Download Physiotherapy in Rheumatoid Arthritis

Physiotherapy in Rheumatoid Arthritis
Vural Kavuncu, MD; Deniz Evcik, MD
Medscape General Medicine. 2004;6(2):3. ©2004 Medscape
Posted 05/17/2004
Abstract and Introduction
Abstract
Rheumatoid arthritis (RA) is a chronic and painful clinical condition that leads to progressive
joint damage, disability, deterioration in quality of life, and shortened life expectancy. Even
mild inflammation may result in irreversible damage and permanent disability. The clinical
course according to symptoms may be either intermittent or progressive in patients with RA.
In most patients, the clinical course is progressive, and structural damage develops in the first
2 years. The aim of RA management is to achieve pain relief and prevent joint damage and
functional loss. Physiotherapy and rehabilitation applications significantly augment medical
therapy by improving the management of RA and reducing handicaps in daily living for
patients with RA. In this review, the application of physiotherapy modalities is examined,
including the use of cold/heat applications, electrical stimulation, and hydrotherapy.
Rehabilitation treatment techniques for patients with RA such as joint protection strategies,
massage, exercise, and patient education are also presented.
Introduction
RA is a chronic and progressive disease leading to considerable physical functional loss and
disability. Currently, there is no curative therapy for RA; therefore, patients are subjected to
various life-long treatment modalities. Thus, an important component of successful
management of the disease is educating patients and informing them about the planned
treatment modalities. Objectives of physiotherapy and rehabilitation applications in patients
with RA are to prevent disability, to increase functional capacity, to provide pain relief, and to
provide patient education.[1]
Before starting therapy, the physiotherapy needs of patients are determined in accordance
with their incapacity, disability, and handicaps. Physical assessment should include these
components:





Functional assessment (ie, transfer status, analysis of gait, activities of daily living);
Range of joint motion (ROM) (for all joints);
Muscle strength test (manual or by isokinetic equipment);
Postural assessment; and
Evaluation of respiratory function.
It should be remembered that presence of inflammation, instability, and contractures may
affect the results of these evaluations and tests. Scales such as Arthritis Impact Measurement
Scale I and II, Health Assessment Questionnaire, and Functional Independence Measure may
be used for functional assessment.[2-4]
In this review, physiotherapy modalities and rehabilitation treatment techniques for patients
with RA are examined and are shown in Table 1 .
Physiotherapy Modalities
Physiotherapy modalities are commonly used in the treatment of RA. These include cold/hot
applications, electrical stimulation, and hydrotherapy.
Controlled studies performed with adequate numbers of cases and using validated objective
measures to evaluate various physiotherapy and rehabilitation methods in RA are quite rare.
This is because the disease process may be affected by various factors, and the actual
effectiveness of the investigated agents is difficult to determine. However, various
physiotherapy agents are commonly used in daily practice; most often, their use is based on
personal experiences.
Cold/Hot Applications
Cold/hot modalities are the most commonly used physical agents in arthritis treatment. It is
well known that cold application is mostly used in acute stages whereas hot is used in chronic
stages of RA.
By using heat, analgesia is accomplished, muscle spasm relieved, and elasticity of
periarticular structures obtained. Heat can be used before exercise for maximum benefit.
Thermotherapy may be applied as a superficial hot-pack, infrared radiation, paraffin,
fluidotherapy, or hydrotherapy. Applications are recommended for 10-20 minutes once or
twice a day. Caution is necessary in patients with sensorial deficits and impaired vascular
circulation in hands and feet because of burn risk. Cold application is preferred in active joints
where intra-articular heat increase is undesired. Cold-pack, ice, nitrogen spray, and
cryotherapy are different methods of applying cold-therapy.
Cartilage-destroying enzymes are produced within the inflamed joints of patients with RA.
