Refer to: Conservative management of rheumatoid arthritisMedical Staff Conference-University of California, San Francisco. West J Med 129:121-125, Aug 1978
Medical Staf Conference
Conservative Management Rheumatoid Arthritis
of
These discussions are selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from transcriptions, they are prepared by Drs. David W. Martin, Jr., Associate Professor of Medicine, and Robert C. Siegel, Associate Professor of Medicine and Orthopaedic Surgery, under the direction of Dr. Lloyd H. Smith, Jr., Professor of Medicine and Chairman of the Department of Medicine. Requests for reprints should be sent to the Department of Medicine, University of California, San Francisco, CA 94143.
DR. SMITH: * The topic for this morning's Grand Rounds is the management of rheumatoid arthritis. Dr. Kenneth H. Fye will lead the discussion. DR. FYE: t Today's presentation will be unusual for a Grand Rounds in that the emphasis will be clinical. Discourse on the latest laboratory efforts to define the etiology and pathogenesis of the disease will be assiduously avoided. I will present a general description of rheumatoid arthritis and then proceed to a discussion of that therapeutic discipline-physical therapy-that has traditionally (and perhaps symbolically) been relegated to the basement of virtually every medical institution with which I have had contact. I will end with a brief outline of the role that orthopedic surgical therapy plays in the care of patients with rheumatoid arthritis. Rheumatoid arthritis is an autoimmune, systemic, inflammatory disease whose major, but by no means only, manifestations are articular.12 The disease affects women of childbearing age with a sex ratio of 3:1. The arthritis is symmetrical, polyarticular, inflammatory and erosive; it *Lloyd H. Smith, Jr., MD, Professor and Chairman, Department of Medicine tKenneth H. Fye, MD, Assistant Clinical Professor of Medicine
typically involves the small joints of the hands and feet. Patients characteristically complain of morning stiffness, as well as pain and tenderness, of the involved joints. The classic deformities associated with rheumatoid arthritis are due largely to periarticular inflammation, which results in muscle spasm, atrophy, and laxity of periarticular supporting structures. The swan neck deformity (hyperextension of the proximal interphalangeal joint and hyperflexion of the distal interphalangeal joint), the boutonniere deformity (hyperflexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint), ulnar deviation and subluxation of the metacarpal phalangeal joints, and lysis of tendons are all due to soft tissue inflammation. Large joints, such as elbows, shoulders, knees and hips, can be involved in the inflammatory process, particularly late in the course of the disease. Cervical spine involvement, seen in 30 percent of patients, may lead to laxity of the transverse ligament. In such patients the odontoid process may impinge upon the spinal cord during flexion of the neck. Even though laxity of the transverse ligament may be seen on x-ray studies, one should consider surgical therapy (fusion of THE WESTERN JOURNAL OF MEDICINE
121
MANAGEMENT OF RHEUMATOID ARTHRITIS
the cervical spine) only in patients with a neurologic deficit secondary to the cervical spine defect. The many extra-articular manifestations of rheumatoid arthritis are consistent with the systemic nature of the disorder. Constitutional findings, such as fever, chills, weight loss, lethargy and fatigue, reflect systemic inflammation. In 25 percent of patients, usually those with a positive rheumatoid factor and definite erosive arthritis, rheumatoid nodules will develop. Rarely, the manifestations of nodule formation may actually overshadow the arthritis. One of the commonest ocular expressions of rheumatoid disease, episcleritis, tends to be benign and does not require aggressive therapy. However, rheumatoid nodule formation on the sclerae should be treated vigorously, because scleronodular disease can lead to thinning (scleromalacia) and even perforation of the sclera. Pulmonary disease is not rare in patients with rheumatoid arthritis. In 15 percent of patients there will be pleural disease-ranging from pleural nodulosis to nonspecific pleuritis with or without pleural fluid. Parenchymal findings, seen in 1 to 2 percent of patients, include diffuse interstitial lymphocytic infiltration, interstitial fibrosis, pulmonary nodular disease and infections-such as bronchitis, pneumonia or empyema. Caplan syndrome is an entity that has stirred a great deal of controversy in rheumatologic circles. It probably represents only the development of pulmonary rheumatoid nodules in patients with rheumatoid arthritis who happen to be miners with pneumoconiosis.
