) are in bold.

Basic Knowledge

• Etiology, epidemiology, clinical course, common progression, and pathophysiology:
  1. Common Rheumatic Diseases

     a. Rheumatoid Arthritis

     b. Degenerative Joint Diseases/Osteoarthritis

     c. Fibromyalgia

     d. Osteoporosis

     e. Low Back Pain Syndrome

  2. Additional Rheumatic Diseases

     a. Spondylarthropathies (such as Ankylosing Spondylitis)

     b. Juvenile Arthritis

     c. Systemic Lupus Erythematosus

     d. Systemic Sclerosis

     e. Polymyositis/Dermatomyositis

     f. Psoriatic Arthritis

     g. Gout

• Medications commonly used with rheumatic diseases
  1. Purpose of medication
  2. Side effects
  3. Speed of efficacy
• Impact of the above diseases on all phases of a patient’s life
• Pathomechanics of deformity, inducing nature of periarticular and articular destruction
• Common types of surgery, precautions for treatment, and the process of tissue healing
  1. Joint Replacement
  2. Osteotomy
  3. Arthroscopy
  4. Resection
  5. Synovectomy
  6. Arthrodesis
  7. Spinal Surgery (decompression/fusion)
• Basic diagnostic techniques
  1. Lab Tests
  2. X-ray Findings
  3. MRI, CT SCAN
  4. Thermogram
  5. NCV, EMG
  6. Bone Density
• G. Roles of other health professionals in treating rheumatologic patients (e.g., identify need for consultants necessary to fully maximize care, such as referrals to Occupational Therapy, Social Service, Psychological Services, Clinical Dietitian, Rheumatologist, Nurse Practitioner, Orthotist)

Patient Evaluation

• History of current illness: comorbid problems, previous intervention
• Knowledge of the disease and the treatment regimen
• Ability to cope with the chronicity of the illness/coping skills
• Pain status
• Ambulation/gait deviations
• Transfer status
• Range of motion/lag
• Muscle strength
• Fatigue/endurance levels
• Swelling and/or synovitis of joints
• Deformity (identify, evaluate, and understand impact on function)
  1. Subluxation
  2. Dislocation
  3. Hand/thumb/wrist deformities (identify and understand impact on function)

     a. Heberden’s nodes

     b. Bouchard’s nodes

     c. Lunar deviation

     d. Wrist/hand subluxation

     e. Swan neck

     f. Boutonniere

     g. Carpometacarpal (CMC) squaring

  4. Varus/valgus (lower extremities)
  5. Pronation/supination of feet
  6. Foot deformities (pes planus, hallux valgus, toe deformities, tarsel tunnel syndrome)
• Joint stability/integrity
  1. Laxity
  2. Atrophy (of adjacent muscle)
  3. Special tests (leg length discrepancy, Fabre’s scour test, chest expansion, intermalleolar spread, etc.)
• Morning stiffness/gelling
• Skin and vascular integrity
• Neurologic signs
• Posture
• Cardiorespiratory function
• Coordination/balance
• Ability to participate in functional activities:
  1. Personal care
  2. Occupational activities
  3. Recreational activities
• Environment
  1. Home
  2. Work
  3. School

Designing a Physical Therapy Plan of Care

The physical therapist should be able to form a plan of care based on:

• Patient history
• Patient goals expectations and motivation
• Pain and/or tolerance for activity
• Deficits in muscle strength and range of motion
• Status of joint deformities (fixed versus flexible)
• Deficits in functional activities
• Ambulation status/gait deviations
• Tolerance for physical therapy modalities
• Need for adaptive and orthotic equipment
• Potential problems which could develop as a result of the disease process or patient’s lifestyle
• Safety considerations (balance/coordination)

  The physical therapist should also be able to do the following:

  1. Recognize and respond to changes in the patient’s physiologic status
  2. Recognize and respond to changes in the patient’s psychological status/ ability to cope with the disease
  3. Continue, modify, or discontinue physical therapy treatment based upon reassessment of the patient
  4. Design a discharge plan of care and instruct patient in home program based upon the results of ongoing physical therapy assessment
• Recognize and consider available resources to the patient and factors including but not limited to the following:
  1. Physical/psychological capacity to benefit from therapy (this may include psychological readiness and acceptance level)
  2. Family, community, environmental support
  3. Educational level/style of learning
  4. Cultural background
  5. Environmental/architectural barriers
• Confer with other health professionals to develop a unified multidisciplinary approach to treatment which avoids duplication of services and provides the most efficient program possible
• Design and implement program which take into consideration insurance mandates/stresses appropriate priorities
• Prescribe/fabricate/apply orthotic equipment

Implementing a Treatment Program

The physical therapist should be able to safely, effectively, and efficiently implement the following programs based on prioritization of patient problems and an understanding of available time frames and resources:

• A therapeutic exercise program for the patient
• An ambulation program for the patient
• A pain management program including but not limited to the efficacious use of physical therapy modalities
• A joint protection/energy conservation program including but not limited to: active devices, orthotics, braces, strategies for joint protection in functional activities. Also guidance with occupational recreational/daily activities to minimize joint overuse.
• An aerobic conditioning program for the patient
• An efficient, goal-oriented home program
• Solutions for adapting the patient’s home and work environments
• Education in self-management of the disease process including instruction in use of modalities, joint protection, and self-modification of the home exercise program in response to disease status changes

Planning And Implementation of Patient Education

The physical therapist should be able to design and implement patient education strategies including the following:

• Lectures
• Leading discussions
• Individualized instruction
• Programmed learning
• Leading practice skills and activities
• Role playing techniques
• Modeling correct behavior

Instruct about the following:

• The nature and common progression of the rheumatic disease
• Available community resources
• Hazards of unproved remedies/methods
• Physical/sexual problems related to contractures, deformities, and post-operative total joint replacement
• Proper use of therapeutic exercise and level of activity
• Joint protection/energy conservation
• Therapeutic equipment (exercise equipment, modalities, TENS, biofeedback, etc.)
• Therapeutic heat and cold
• Therapeutic massage
• Orthotic devices and supports

The physical therapist should be able to:

• Design and implement a community education program about physical therapy and arthritis
• Select and refer the patient to other health professionals for treatment, education, and/or utilization of community resources
• Evaluate commercially produced information regarding rheumatic disease intervention

Patient Adherence to Treatment

The physical therapist will enhance the patient’s adherence to the treatment program as follows:

• Determine the patient’s and family’s expectations about treatment
• Determine treatment goals of the patient and physical therapist
• Design a treatment program that has simplicity in terms of number of exercises/tasks the patient must do and that transfers to the patients life situation
• Establish that the patient knows what is expected by having him/her repeat or demonstrate what has been instructed
• Provide written instructions for home programs
• Interpret and respond appropriately to the nonverbal messages of patients

Research Activities