Levels of destructive enzymes such as collagenase, elastase, hyaluronidase, and protease are
affected by the temperature of local joints. With temperatures of 30° Celsius or lower, effects
of these enzymes are negligibly small. Normal intra-articular temperature is 33° Celsius,
whereas it may rise up to 36° Celsius in patients with RA. Increasing intra-articular
temperature is also related to an increase in collagenase activity and cartilage damage. Despite
the inhibition of cell proliferation and metabolic activation within the synovial fluid at 41-42°
Celsius, it cannot be used as a therapeutic method because of irreversible joint damage.[5]
Various studies have investigated the changes within joints upon application of heat. Intraarticular temperature increased by superficial heat application.[6] In the first 5 minutes, the
joint temperature decreased but subsequently, as expected, it began to rise. It has been
suggested that within the first few minutes, superficial vessels become dilated and circulation
moves away from the inflamed synovial tissue. The opposite of this occurs during the cold
application. Effects of heat application change between normal healthy subjects and patients
with inflamed joints.[7] Accordingly, skin temperature rises with paraffin at the most and intraarticular joint temperature with diathermy application. Temperature increase with short-wave
diathermy application continues for 40 minutes.[8] However, it has been observed that
increased intra-articular temperature has no beneficial effect on clinical prognosis or
radiologic progression. Skin temperature decreases the most by cold air application, whereas
intra-articular temperature decreases the most by ice application. Increased intra-articular
temperature by cold-pack application may be explained by reactional temperature rise with
short-term application, which was previously mentioned.
Electrical Stimulation
Electrostimulation is used in patients with RA to relieve pain. Transcutaneous electrical nerve
stimulation (TENS) therapy is the most commonly used method. Mannheimer and Carlsson[9]
applied TENS at various frequencies and reported that the highest frequency TENS[10] was the
most beneficial, with an analgesia that persisted up to 18 hours. Various studies have reported
an increase in hand grip strength after daily application of 15 minutes of TENS[11] and a
decrease in pain after using TENS once a week for 3 weeks.[12] Levy and colleagues[13]
observed reduction of synovial fluid and inflammatory exudate following TENS application
in acute arthritis and suggested that pain relief may be partially explained by this effect.
Postoperative pain control by TENS therapy following knee joint arthroplasty reduces need
for analgesic drugs and hospital stays. Due to the variations between the materials and
methods of the studies, it is difficult to interpret TENS applications. Nevertheless, TENS is
generally a short-acting therapy (6-24 hours), and the most beneficial frequency is 70 Hz. It
also has a high placebo effect. It cannot be used in every painful joint simultaneously, which
is a disadvantage in patients with polyarticular involvement. Interferential current can also be
used for analgesia. Studies have shown its efficacy on pain relief, swelling, and improvement
in ROM.[14] Also, no difference was found between interferential current and TENS in the
magnitude of analgesia.[15]
Hydrotherapy
There has been widespread use of balneotherapy by patients with rheumatic diseases since the
old times in search of a cure for their ailment. Therefore, there are some suggestions that the
science of rheumatology has been developed in balneotherapy.[16] Initially, the term
"balneotherapy" was used to discriminate thermal and mineral water therapy from
hydrotherapy, but today these terms are often used interchangeably. In recent years,
balneotherapy has served as one of the therapeutic alternatives in other rheumatoid diseases,
particularly in chronic degenerative diseases. Objectives of balneotherapy are to increase
ROM, to strengthen muscles, to relieve painful muscle spasms, and to improve the patient's
well-being.
Balneotherapy in arthritis treatment is a disputed issue. O'Hare and colleagues[17] have
reported an increase in diuresis, hemodilution, and a reduction in rheumatoid factor levels. In
contrast, Becker[18] has attributed the main effect to a decrease in joint loading, relaxation, and
an increase in general physical conditioning. There have been studies showing beneficial
effects of balneotherapies on several factors such as reduction in pain and grip strength.[19,20]
Effectiveness of balneotherapy is not only associated with hot water but also with the
minerals contained in the water. It has been claimed that mineral waters have some positive
effects in balneotherapy. Water has mechanical, chemical, and physical action mechanisms.
