Physical therapy in patients with rheumatoid arthritis and axial spondyloarthritis: the patients’ perspective

Objective To assess the duration, frequency, and content of individual physical therapy (PT) in patients with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA). Method In this cross-sectional study, an electronic questionnaire aimed at people with RA and axSpA was distributed through various communication channels of the Dutch Arthritis Foundation. It comprised questions on sociodemographic and health characteristics, received PT (currently and/or in the past year) and, if applicable, its duration, frequency, and content (active exercises, manual treatment, physical modalities, and/or counselling/education). Results The study included 257 and 94 patients with self-reported diagnoses of RA and axSpA, of whom 163 (63%) and 77 (82%) currently or had recently received individual PT. The duration of individual PT was long-term (> 3 months) in 79% of RA and 83% of axSpA patients, with an average frequency of once per week in most. Although active exercises and counselling/education were each reported by ≥ 73% of the patients with RA and axSpA who received long-term individual PT, passive treatment modalities were also often offered (≥ 89%), in particular massage, kinesiotaping, and/or passive mobilization. The same pattern was seen in patients receiving short-term PT. Conclusion The majority of patients with RA and axSpA received PT currently or in the past year, usually individually, long-term, and at a frequency of once a week. Although active exercises and education are recommended in guidelines, passive treatment options that are not advised were relatively often reported. An implementation study to identify barriers and facilitators regarding adherence to clinical practice guidelines seems warranted.

Despite major advances in the medical treatment of people with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA), the disease burden is substantial for many of them (1)(2)(3)(4).To reduce the consequences of pain, stiffness, fatigue, functional disability, emotional distress, and/or participation limitations in these patients, the provision of nonpharmacological care by health professionals is of paramount importance (1,(5)(6)(7).Physical therapy (PT) is considered to be an important form of non-pharmacological care in these groups and is recommended in various national and international guidelines and recommendation (8)(9)(10)(11)(12).These guidelines recommend, in particular, active exercise therapy and education, whereas passive treatment modalities are either not recommended or discouraged (8)(9)(10)(11)(12).
Yet, little is known about the delivery of PT in daily clinical practice.Regarding RA, studies reported that over a period of 1 year about 25-50% of patients received PT (13)(14)(15), for axSpA the rates vary between 50% and 80% (16,17).With respect to the duration of PT, two studies in patients with axSpA reported that most patients received individual PT ≥ 5 years, with an average frequency of less than once a week (16,17).
Moreover, few studies are available regarding the content of PT in patients with RA or axSpA in daily practice.In a German study in 7326 patients with RA, prescription of passive treatment modalities in the previous year ranged between 13% and 39%, whereas patient education was reported by 5% (15).In a Canadian study, 83% of 253 patients with RA reported that they had received exercise therapy or heat/cold therapy in the past and 32% had tried education classes (18).A survey among patients with axSpA in Switzerland and the Netherlands found that about half of the patients received active exercises, whereas passive treatment modality ranged from 2% to 55%, with massage being the most often reported passive treatment modality (16,17).Education on physical activity and sports was reported by 32% or more of the responders (16,17).
The results of studies among patients appear to be in line with surveys among physiotherapists.A Canadian survey among 298 physiotherapists found that the most often reported treatment modalities were mobility exercises and patient education, for both RA and axSpA (> 90%) (19).In addition, less than two-thirds of the physiotherapists selected strengthening exercises as intervention for these patients (19).Two other studies among physiotherapists treating patients with RA in the Netherlands (n = 233) and Ireland (n = 457) found that exercise therapy and education were applied by the majority of the physiotherapists, whereas 32-91% of the physiotherapists reported never applying passive therapies (20,21).
The above-mentioned results are difficult to interpret as the methods employed varied with respect to patient selection, treatment modalities included in the survey, and/or the time windows.Some of the studies were executed more than 20 years ago, limiting the generalizability to current delivery of PT.Furthermore, none of the above-mentioned studies examined factors associated with delivery of PT or its duration.Previous literature found that patient characteristics such as age were associated with PT, with older patients receiving less PT (13).
To optimize the delivery of PT in RA and axSpA, an evaluation of its current usage and content is needed.Therefore, this study aimed to assess whether patients received PT, and, if so, to assess the duration, frequency, and content of individual PT, in particular the delivery of active and/or passive treatment modalities.In addition, we studied the patient characteristics of those receiving and not receiving individual PT, and those receiving short-or long-term PT.

Study design
This study was part of a larger cross-sectional survey study on the use of PT in people with rheumatic and musculoskeletal diseases, which was executed between December 2020 and July 2021.An exemption for additional medical ethical review was provided by the Medical Research Ethics Committee of the Leiden University Medical Center (LUMC) (N20.153).The study was conducted in accordance with the Handbook for Good Clinical Research Practice of the World Health Organization (22) and the principles of the Declaration of Helsinki (23).All participants provided informed consent for their participation.For the current study, only data from patients reporting a diagnosis of RA and/or axSpA were analysed.

