Rheumatoid arthritis: my minimum evidence standard

Step 01

Rheumatoid arthritis is classified in ICD-11 as a joint disease, and its pain as secondary to it

ICD-11 classification

In ICD-11, the World Health Organization's classification of diseases, rheumatoid arthritis sits with the diseases of the musculoskeletal system. The pain it causes is classified separately, as chronic secondary musculoskeletal pain from persistent inflammation: pain that is a consequence of the disease rather than a condition in its own right.

This matters for your file. The impairment is the joint disease (inflammation, joint damage, and loss of strength and movement), and pain is one of its effects. A strong file also records whether you are seropositive or seronegative (the blood test result), and whether imaging shows erosions or joint damage. Both are usually already in rheumatology letters; a strong file brings them forward.

Juvenile arthritis is coded separately (FA24.1) and isn't covered on this page.

The next step is what's driving the pain.

Step 02

Rheumatoid arthritis pain is mostly inflammatory, and it can continue after the inflammation is controlled

Pain mechanism

Pain is classified by mechanism: nociceptive (from tissue), neuropathic (from nerve injury or disease), or nociplastic (from altered pain processing in the nervous system). In rheumatoid arthritis, pain is mostly nociceptive. Inflammation in the joint lining releases substances that sensitise nociceptors, the nerve endings that respond to potential harm, so movement and pressure that wouldn't normally hurt become painful. Joint damage adds a structural source. For some people, persistent input changes how the spinal cord and brain process it (central sensitisation), adding a nociplastic contribution.

That's why “well controlled” describes the disease, not the person. A low disease activity score means the inflammation is controlled. It doesn't mean the pain has gone, or that you can do what you did before. A strong file records disease activity, pain and function as three separate things, each measured.

The next step is the criteria the diagnosis is checked against.

Step 03

Rheumatoid arthritis is diagnosed against the 2010 ACR/EULAR criteria

Diagnostic criteria

AAPT has not published criteria for rheumatoid arthritis. The recognised standard is the 2010 classification criteria of the American College of Rheumatology and EULAR, which ICD-11 uses in its own definition. In practice a rheumatologist makes the diagnosis, applying them alongside the history, examination and tests. They apply to someone with at least one swollen joint that isn't better explained by another disease, and score four areas.

A strong file also records imaging, the rheumatologist's confirmation of the diagnosis and its date, and disease activity scores over time. The Australian Rheumatology Association's Clinical Care Standard expects disease activity to be assessed regularly, so these scores are usually already in the record. The file also records which other causes of joint pain and swelling were considered, for example psoriatic arthritis, lupus, gout, viral arthritis, osteoarthritis and polymyalgia rheumatica. Osteoarthritis often occurs alongside rheumatoid arthritis, and a file that says which joints belong to which condition is much easier to read.

Once the diagnosis is settled, the question most refusals come down to is what has been tried.

Step 04

A rheumatoid arthritis treatment history is easiest to read when it covers the nine elements of pain management

Treatment history · s 24(1)⁠(b)

Rheumatoid arthritis is on the NDIS's List B, the conditions it accepts as likely to cause a permanent impairment (Amgad [130]). So the treatment record matters for a different reason here. It rarely decides permanence on its own, but it shows what the disease has done despite treatment, and why the function your file describes is the function that remains. I check it against the nine elements of pain management (HEAPPPPSS). For each one, the table names a published source, Australian where one exists. For a support request, the same record shows where treatment ends and disability support begins, which is how the NDIS decides whether the health system should fund it instead.

For each element in your file, the NDIS looks for what was done and what happened, in pain and in function. For medicines, that means what was tried, whether it was taken as prescribed, and why it was changed or stopped; the reason for each change matters as much as the list. If an element never appears, the file says nothing about it, and the NDIS decides what that silence means.

A rheumatologist's summary carries weight. In one decision in my index, the treating rheumatologist's statement that the disease was “maximally treated”, with other available therapies already tried, was accepted (Kelly [138], [140]). Where your rheumatologist has said something like that, a strong file quotes it.

Permanence is one requirement. Function is the other one a rheumatoid arthritis file most often has to show.

Rheumatoid arthritis function is shown best across a whole day and the week that follows, not in one appointment

Function over time · s 24(1)⁠(c)

Rheumatoid arthritis flares and settles, so an appointment in a good week sees a good week. Stiffness on waking can last more than an hour, and joint pain, swelling and fatigue after a demanding day often run into the next. A strong file counts the bad days and says what changes on them. It records which tasks can't be done, or need another person's help, not only which are slower. A single appointment sees one task on one day, so it tends to make you look more capable than you are.

A strong file follows what happens after a run of ordinary activities. I follow up at 24 hours, 72 hours and 7 days.

For an access request, I then match what your file shows to the six activity domains in s 24(1)⁠(c), the areas of daily life the NDIS assesses. For a support request, the same record shows what the support keeps you doing and what slips without it. Either way, that's done for each person, not for each condition.

Three published rheumatoid arthritis decisions show how files like this have fared at the Tribunal.