Its mechanical action occurs during the bath when the body weight decreases by 50% to 90%
depending on the type of bath. In cases of muscle weakness or widespread painful joint
inflammation, this action allows the patients to perform their exercise programs. In addition,
various studies have shown that balneotherapy leads to muscle, tendon, and ligament
relaxation and a feeling of well-being.[21] Here the action mechanism provides exponential
benefits. Decreasing perception of pain by increasing the pain thresholds at free nerve
endings, relieving muscle spasm by effecting gamma muscle fibers, peripheral vasodilatation,
and removal of painful mediators are among these mechanisms. In addition, balneotherapy
has a sedating effect by increasing acetylcholine release from the central nervous system
through activation of parasympathetic nervous system. Endorphin release throughout the
therapy also contributes to improved action mechanisms.[22,23]
Effects of balneotherapy on the immune system have recently become a subject of interest.
There are some speculations about its immunostimulatory and inhibitory effects. In particular,
alterations in release of interleukin-1 and interleukin-6, tumor necrosis factor-alpha, and
gamma-interferon, which have a role in etiopathogenesis of inflammatory arthritis, have been
reported.[24,25]
Environmental changes while at balneotherapy should also be considered. Physical and
mental comfort, cessation of home duties, and vacation atmosphere are among positive factors
that may also contribute to the healing process.
In conclusion, although the effects of balneotherapy are currently not clarified, it is a
palliative treatment in rheumatoid diseases through various mechanisms. There is need for
further appropriately designed studies encompassing assessment of quality of life as an
outcome measure.
Rehabilitative Treatment
Physiotherapy treatment is important in helping patients with RA manage their disease. In
conjunction with occupational therapists, physiotherapists educate patients in joint protection
strategies, use of assistive devices, and performance of therapeutic exercises.
Joint Protection Strategies
Joint protection strategies, such as rest and splinting, using compressive gloves, assistive
devices, and adaptive equipment, have beneficial effects in managing RA symptoms and
deformities.
Rest and Splinting. The joints should be put into rest during the acute stage of the disease.
Bed rest relieves the pain in cases of extensive joint involvement. It is critical, at this stage, to
put the joints into rest at a functional position. Rest position should be as follows: shoulder
joint in 45° abduction, both wrist joints in 20° to 30° dorsal flexion, fingers slightly in flexion,
hips at 45° abduction without any flexion, knees totally extended, and feet in a neutral
position.[26] Splints may be used to give desired position at rest and functional positioning to
the involved active joints. Increased compliance can be gained by offering the patient splints
made of soft materials.[27] Orthosis and splinting are used for the following objectives[28]: to
diminish pain and inflammation, to prevent development of deformities, to prevent joint
stress, to support joints, and to decrease joint stiffness.
Various reports have shown benefits of wrist splints in controlling pain and inflammation and
preventing the development of deformities.[29,30] Flexible wrist orthosis increases hand grip
strength by 20% to 25%.[31] Various ring orthoses have been developed to prevent finger
deformities. Major factors determining patient compliance to the orthosis are size of the
orthosis, the heat generated at the skin by the orthosis, hardness of the parts in contact with
the skin, and whether it interferes with functions of the hand. Joint stress in the feet may be
alleviated by medial arc supporting pad at the sole of the foot and by metatarsal pad.
Viscoelastic soles may decrease shock loading occurring at proximal tibia during the gait, by
up to 40%.[32] Philadelphia corset may be recommended if atlantoaxial involvement is
present. Orthosis provides better immobilization and may be used in the presence of cervical
instability.
Compression Gloves. Patients using compression gloves have reported reduced joint
swelling and increased well-being.[33] However, there is no positive evidence regarding
improved grip strength or hand functions from using gloves. Improvement may be provided
by using compression gloves for hour intervals or only at night in patients with inflammation
in their hands or fingers.[34] Gentle compression is beneficial because of the containment of
joint swelling and subsequent decrease of pain.
Assistive Devices and Adaptive Equipment. Occupational therapy improves functional
ability in patients with RA. Occupational therapy interventions such as assistive devices and
adaptive equipments have beneficial effects on joint protection and energy conservation in
arthritic patients.[35] Assistive devices are used in order to reduce functional deficits, to
diminish pain, and to keep patients' independence and self-efficiency. Loading over the hip
joint may be reduced by 50% by holding a cane.[36] In fact, most of these instruments are
originally designed for patients with neurologic deficits; therefore, certain adaptations may be
needed for them to be used in patients with arthritis. Elevated toilet seats, widened gripping
handles, arrangements related with bathrooms, etc. might all facilitate the daily life. The
procedures needed to increase compliance of the patient with the environment and to increase
functional independence are mainly determined by the occupational therapist. Catalogues
introducing various assisting equipment models designed for every kind of requirement
should be presented to patients.
