With ‘biologic’ use do we still need rehabilitation services?

We push for research to learn more about arthritis. We cheer when research results in a new treatment that reduces or eliminates joint and organ destruction, and allows us to remain employed and relatively pain free. But how often do we stand back and ask if this wonderful 'new' knowledge requires a change to the 'old' way of treating this disabling disease? 'Biologics' have been hailed as a collection of miracle drugs that have taken some arthritis patients out of wheelchairs and prevented others from having to use one. Has the use of biologics altered the need for rehabilitation education and services for people with rheumatic diseases?

This excellent question was asked recently by Dr. Angela Busch, Director of the School of Physical Therapy at the University of Saskatchewan, and a CAPA member. She extended an invitation to me to meet at a local Saskatoon cafe to talk about it over a cup of coffee. So I could provide more than a rough guess based mostly on my own rehab experience and the second-hand information of many others, I cobbled together an informal, 'quick-and-dirty” survey. I sent it to our Steering Committee and several members at large, including Anne Lyddiatt, CAPA member and national trainer for the Patient Partners in Arthritis Program, to share with their networks. The response was absolutely terrific – and fast – and came from BC, AB, SK, MB, ON, PQ, NB and NS. Arthritis types were osteoarthritis (OA), rheumatoid arthritis (RA), ankylosing spondylitis (AS), Lupus, polymyalgia rheumatica, psoriatic arthritis (PsA) with spondylitis, and juvenile idiopathic arthritis (JIA). As responses arrived all identifying information was removed so they cannot be associated with any individual. Dr Busch was impressed by the depth and breadth of the information, the experiences and insights of the contributors, and by the fact that so many different types of arthritis were represented with both 'standard' treatments and biologics. In fact, she has asked permission to use the de-identified pooled information as an educational tool with her graduate students.

What did the survey reveal? Of the six questions asked, the first was whether the respondent's treating physician uses physical therapy (PT) and/or occupational therapy (OT) in his/her practice. Three-quarters of the physicians were reported to routinely use physical therapy as part of arthritis treatment and/or with pre- and post-surgery patients. However, approximately one-third of these doctors waited for the patient to request PT or OT before prescribing it, and many left the patient to find their own PT services. One-quarter of respondents replied that their physicians had never suggested PT or OT services to them.

Another question asked if people taking biologics had been prescribed, or had suggested, PT &/or OT services. The range of responses was interesting. Some mentioned they had significant joint damage before being put on a biologic and so still required surgery, and both pre- and post-surgical PT & OT had been very useful. One patient pointed out that even on biologics arthritis tends to flare and physical therapy is helpful to bring these under control. Another said that so much damage had been done prior to beginning a biologic that both PT and OT was necessary to help regain as much mobility and ability for self-care as possible. In this case the OT helped with aids for daily living, made resting and working splints and provided custom orthotics. Someone else reported that she had taken biologics with success for ten years, but most recently consulted a physical therapist because of taking several falls. The exercises that were given to her have restored her balance. Other comments included the useful observations on patient progress made by a PT, and a PT referring the patient back to the rheumatologist when deterioration in the patient's condition was seen.

The survey also asked if the PT and/or OT services received had been beneficial. Almost all agreed, and mentioned they had learned about their disease and how to manage it, about pain management, exercise and weight loss, provision of orthotics and splints, and more. Many said they returned for help whenever they ran into a new problem. Some reported they had worked with their therapist over long periods of time to achieve and maintain a goal such as full range of motion. One person commented that in her opinion physical therapists know much more about 'how muscles and bones work' and their potential problems than most family doctors. Another said that she believed that the help she received from her PT over many years have saved her knees from surgery, and still another visits her physical therapist to develop a treatment plan before seeing her family doctor. One individual, more severely affected by her arthritis, recounted how occupational therapists are central to her independence through the adaptation of her apartment, home management, and finding creative ways to help her maintain activities of daily living.

Not all comments were positive however. Both knowledge and attitudes were perceived to affect the services that arthritis patients get. To the question concerning availability of PT and OT services, access was seen as a problem in about 50% of replies. Wait times were listed by several individuals as a significant problem. The reduction in provincial funding for PT and OT services was seen by one person as making access more difficult, and another mentioned that private health insurance or being able to pay for services facilitated more ready access. In most cases of publicly funded services the time required to see a therapist was given as anywhere from 3-6 months. Occupational therapist numbers were perceived to be small with most working with post-surgical patients in a hospital setting and not many practicing in the community. Respondents also identified the small number of therapists with special training or experience in treating people with arthritis as sometimes being a problem, and one person spoke of damage done inadvertently to a patient’s knee by a PT with limited current knowledge of RA. In addition, some patients get the sense that therapists in high demand may be reluctant to take arthritis patients because dealing with such patients can be more time consuming and challenging.

In the next edition of CAPA Voices we plan to present the perspective of the University of Saskatchewan graduate students in Physical Therapy who developed themes from the pooled survey responses.