Transcript Structure of a rehabilitation program

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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
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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.
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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.
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Cold application is preferred in active joints where intraarticular heat increase is undesired. Cold-pack, ice, nitrogen
spray, and cryotherapy are different methods of applying
cold-therapy.
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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 inflammation.
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
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Transcutaneous electrical nerve stimulation (TENS) therapy
is the most commonly used method.
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The highest frequency TENS is the most beneficial, with an
analgesia that persists up to 18 hours.
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Various studies have reported an increase in hand grip
strength after daily application of 15 minutes of TENS and a
decrease in pain after using TENS once a week for 3 weeks
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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.
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Postoperative pain control by TENS therapy following knee
joint arthroplasty reduces need for analgesic drugs and
hospital stays.
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.
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Joint Protection Strategies
1.
Rest and Splinting
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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.
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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
Orthosis and splinting are used for the following objectives
o to diminish pain and inflammation,
o to prevent development of deformities,
o to prevent joint stress,
o to support joints, and
o to decrease joint stiffness.
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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
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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%.
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Patients using compression gloves have reported reduced
joint swelling and increased well-being.
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.
Gentle compression is beneficial because of the
containment of joint swelling and subsequent decrease of
pain.
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Occupational therapy interventions such as assistive
devices and adaptive equipment have beneficial effects on
joint protection and energy conservation in arthritic
patients.
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
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Massage is a commonly used treatment tool that improves
flexibility, improves general well being, and can help to
diminish swelling of inflamed joints
Pain thresholds both at the massage site and at the knee
and ankle decrease after applying oscillatory manual
massage to the intervertebral paraspinal region.
Massage is found to be effective on depression, anxiety,
mood, and pain.
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.
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Muscle weakness in patients 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.
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Prior to establishing an exercise program for patients with
joint diseases, the following characteristics should be
considered:
o whether the involvement of the joints is local or systemic,
o stage of the disease,
o age of the patient,
o and compliance of the patient with the therapy.
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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.
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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.
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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
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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.
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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.
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In patients with joint diseases, 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
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Multidisciplinary education with the participation of
rheumatologists, orthopedicians, physiotherapists,
psychologists, and social workers for patients with arthritis
is preferable
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In such programs, 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.
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