Massage Therapy. Massage is a commonly used treatment tool that improves flexibility,
enhances a feeling of connection with other treatment modalities, improves general well
being, and can help to diminish swelling of inflamed joints. Dhondt and colleagues[37] have
reported that pain thresholds both at the massage site and at the knee and ankle have
decreased after applying oscillatory manual massage to the intervertebral paraspinal region.
Massage is found to be effective on depression, anxiety, mood, and pain.[38] This finding leads
to the question of whether there are some changes in peripheral nociceptive perception and
central information in RA. Also, massage decreases stress hormone levels.[39]
Therapeutic Exercise
Muscle weakness in patients with RA may occur because of immobilization or reduction in
activities of daily living. Maintenance of normal muscle strength is important not only for
physical function but also for stabilization of the joints and prevention of traumatic injuries. It
may be proposed that exercise therapy has beneficial effects on increasing physical capacity
rather than reducing the activity of the disease.[40]
Prior to establishing an exercise program for patients with RA, the following characteristics
should be considered: whether the involvement of the joints is local or systemic, stage of the
disease, age of the patient, and compliance of the patient with the therapy. Duration and
severity of the exercise are adjusted according to the patient. ROM exercises, stretching,
strengthening, aerobic conditioning exercises, and routine daily activities may be used as
components of exercise therapy.
There should be no straining exercises during the acute arthritis. However, every joint should
be moved in the ROM at least once per day in order to prevent contracture. In the case of
acutely inflamed joints, isometric exercises provide adequate muscle tone without
exacerbation of clinical disease activity. Moderate contractures should be held for 6 seconds
and repeated 5-10 times each day. It should be remembered that if isometric exercises are
performed in a magnitude of more than 40% of maximum voluntary contraction, they may
lead to impairment in blood circulation and fatigue after the exercise. If the disease activity is
low, then isotonic exercises should be performed by using very low weights. Low-intensity
isokinetic knee exercises (by 50% of the maximum voluntary contraction) were reported to be
safe and effective in patients with RA.[41] If pain persists more than 2 hours or too much
fatigue, loss of strength, or increase in joint swelling occurs after an exercise program, then it
should be revised. Also, walking does not lead to intra-articular pressure increase in healthy
subjects but does so in a knee with inflammation and effusion. Thus, patients with active
arthritis should particularly avoid activities such as climbing stairs or weight lifting.
Producing excessive stress over the tendons during the stretching exercises should be avoided.
In sudden stretches, tendons or joint capsules may be damaged. Finally, in chronic stage with
inactive arthritis, conditioning exercises such as swimming, walking, and cycling with
adequate resting periods are recommended. They increase muscle endurance and aerobic
capacity and improve functions of the patient in general, and they also make the patient feel
better.
Patient Education
In patients with RA, sociopsychological factors affecting the disease process such as poor
social relations, disturbance of communication with the environment, and unhappiness and
depression at work are commonly encountered. Scholten and colleagues[42] have organized
multidisciplinary education with the participation of rheumatologists, orthopedicians,
physiotherapists, psychologists, and social workers for patients with arthritis. In this program,
there is information about benefits and adverse effects of drug therapy, importance of
physiotherapy, use of orthosis, psychological coping methods, self-relaxation, and various
diets. In addition, patients are taught how to perform the scheduled exercises and how to
protect the joints during routine daily life. Patients who have participated in this program have
revealed improvement in disability associated with the disease, psychosocial interaction, and
clinical prognosis. All clinics that deal with the treatment of rheumatic diseases should
provide education and information to their patients about their condition and the various
physical therapy and rehabilitative options that are available to improve their quality of life.
