Physiotherapy, occupational therapy and rehabilitation

When people picture arthritis treatment they usually picture medicines, and medicines matter: they control the inflammation and protect the joints from damage. But treatment has a second half that is just as important and often less well understood. Rehabilitation is the collection of movement-based and practical therapies that restore strength, restore movement and help you get back to daily life. It is not an optional extra bolted on at the end. For osteoarthritis, UK guidance from NICE makes therapeutic exercise a core treatment, and for rheumatoid arthritis NICE recommends that people have access to specialist physiotherapy and specialist occupational therapy. Rehabilitation and medicines are two halves of one plan, and they work best together.

This guide brings the main therapies together in one place, and it is worth being honest at the outset about how the practice fits in. Dr Borukhson diagnoses the problem, including with ultrasound, brings any active inflammation under control, and decides the timing and coordination of rehabilitation. The hands-on therapy itself is delivered by physiotherapists, occupational therapists and hand therapists, to whom the practice refers. The value a specialist adds is getting the diagnosis right, settling the inflammation, and making sure rehabilitation happens at the right moment rather than in isolation.

Physiotherapy is the backbone of rehabilitation in arthritis. A physiotherapist assesses how your joints and muscles move, then builds a graded, supervised programme tailored to you: strengthening the muscles that support a joint, restoring range of movement, and rebuilding fitness at a pace your body can handle.

This is where it helps to draw a clear line between supervised physiotherapy and self-directed exercise. The regular activity you do on your own, walking, swimming, strengthening, keeping generally active, is one of the most effective things you can do for arthritis, and our guide to arthritis and exercise is devoted to it. Physiotherapy is different in that it is assessed, tailored and supervised. It comes into its own when you are recovering from an injury, when a joint has been left stiff or weak after a flare, when you are unsure how hard to push, or when a specific problem such as a frozen shoulder or a rotator cuff problem needs a targeted programme. Alongside exercise, physiotherapists use hands-on (manual) techniques and advice on managing pain. Once you have your confidence and a routine, much of the ongoing work becomes self-directed exercise that you continue yourself.

Hydrotherapy, also called aquatic physiotherapy, is exercise carried out in a warm-water pool under the guidance of a physiotherapist. The water is kept comfortably warm, warmer than an ordinary swimming pool, and it supports your weight so that painful or stiff joints can move with far less strain. For some people, particularly when land-based exercise is too painful to get going, warm water offers a gentler way in, and the warmth itself can be soothing.

It suits people whose joints are too sore to exercise easily on dry land, and it can be a useful bridge into a more active routine. The honest position is that the evidence for hydrotherapy is more modest than for land-based exercise: it can help symptoms and confidence in the short term, but it has not been shown to be better than exercising on land, and NHS access varies from area to area. Think of it as a helpful option for the right person rather than a treatment everyone needs.

Occupational therapy answers a different question: not how a joint moves in the abstract, but how you manage the actual tasks of your day. An occupational therapist looks at the activities you find difficult, at work, at home or in your hobbies, and finds practical ways to make them easier on your joints.

Their toolkit includes joint protection, which is learning to use and position joints in ways that reduce strain; energy conservation and pacing, which is planning activity so that fatigue and pain do not derail your day, and which our guide to fatigue and arthritis explores further; assistive devices and gadgets that take the load off vulnerable joints; and splints or orthoses that rest or support a joint. Splinting is especially valuable for the hands and wrists, where a well-fitted splint can ease conditions such as carpal tunnel syndrome, trigger finger and De Quervain's tenosynovitis. Hand therapy, delivered by physiotherapists or occupational therapists with specialist training, combines these measures with tailored exercises to keep the hands working, which matters a great deal in rheumatoid arthritis and psoriatic arthritis.

Rehabilitation is most effective when it is timed well, and this is where specialist input earns its place. A therapy programme works best once pain and active inflammation are settling, when the joint can move more freely and the effort you put in is not fighting against an actively inflamed joint.

Several moments lend themselves naturally to rehabilitation. After a steroid injection or a hyaluronic acid injection, the window of reduced pain is an ideal time to rebuild strength and movement, so the benefit of the injection is consolidated rather than lost. Once a flare has settled, physiotherapy helps restore what stiffness and disuse took away. After any period of immobility, whether from illness, injury or a spell of severe pain, a graded programme rebuilds lost condition safely. Rehabilitation around planned surgery, before and after an operation, follows the same logic and is arranged with your surgical team. Confirming the diagnosis and the target with ultrasound-guided injections, and getting inflammation under control before and while a programme runs, is exactly how the practice helps rehabilitation succeed rather than stall.

