Physiotherapy in Rheumatoid Arthritis

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.

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

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. Intra-articular 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 intra-articular 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.