Table 1. Physiotherapy Modalities and Rehabilitation Treatment Techniques Used in
Rheumatoid Arthritis Patients
1. Physiotherapy Modalities
2. Rehabilitation Treatment Technique
- Hot/cold applications
- Rest and splinting
- Electrical stimulation
- Compression gloves
- Hydrotherapy and spa therapy - Assistive devices and adaptive equipment
- Massage therapy
- Therapeutic exercise
- Patient education
References
1. Sandy B, Ganz PT, Harris LL. General overview of rehabilitation in the rheumatoid
patient. Rheum Dis Clin North Am. 1998;24:181-201. Abstract
2. Wade TD. Measurement in Neurological Rehabilitation. New York: Oxford
University Press; 1992:189.
3. Wade TD. Measurement in Neurological Rehabilitation. New York: Oxford
University Press; 1992:349-350.
4. Wade TD. Measurement in Neurological Rehabilitation. New York: Oxford
University Press; 1992:218-223
5. Harris ED, McCroskery PA. The influence of temperature and fibril stability on
degradation of cartilage collagen by rheumatoid synovial collagenase. N Engl J Med.
1974;290:1-6. Abstract
6. Oosterveld FG, Rasker JJ. Effects of local heat and cold treatment on surface and
articular temperature of arthritic knees. Arthritis Rheum. 1994;37:1578-1582. Abstract
7. Fredrikus GJ, Oosterveld FG, Rasker J. Treating arthritis with locally applied heat or
cold. Semin Arthritis Rheum. 1994;24:82-90. Abstract
8. Mainardi C, Walter JM, Spiegel PK, Goldkamp OG, Harris ED. Rheumatoid arthritis:
failure of daily heat therapy to affect its progression. Arch Phys Med Rehabil.
1979;60:390-392. Abstract
9. Mannheimer C, Carlsson CA. The analgesic effect of transcutaneous electrical nerve
stimulation (TENS) in patients with rheumatoid arthritis. A comparative study of
different pulse patterns. Pain. 1979;6:329-334. Abstract
10. Mannheimer C, Lund S, Carlsson CA. The effect of transcutaneous electrical nerve
stimulation (TNS) on joint pain in patients with rheumatoid arthritis. Scand J
Rheumatol. 1978;7:13-16. Abstract
11. Kumar VN, Redford JB. Transcutaneous nerve stimulation in rheumatoid arthritis.
Arch Phys Med Rehabil. 1982;63:595-596. Abstract
12. Abelson K, Langley GB, Sheppeard H, Vlieg M, Wigley RD. Transcutaneous
electrical nerve stimulation in rheumatoid arthritis. N Z Med J. 1983;96:156-158.
Abstract
13. Levy A, Dalith M, Abramovici A, Pinkhas J, Weinberger A. TENS in experimental
acute arthritis. Arch Phys Med Rehabil. 1987;68:75-78. Abstract
14. Jarit GJ, Mohr KJ, Waller R, Glousman RE. The effects of home interferential therapy
on post-operative pain, edema, and range of motion of the knee. Clin J Sport Med.
2003;13:16-20. Abstract
15. Johnson MI, Tabasam G. An investigation into the analgesic effects of interferential
currents and transcutaneous electrical nerve stimulation on experimentally induced
ischemic pain in otherwise pain-free volunteers. Phys Ther. 2003;83:208-223.
Abstract
16. Fam AG. Spa treatment in arthritis: a rheumatologist's view (editorial). Br J
Rheumatol. 1993;23:771-773.
17. O'Hare JP, Haywood A, Summerhayes C, et al. Observations on the effect of
immersion in bath spa water. BMJ. 1985;291:1747-1751. Abstract
18. Becker BE. The biologic aspects of hydrotherapy. J Back Musculoskel Rehabil.
1994;4:255-264.
19. Elkayam O, Wigler I, Tishler M, et al. Effect of spa therapy in Tiberias on patients
with rheumatoid arthritis and osteoarthritis. J Rheumatol. 1991;18:1799-1803.
Abstract
20. Sukenik S, Neumann L, Flusser D, Kleiner-Baumgarten A, Buskila D. Balneotherapy
for rheumatoid arthritis at the Dead Sea. Isr J Med Sci. 1995;31:210-214. Abstract
21. Evcik D, Kizilay B, Gokcen E. The effects of balneotherapy on fibromyalgia patients.
Rheumatol Int. 2002;22:56-59. Abstract
22. Van Tubergen A, Boonen A, Landewe R, et al. Cost effectiveness of combined spaexercise therapy in ankylosing spondylitis: a randomized controlled trial. Arthritis
Rheum. 2002;47:459-467. Abstract
23. Strauss-Blasche G, Ekmekcioglu C, Klammer N, Marktl W. The change of well being
associated with spa therapy. Forsh Komplementarmed Klass Naturheilkd. 2000;7:269274.