In the UK there are several routes to physiotherapy and occupational therapy, and which is open to you depends partly on where you live. Both are available on the NHS and privately. The usual routes are a referral from your GP or from a specialist, and for physiotherapy in particular many areas now allow self-referral, where you contact an NHS musculoskeletal physiotherapy service directly without seeing a GP first. Availability of self-referral, and of specific services such as hydrotherapy, varies considerably from area to area, so it is worth checking what your local service offers. A specialist assessment can help by identifying which therapy is most likely to benefit you, arranging the referral, and timing it to fit the rest of your treatment.

It is worth being honest about how the evidence lines up, because not every therapy is equally well proven. Supervised, graded exercise from a physiotherapist has strong and consistent evidence for reducing pain and improving function, and it is recommended in national guidance for both osteoarthritis and inflammatory arthritis. Occupational therapy, and joint protection in particular, is well supported for protecting function and easing the strain of everyday tasks, especially in the hands.

Other therapies have more modest or mixed evidence, and it is fairer to say so than to oversell them. Hydrotherapy can help in the short term but has not been shown to be better than land-based exercise. Passive treatments such as TENS machines, which pass a mild electrical current across the skin to ease pain, and wax baths for the hands, may give some people short-term comfort but have limited evidence behind them and are best seen as optional extras rather than core treatment. None of this makes the gentler options worthless. It simply means the strongest effort is best aimed at the therapies with the strongest evidence, with the others added where they genuinely help an individual.

It is easy to think of arthritis care as a matter of finding the right medicine, and to treat everything else as advice to be got through. Rehabilitation deserves better than that. For many people it is the part of treatment that most directly restores what arthritis takes away: the strength to climb the stairs, the movement to reach a shelf, the confidence to keep doing the things that make up a life. Medicines and rehabilitation are not rivals; each makes the other work better, and the joints protected by good treatment are the joints that respond best to therapy. The role of a specialist is to make sure the two are joined up: the right diagnosis, the inflammation controlled, and rehabilitation started at the right moment and pointed in the right direction, with the hands-on work carried out by the physiotherapists and occupational therapists who do it best. Rehabilitation is not what you turn to when treatment has run out of options. It is one of the treatments.

What is the difference between physiotherapy and exercising on my own?

Both matter, and they work together. Self-directed exercise, which our guide to arthritis and exercise covers, is the regular activity you keep up to hold on to strength and movement. Physiotherapy is assessed, tailored and supervised: a physiotherapist examines your specific joints, sets a graded programme, corrects technique and adds hands-on treatment where it helps. It comes into its own after an injury or a flare, or when you are not sure how hard to push. Once you have your confidence and a routine, much of the ongoing work becomes self-directed exercise that you carry on yourself.

Does the practice provide physiotherapy and occupational therapy?

Not directly, and it is worth being clear about that. Dr Borukhson diagnoses the problem, including with point-of-care ultrasound, gets any active inflammation under control, and decides the timing of rehabilitation, notably around an injection or once a flare has settled. The hands-on therapy itself is delivered by physiotherapists, occupational therapists and hand therapists, to whom the practice refers. The aim is that treatment and rehabilitation are coordinated rather than happening in isolation.

Is hydrotherapy (warm-water exercise) worth trying?

It can be, particularly if your joints are too painful to exercise easily on land. Warm water supports your weight and eases movement, and many people find it a gentler way to start. The honest position is that the evidence for hydrotherapy is more modest than for land-based exercise, so it is best thought of as a helpful option for some people rather than something everyone needs. Access through the NHS varies by area, and a physiotherapist can advise whether it suits you.

How do I arrange physiotherapy or occupational therapy in the UK?

You can reach these therapies through your GP or a specialist referral, on the NHS or privately, and in many areas you can now refer yourself to an NHS musculoskeletal physiotherapy service without seeing a GP first. What is available, including self-referral and services such as hydrotherapy, depends on where you live. A specialist assessment can identify which therapy is most likely to help, arrange the referral, and time it to fit the rest of your treatment.

When is the best time to start rehabilitation?

Timing matters. Rehabilitation tends to work best once pain and active inflammation are settling, so a therapy programme often follows a steroid injection or the settling of a flare, when the joint can move more freely. Confirming the diagnosis and controlling inflammation first means the effort you put in is not fighting against an actively inflamed joint. Your specialist and physiotherapist will help you judge the right moment.