Structure of a rehabilitation program- CME - Presentation By Dr. Sidra Zahoor (Continuing Medical Education)
Pre Rehab Assessment
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
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.
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.
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
Transcutaneous electrical nerve stimulation (TENS) therapy is the most commonly used method.
The highest frequency TENS is the most beneficial, with an analgesia that persists up to 18 hours.
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
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.
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.
Joint Protection Strategies
1.Rest and Splinting
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.
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
to diminish pain and inflammation,
to prevent development of deformities,
to prevent joint stress,
to support joints, and
to decrease joint stiffness.
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
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%.
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.
Assistive Devices and Adaptive Equipment
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
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.
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.
Prior to establishing an exercise program for patients with joint diseases, 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
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.
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
Multidisciplinary education with the participation of rheumatologists, orthopedicians, physiotherapists, psychologists, and social workers for patients with arthritis is preferable
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.