Participants, recruitment, and setting
Individuals were eligible for the current study if they were aged 16 years or older, diagnosed with RA or axSpA (self-reported), and able to complete an online questionnaire in Dutch.Patients reporting both an RA and an axSpA diagnosis were excluded.Patients were recruited by the Dutch Arthritis Society; a questionnaire was disseminated between December 2020 and July 2021 via their website (www.reumanederland.nl),newsletter, and Facebook page.Patients were also recruited by the Facebook page of the LUMC.In the Netherlands, PT can be delivered either on referral or with direct access (no referral from physician needed).For both RA and axSpA, PT is not included in the basic (national, compulsory) insurance.Thus, reimbursement depends on whether patients have additional health insurance, with the reimbursed number of sessions depending on the insurance policy.The reimbursement of group exercise therapy for people with axSpA is variable, depending on the local organization.

Assessments
The assessment consisted of an online questionnaire that was completed once.The questionnaire was taken via the OnlinePROMs® software (2020; Interactive Studios) (conform SO27001 and NEN7510).The questionnaire comprised questions on the participants' sociodemographic and health characteristics, and on the use of PT.The questionnaire was completed anonymously and did not include any personal data, and the results could not be linked to an IP address.
Participants' sociodemographic and health characteristics.Sociodemographic characteristics included age (years), gender (female/male/other/ rather not say), level of education (low: primary school or lower vocational education; medium: lower general secondary school or intermediate vocational education; high: higher general secondary school, higher vocational education, or university; other: none of these categories), having paid employment if < 66 years old (66 years and 4 months was the pensionable age in the Netherlands in 2021) (yes/no), status of living (living alone; yes/no), and treatment by a rheumatologist, currently or in the past (yes/no).
The presence of the comorbidities currently or in the past 12 months was assessed by a questionnaire that has been applied previously in research by our group (24).We classified the comorbidities into the presence of diabetes, cardiovascular diseases, pulmonary diseases, cancer, migraine or severe headache, gastrointestinal complaints > 3 months, musculoskeletal pain not related to the rheumatic disease, allergy, urinary incontinence, liver disease, kidney diseases, depression, obesity, Parkinson's disease, and multiple sclerosis.
Health-related quality of life (HRQoL) was assessed using the validated Dutch translated Euro-Qol-5 Dimensions 5-Level (EQ-5D-5L), comprising five questions covering the dimensions self-care, usual activities, pain/discomfort, mobility, and anxiety/depression (25,26).The EQ-5D-5L score ranges from −0.446 to 1.000, with a score below zero representing a state that is considered to be worse than death (25,26).Calculations were standardized to the Dutch population (27).In addition, patients completed a thermometer or visual analogue scale (EQ-VAS) on their perceived health status, with the score ranging from 0 (worst) to 100 (best).
Physical therapy treatment.The questionnaire on PT was based on an earlier, self-developed questionnaire that was administered to patients undergoing total hip or total knee arthroplasty (28) and in patients with systemic sclerosis (29).It addressed the following aspects: PT treatment related to the rheumatic disease currently or in the past 12

Patient characteristics
In total, 361 people completed the questionnaire, of whom 10 were excluded because they reported to have been diagnosed with both RA and axSpA, leaving 257 respondents reporting a diagnosis of RA and 94 of axSpA.Their characteristics are shown in Table 1.In both groups, about one-third of the patients had one or more comorbidities.
The majority of patients (≥ 86%) with RA and axSpA had additional insurance for PT, mostly covering 10 PT sessions or more.Statistical comparisons of the characteristics of patients who did and did not receive individual PT, or who received short-term versus long-term PT, were only performed in the RA patient group.Because in the axSpA patient group, there were fewer than 20 patients in both the group that did not receive individual PT and the group that received short-term PT.All differences between the groups, including 95% CIs, are shown in Online Supplementary Tables S1 and S2.Comparison of the patients with RA who did and those who did not receive individual PT showed that patients receiving individual PT were less often in paid employment (44% vs 68%), less often had a medium level of education (35% vs 48%), and had lower average EQ-5D-5L (0.60 vs 0.66) and EQ-VAS scores (61.2 vs 67.6) compared to those who did not receive individual PT.Moreover, patients with RA who received individual PT more often had additional health insurance compared to those who did not receive PT (93% vs 72%).Although statistical comparisons of the characteristics of patient with axSpA who were and were not receiving individual PT were hampered by the small number of patients with axSpA not receiving PT (n = 17), similar patterns were found.Of the patients with axSpA who reported individual PT, 63% had paid employment, and mean scores of 0.59 on the EQ-5D-5L and 59.4 on the EQ-VAS were generated.Of the patients with axSpA who did not report individual PT, 71% had paid employment, and they had mean scores of 0.69 on the EQ-5D-5L and 73.4 on the EQ-VAS.Additional insurance was reported by 92% of the patients with axSpA who received individual PT and by 59% of those who did not receive individual PT.

Physical therapy treatment
Such differences were not seen between RA patients with short-term and long-term PT.The results of the comparison between groups are shown in Online Supplementary Tables S1 and S2.