Vascular inflammation is a major component of rheumatoid disease.3'4 The commonest form of vascular involvement is a bland, obliterative vasculitis involving small capillaries and venules. In 30 percent of patients with rheumatoid arthritis this form of vascular involvement is present; it is associated with a mild stocking-glove peripheral neuropathy. The lateral malleolar ulcers seen in 10 to 15 percent of patients with severe rheumatoid disease are due to vasculitic involvement of small cutaneous arterioles. In less than 1 percent of patients a systemic, necrotizing arteritis will develop that is clinically and histologically indistinguishable from periarteritis nodosa. Peripheral neuropathy is a frequent finding in patients with rheumatoid arthritis. Vasculitis may result in either a stocking-glove peripheral neuropathy or a mononeuritis multiplex, depending upon the severity of the vascular inflammatory process.\In
122
AUGUST 1978 * 129 * 2
addition, synovial proliferation at various points in the body, such as the carpal tunnel, can lead to compression syndromes. As discussed above, in patients who have cervical spondylitis with laxity of the transverse ligament, one may see cervical myelopathy. Cardiac involvement in rheumatoid disease is generally limited to the development of myocardial or epicardial nodules which cause nonspecific abnormalities seen on electrocardiograms. Splenomegaly and leukopenia in a patient with rheumatoid arthritis is known as Felty syndrome.5 Other clinical manifestations of Felty syndrome include lateral malleolar ulcers, rheumatoid nodule formation, lymphadenopathy, hepatosplenomegaly and recurrent infections.5 These patients tend to have rheumatoid factors, antinuclear antibodies, thrombocytopenia and anemia, as well as leukopenia. Sj6gren syndrome (keratoconjunctivitis sicca and xerostomia in patients with an autoimmune rheumatic disorder) is seen in 30 percent of patients with rheumatoid arthritis and must be considered in the differential diagnosis of any patient with rheumatoid disease in whom ocular complaints develop.6
Diagnosis The diagnosis of rheumatoid arthritis rests, primarily on the history and physical examination findings, but laboratory studies do offer clinicians valuable information. Patients with rheumatoid arthritis virtually always have an elevated erythrocyte sedimentation rate. Mild anemia, reflecting chronic inflammatory disease, is very common. Rheumatoid factors are seen in 75 percent and antinuclear antibodies in 20 percent of patients. In individual patients one may see a variety of immunoglobulin abnormalities, including hypergammaglobulinemia or cryoglobulinemia. Radiologic evaluation may show soft tissue swelling, diffuse or periarticular osteoporosis, marginal erosions, ulnar deviation or subluxation of involved joints. Occasionally, biopsy confirmation of the presence of rheumatoid nodules in synovium or other involved tissues can be of diagnostic value.
Therapy In rheumatoid arthritis as in every other disease, diagnostic evaluation is only a prelude to therapy. The treatment of rheumatoid arthritis must be directed both against the systemic and articular manifestations of the disorder. Treat-
MANAGEMENT OF RHEUMATOID ARTHRITIS
ment of the systemic disease consists largely of pharmacologic control of specific manifestations.8 Steroids or cytotoxic agents are used to treat rheumatoid vasculitis and nodulosis. Gold, penicillamine, lithium and splenectomy have all been advocated in the therapy of Felty syndrome. The patients with Sjogren syndrome are usually treated symptomatically, although in a rare patient administration of prednisone or cytotoxic drugs may be required. Treatment of the articular manifestations is intended to decrease pain and stiffness by controlling inflammation and to maintain or increase joint function by improving muscular strength, preserving articular motion, protecting joint stability and preventing deformity. Basically, there are three therapeutic modalities available to a clinician who is treating a patient with rheumatoid arthritis. In the remainder of this presentation I discuss the roles that physical therapy9"10 and orthopedic surgical therapy" play in the treatment of a patient with rheumatoid arthritis. The third modality, pharmacologic control of inflammation, will not be discussed in this presentation. Temperature manipulation One of the keystones of physical therapy is the use of temperature manipulation. As a therapeutic modality, heat has antispasmodic, analgesic, and anti-inflammatory effects. The application of heat to an inflamed joint will increase the blood flow in and around articular tissues. Thermocouple studies have shown that the application of surface heat will decrease intraarticular temperatures and, therefore, interfere with the efficiency of the activated enzymes that mediate tissue inflammation. There are a variety of methods by which heat can be applied. Total body heat, applied simply with hot tubs or showers, is useful for the alleviation of morning stiffness and the facilitation of range of motion exercises of large joints, such as the hips. Heat can be applied to small joints by the use of hot water or paraffin baths. For larger joints, such as the shoulders or knees, hot packs are a convenient mode of heat application. Heat lamps can be used for large flat areas, such as the back, and are indicated when skin problems preclude the use of other forms of heat application. Ultrasound has proved to be an effective way of applying deep heat without burning surface tissues, but ultrasound should be used only by experienced personnel; the improper use of this