24. Kuboto K, Kurabayashi H, Tamura K, et al. A transient rise in plasma beta endorphin
after a traditional 47.0C hot-spring bath in Kusatsu-Spa, Japan. Life Sci.
1992;15:1877-1880.
25. Kappel M, Diamant H, Hansen MB, et al. Effects in vitro hyperthermia on the
proliferative response of blood mononuclear cell subsets, and detection of interleukins
1-6, tumor necrosis factor-alpha and interferon-gamma. Immunology. 1991;73:304308. Abstract
26. Chan AS, Vallbona C. Immobilization. In: Garrison SJ, ed. Handbook of Physical
Medicine and Rehabilitation. Philadelphia, Pa: Lippincott Williams and Wilkins;
2003:152-160.
27. Callinan NJ, Mathiowetz V. Soft versus hard resting hand splints in rheumatoid
arthritis: Pain relief, preference and compliance. Am J Occup Ther. 1995;50:347-353.
28. Falconer J. Hand splinting in rheumatoid arthritis: a perspective on current knowledge
and directions for research. Arthritis Care Res. 1991;4:81-86. Abstract
29. Philips CA. Management of the patient with rheumatoid arthritis: the role of the hand
therapist. Hand Clin. 1989;5:291-309. Abstract
30. Ouellette EA. The rheumatoid hand: orthotics as preventive. Semin Arthritis Rheum.
1991;2:65-72.
31. Kjelen I, Moller G, Kvien T. Use of commercially produced elastic wrist orthosis in
chronic arthritis: a controlled study. Arthritis Care Res. 1995;8:108-113. Abstract
32. Voloshin D, Wosk J. Influence of artificial shock absorbers on human gait. Clin
Orthop. 1981;160:52-56. Abstract
33. Culic DD, Battagalia MC, Wichman BS, Schmid FR. Efficacy of compression gloves
in rheumatoid arthritis. Am J Phys Med. 1979;58:278-284. Abstract
34. Nicholas JJ. Physical modalities in rheumatological rehabilitation. Arch Phys Med
Rehabil. 1994;75:994-1001. Abstract
35. Neumann DA. Biomechanical analysis of selected principles of hip joint protection.
Arthritis Care Res. 1989;2:146-155. Abstract
36. Steultjens E, Dekker J, Bouter L, Schaardenburg D, Kuyk M, Ende C. Occupational
therapy for rheumatoid arthritis. Cochrane Database Syst Rev. 2004;1:CD003114.
37. Dhondt W, Willaeys LA, Verbruggen A, Oostendorp RAB, Duquet W. Pain threshold
in patients with rheumatoid arthritis and effect of manual oscillations. Scand J
Rheumatol. 1999;28:88-93. Abstract
38. Walach H, Guthlin C, Konig M. Efficacy of massage therapy in chronic pain: a
pragmatic randomized trial. J Altern Complement Med. 2003;9:837-846. Abstract
39. Field T, Hernandez-Reif M, Seligman S, et al. Juvenile rheumatoid arthritis: benefits
from massage therapy. J Pediatr Psychol. 1997;22:607-617. Abstract
40. Van den Ende CHM, Vliet Vlieland TPM, Munneke M, Hazes JMW. Dynamic
exercise therapy in rheumatoid arthritis: a systematic review. Br J Rheumatol.
1998;37:677-687. Abstract
41. Lynberg KK, Ramsing BU, Nawrocki A, Harreby M, Samsoe BD. Safe and effective
isokinetic knee extension training in rheumatoid arthritis. Arthritis Rheum.
1994;37:623-628. Abstract
42. Scholten C, Brodowicz T, Graninger W, et al. Persistent functional and social benefit
5 years after a multidisciplinary arthritis training program. Arch Phys Med Rehabil.
1999;80:1282-1287. Abstract