Content of physical therapy
Table 2 shows the content of individual PT, taking into account both short-term and long-term PT.The proportions of patients with RA reporting forms of active exercise (i.e.aerobic, muscle strengthening, active range of motion exercises, or functional exercises such as balance exercises) ranged from 32% to 68% in short-term PT and from 41% to 69% in long-term PT.In patients with axSpA, the proportions reporting forms of active exercise were 27-55% in those receiving short-term PT and 30-77% in those receiving long-term PT.Regarding manual treatment, i.e. massage and passive mobilization, in patients with RA the proportions ranged from 35% to 42% in those receiving short-term PT and from 58% to 67% in those with long-term PT.In patients with axSpA, the proportions reporting passive manual treatment were 55-82% in those receiving short-term PT and 57-75% in those with long-term PT.With respect to physical modalities (passive), the most frequently reported modalities were kinesiotaping and dry needling.Regarding counselling/education, exercises to perform at home were the most often reported topic in both patients with RA [shortterm PT n = 23 (82%) and long-term PT n = 77 (93%) of patients reporting counselling/education] and patients with axSpA [short-term PT n = 7 (70%) and long-term PT n = 45 (94%) of patients reporting counselling/education].   found that younger patients (< 55 years) received PT more frequently than older patients (13), whereas in our study no impact of age on the number of PT sessions was seen.In the total group of 257 and 94 patients with RA and axSpA, the majority of patients had additional health insurance.However, the patients with RA and axSpA receiving individual PT more often had additional health insurance than those not receiving PT.This finding may indicate that access to PT care is influenced by insurance status.
Regarding the duration of the PT, in both RA and axSpA, the majority of patients reported PT treatment for more than 3 months.For RA, the proportion of patients receiving long-term PT is difficult to compare with other studies, whereas for axSpA the overall longterm PT is in line with previous studies in Switzerland and the Netherlands (16,17).It must be noted that, in particular, in the axSpA group the number of patients with short-term PT was very small.Additional research into the underlying needs for long-term PT treatment, including both patients and their treating physiotherapists, is needed.
Concerning the content of PT treatment, our results are in line with previous studies suggesting that the use of active exercises is suboptimal, whereas some passive interventions are applied relatively often (i.e.massage, passive mobilization, kinesiotaping, and dry needling).This finding needs further exploration, as in some clinical practice guidelines for the management of RA and axSpA, the application of active rather than passive treatment modalities is recommended.An example is the American College of Rheumatology recommendations for management of ankylosing spondylitis and non-radiographic axSpA (32), stating that educating patients in self-management in using an independent exercise programme is one of the main goals of PT.Thus, active interventions are preferred over passive interventions, where passive interventions could supplement, but not substitute for, active PT.On the national level, a Dutch PT guideline for the management of RA (10) discourages the use of passive interventions, including low-level laser therapy, electrostimulation, ultrasound, massage, thermotherapy, medical taping, and dry needling, and states that passive mobilization can only be considered to support active exercise therapy as a shortterm intervention in patients without active inflammation (10,33).Moreover, a national set of recommendations on PT in axSpA also stresses the use of active exercises rather than passive interventions (11).The rationale for the use of specific treatment modalities was, however, beyond the scope of this paper.So, despite evidence-based recommended exercise therapy including strengthening and aerobic exercise for patients with RA and axSpA, physiotherapists underused these guidelines.There is a need to increase awareness of the recommended guidelines for patients with axSpA and RA.This study has a number of limitations.First, the diagnosis was based on self-report, and therefore the RA and axSpA diagnoses cannot be confirmed.Secondly, recruitment was carried out in the community rather than in rheumatology clinics.We therefore cannot calculate a response rate or determine the extent to which response bias has occurred.Thirdly, patients with RA and axSpA recruited from the community may have different characteristics from those who are treated by rheumatologists.However, as most patients indicated that they had been treated by a rheumatologist, the impact of the recruitment may have had little impact in that respect.Also, we did not ask the patients about their satisfaction with treatment other than the number of sessions, such as satisfaction with its overall effect, the expertise of the therapist, or the equipment in the practice.Finally, although the questionnaire was based on one used in previous research projects (28,29), it is conceivable that patients did not accurately report the characteristics of the treatment that they received.On the other hand, in studies where a similar survey was administered to both patients and physiotherapists, overall similar results were obtained (29,34).

Conclusion
The results show that the majority of patients with RA and axSpA received individual PT, currently or in the past year, long-term, and at a frequency of once a week.Passive treatment options (i.e.massage, passive mobilization, kinesiotaping, and dry needling) were relatively often applied in the individual PT treatments, although active exercises and education are recommended in national and international guidelines for patients with RA and axSpA.These results underline the need to evaluate the barriers and facilitators for the use of treatment recommendations among the various stakeholders.Following these results, a tailored implementation strategy to optimize adherence to practice guidelines could be developed and evaluated.

Table 1 .
Characteristics of patients with rheumatoid arthritis or axial spondyloarthritis with no, short-term, or long-term individual physical therapy (PT).