technique has been associated with significant complications. One must keep the crystal moving constantly to prevent deep tissue burns. Ultrasound should not be used in patients who have metallic implants or prosthetic devices because the metal can be heated to dangerously high temperatures. Because the metabolic demands of treated tissues will be increased, ultrasound should not be used over areas of vascular insufficiency. The brain and sense organs should not be exposed to ultrasound because of the possibility of heat coagulation. It is also recommended that ultrasound not be employed if there is a question of infection or malignancy because of the theoretical possibility of hematologic spread of pathologic factors following the microagitation that is associated with the use of ultrasound. Diathermy (ultra-high frequency radio waves of 2,450 megacycles) offers no significant benefits over ultrasound or more traditional methods of heat application. The use of cold can also be of value in patients with rheumatoid arthritis. Hypothermia is particularly effective in the treatment of bursitis, tendinitis or acutely inflamed joints that are close to the skin surface. In these instances, cold packs may directly cool inflamed tissues and decrease the efficiency of inflammatory enzymes. In addition, cold does have an analgesic effect on nerve endings. There are problems with the use of cold therapy. Prolonged application of cold packs can lead to frostbite of the skin or muscle spasm. In addition, it is difficult to effectively cool deepseated joints. Experience has shown that it is better to use temperature manipulation as a therapeutic modality for short periods (10 to 30 minutes) several times a day than for a long period of time once a day. Unfortunately, in young or working patients frequent application of temperature manipulation is often impractical. Rest A second aspect of physical therapy, and one that is commonly overlooked, is the appropriate use of rest. Patients with rheumatoid arthritis characteristically complain of severe fatigue in the early afternoon. Fatigue time, which is the interval between arising in the morning and the onset of severe fatigue in the afternoon, is so characteristic that it is traditionally used by rheumatologists as a measure of disease activity. Patients with active disease should be encouraged to take an afternoon nap when severe fatigue begins, THE WESTERN JOURNAL OF MEDICINE
123
MANAGEMENT OF RHEUMATOID ARTHRITIS
so they will be able to play a more active role in evening family life. In patients with an acute systemic flare admission to hospital and total bed rest may be called for, although bed rest should never be used without a concomitant program of appropriate exercise. Splints or braces are often valuable in "resting" individual joints. Static splints simply support an inflamed joint and protect susceptible articular and periarticular supporting structures from undue stress. It is hoped that such protection will prevent or inhibit the development of deformity. Static splints can either be used at night or in the daytime and can be made more or less rigid by the use of various splinting materials. Dynamic splints will support an inflamed joint but will still allow movement and exercise. They are of particular value in the preoperative and postoperative care of patients undergoing orthopedic surgical treatment. Chronic dynamic splinting can be used to restore lost function. An example would be the use of dynamic leg braces which would automatically extend the foot in patients who have foot drop due to either vasculitis with mononeuritis multiplex or to lysis of the posterior tibial tendon. Exercise Exercise is the third major aspect of physical therapy. The goals of an aggressive exercise program are to maintain or improve muscle strength, to prevent muscle contraction, and to prevent fibrous ankylosis of periarticular and articular supporting structures. Ultimately, it is hoped that if these goals are achieved, joint function will be maintained and deformity prevented. The specific type of exercise indicated in any individual patient depends upon the clinical situation. Passive range of motion exercises done by the therapist are indicated for acutely inflamed joints. Isometric exercises can be used to maintain strength when individual joints are too inflamed for significant motion. In less acutely inflamed joints, assistive exercises-that is, exercises in which the therapist will help the patient move his own joints-are valuable. As the arthritis improves, active exercises-exercises done without the aid of a therapist-are useful in restoring muscle strength. Finally, resistive exercises done against the resistance of the therapist or weights are indicated after the articular inflammation has been controlled.
124
AUGUST 1978 * 129 * 2
Exercises, as with temperature manipulation, are most beneficial if done several times a day. The benefits of any therapeutic program in patients with rheumatoid arthritis are greatest if pharmacologic agents are used in conjunction with a solid physical therapy regimen. I have my patients take their anti-inflammatory drugs and then apply heat to affected joints for 10 to 30 minutes. Then, when the patient has received the combined anti-inflammatory, anti-spasmodic and analgesic effects of both the pharmacologic agent and the temperature manipulation, the patient will be better able to do his exercises effectively. The physician who treats patients with rheumatoid arthritis should be able to direct the physical therapy program. Prescriptions for exercises should indicate what type of exercise is to be done (passive, isometric and so on) and which muscles and joints are to be exercised. A trained therapist will know the specific exercise for each muscle group, so individual exercises do not have to be indicated. Assistive Devices Another aspect of physical therapy with which physicians should be acquainted is the use of assistive devices.'2 These devices aid a patient in accomplishing simple tasks that can become overwhelmingly difficult in the face of rheumatoid deformities. Feeding oneself, combing one's hair, brushing one's teeth, or going to the toilet can be frustrating experiences for patients with rheumatoid arthritis. Writing can become a monumental chore. Simply walking from one room to another can be a challenge. Fortunately, a variety of assistive devices, simple and complex, are available to aid debilitated patients accomplish the tasks of daily living.
Surgical Therapy Orthopedic surgical procedures are an integral part of the long range treatment of rheumatoid arthritis. As in the other therapeutic modalities discussed, the goals of orthopedic surgical treatment are to decrease inflammation and pain; prevent or repair deformity; increase joint stability, and, ultimately, maintain or to increase joint function. Some orthopedic procedures are largely prophylactic in nature; that is, they are intended to prevent deformity. Synovectomy is considered to
MANAGEMENT OF RHEUMATOID ARTHRITIS
be a prophylactic measure because it results in the removal of the articular repository of the immune complexes that mediate inflammation. By the removal of this repository, and the removal of the invasive pannus, one hopes to decrease inflammation and to inhibit the destruction of articular tissues. Synovectomy is most successful in decreasing inflammation in those joints such as the knee where all the inflamed synovium can be visualized and removed. It is less successful as prophylactic procedure in those joints where it is impossible to remove all of the inflamed tissues, such as the small joints of the hands. In certain cases, arthrodesis, or fusion of the joint, is indicated to increase joint stability or decrease pain-or both. Arthrodesis is most useful in arthritis of the foot, wrist and thumbs. Arthroplasty, or joint repair, often requires the use of joint prostheses. At present, effective prostheses are available for the hips, fingers and knees. New techniques are being developed that hold the promise of successful arthroplastic procedures in the elbows, shoulders, wrists and ankles. Orthopedic procedures can also be done to repair deformities due to loss of the integrity of periarticular supporting structures. Tendon repairs and the repair of both swan-neck and boutonniere deformities can be done in selected cases. Although rheumatologists are basically internists and constantly strive to avert the need for surgical intervention in their patients, they simply cannot ignore the fact that, in selected cases, orthopedic surgical therapy can be of inestimable value in the total care of patients with the systemic inflammatory disorder we know as rheumatoid -arthritis.
Conclusions There is a tendency for the average physician to become discouraged when treating severe, progressive rheumatoid arthritis. The disorder is chronic, the patients seem to have interminable complaints and the response of the disease to our therapeutic machinations is often painfully slow. However, the treatment of a patient with rheumatoid arthritis can be exceedingly rewarding. There is always something that we, as physicians, have to offer. Physical therapy, new anti-inflammatory agents, orthopedic surgical therapy, and our own optimism can always be used to buoy the flagging spirits of a beleaguered patient. Patients with rheumatoid arthritis tend to be young people who must face years, perhaps a lifetime, of pain and disability. They soon learn to recognize the shortcomings of medical science, but they are still tremendously grateful for what little we can do to help them. REFERENCES 1. Hollander JL, McCarty DJ: Arthritis and Allied Conditions, 8th Ed, Philadelphia, Lea & Febiger, 1972 2. Zvaifler NJ: Rheumatoid synovitis-An extravascular immune complex disease. Arth Rheum 17:297-305, 1974 3. Schmid FR, Cooper NS, Ziff M, et al: Arteritis in rheumatoid arthritis. Am J Med 30:56-83, 1961 4. Theofilopoulos AN, Burtonboy G, LoSpalluto JJ et al: IgM rheumatoid factor and low molecular weight IgM-An association with vasculitis. Arth Rheum 17:272-284, 1974 5. Moore RA, Brunner CM, Sandusky WR, et al: Felty's syndrome: Long-term follow-up after splenectomy. Ann Intern Med
75:380-385, 1971 6. Mason A, Gumpel JM, Golding PL: Sjogren's syndrome-A clinical review. Sem Arth Rheum 2:301-331, 1973 7. Stage DE, Mannik M: Rheumatoid factors in rheumatoid arthritis. Bull Rheum Dis 23:720-725, 1972-3 8. Roe RL: Drug therapy in rheumatic diseases. Med Clin N Am 61:405-418, Mar 1977 9. Ruskin AP: Psychiatry: Physical medicine and rehabilitation-Past, present and future. NY State J Med 76:1355-1359, 1976 10. Swezey RL: Dynamic factors in deformity of the rheumatoid arthritic hand. Bull Rheum Dis 22:649-656 11. Hofer H: Arthroplasty in rheumatoid arthritis. Scand J Rheumatoid 3:57-58, lS74 12. Covalt NK: Home care treatment in arthritis. S Med J 55:729-735, 1962
THE WESTERN JOURNAL OF MEDICINE
125
Medical Staf Conference
Conservative Management Rheumatoid Arthritis
of
These discussions are selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from transcriptions, they are prepared by Drs. David W. Martin, Jr., Associate Professor of Medicine, and Robert C. Siegel, Associate Professor of Medicine and Orthopaedic Surgery, under the direction of Dr. Lloyd H. Smith, Jr., Professor of Medicine and Chairman of the Department of Medicine. Requests for reprints should be sent to the Department of Medicine, University of California, San Francisco, CA 94143.
DR. SMITH: * The topic for this morning's Grand Rounds is the management of rheumatoid arthritis. Dr. Kenneth H. Fye will lead the discussion. DR. FYE: t Today's presentation will be unusual for a Grand Rounds in that the emphasis will be clinical. Discourse on the latest laboratory efforts to define the etiology and pathogenesis of the disease will be assiduously avoided. I will present a general description of rheumatoid arthritis and then proceed to a discussion of that therapeutic discipline-physical therapy-that has traditionally (and perhaps symbolically) been relegated to the basement of virtually every medical institution with which I have had contact. I will end with a brief outline of the role that orthopedic surgical therapy plays in the care of patients with rheumatoid arthritis. Rheumatoid arthritis is an autoimmune, systemic, inflammatory disease whose major, but by no means only, manifestations are articular.12 The disease affects women of childbearing age with a sex ratio of 3:1. The arthritis is symmetrical, polyarticular, inflammatory and erosive; it *Lloyd H. Smith, Jr., MD, Professor and Chairman, Department of Medicine tKenneth H. Fye, MD, Assistant Clinical Professor of Medicine
typically involves the small joints of the hands and feet. Patients characteristically complain of morning stiffness, as well as pain and tenderness, of the involved joints. The classic deformities associated with rheumatoid arthritis are due largely to periarticular inflammation, which results in muscle spasm, atrophy, and laxity of periarticular supporting structures. The swan neck deformity (hyperextension of the proximal interphalangeal joint and hyperflexion of the distal interphalangeal joint), the boutonniere deformity (hyperflexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint), ulnar deviation and subluxation of the metacarpal phalangeal joints, and lysis of tendons are all due to soft tissue inflammation. Large joints, such as elbows, shoulders, knees and hips, can be involved in the inflammatory process, particularly late in the course of the disease. Cervical spine involvement, seen in 30 percent of patients, may lead to laxity of the transverse ligament. In such patients the odontoid process may impinge upon the spinal cord during flexion of the neck. Even though laxity of the transverse ligament may be seen on x-ray studies, one should consider surgical therapy (fusion of THE WESTERN JOURNAL OF MEDICINE
121
MANAGEMENT OF RHEUMATOID ARTHRITIS
the cervical spine) only in patients with a neurologic deficit secondary to the cervical spine defect. The many extra-articular manifestations of rheumatoid arthritis are consistent with the systemic nature of the disorder. Constitutional findings, such as fever, chills, weight loss, lethargy and fatigue, reflect systemic inflammation. In 25 percent of patients, usually those with a positive rheumatoid factor and definite erosive arthritis, rheumatoid nodules will develop. Rarely, the manifestations of nodule formation may actually overshadow the arthritis. One of the commonest ocular expressions of rheumatoid disease, episcleritis, tends to be benign and does not require aggressive therapy. However, rheumatoid nodule formation on the sclerae should be treated vigorously, because scleronodular disease can lead to thinning (scleromalacia) and even perforation of the sclera. Pulmonary disease is not rare in patients with rheumatoid arthritis. In 15 percent of patients there will be pleural disease-ranging from pleural nodulosis to nonspecific pleuritis with or without pleural fluid. Parenchymal findings, seen in 1 to 2 percent of patients, include diffuse interstitial lymphocytic infiltration, interstitial fibrosis, pulmonary nodular disease and infections-such as bronchitis, pneumonia or empyema. Caplan syndrome is an entity that has stirred a great deal of controversy in rheumatologic circles. It probably represents only the development of pulmonary rheumatoid nodules in patients with rheumatoid arthritis who happen to be miners with pneumoconiosis.
Vascular inflammation is a major component of rheumatoid disease.3'4 The commonest form of vascular involvement is a bland, obliterative vasculitis involving small capillaries and venules. In 30 percent of patients with rheumatoid arthritis this form of vascular involvement is present; it is associated with a mild stocking-glove peripheral neuropathy. The lateral malleolar ulcers seen in 10 to 15 percent of patients with severe rheumatoid disease are due to vasculitic involvement of small cutaneous arterioles. In less than 1 percent of patients a systemic, necrotizing arteritis will develop that is clinically and histologically indistinguishable from periarteritis nodosa. Peripheral neuropathy is a frequent finding in patients with rheumatoid arthritis. Vasculitis may result in either a stocking-glove peripheral neuropathy or a mononeuritis multiplex, depending upon the severity of the vascular inflammatory process.\In
122
AUGUST 1978 * 129 * 2
addition, synovial proliferation at various points in the body, such as the carpal tunnel, can lead to compression syndromes. As discussed above, in patients who have cervical spondylitis with laxity of the transverse ligament, one may see cervical myelopathy. Cardiac involvement in rheumatoid disease is generally limited to the development of myocardial or epicardial nodules which cause nonspecific abnormalities seen on electrocardiograms. Splenomegaly and leukopenia in a patient with rheumatoid arthritis is known as Felty syndrome.5 Other clinical manifestations of Felty syndrome include lateral malleolar ulcers, rheumatoid nodule formation, lymphadenopathy, hepatosplenomegaly and recurrent infections.5 These patients tend to have rheumatoid factors, antinuclear antibodies, thrombocytopenia and anemia, as well as leukopenia. Sj6gren syndrome (keratoconjunctivitis sicca and xerostomia in patients with an autoimmune rheumatic disorder) is seen in 30 percent of patients with rheumatoid arthritis and must be considered in the differential diagnosis of any patient with rheumatoid disease in whom ocular complaints develop.6
Diagnosis The diagnosis of rheumatoid arthritis rests, primarily on the history and physical examination findings, but laboratory studies do offer clinicians valuable information. Patients with rheumatoid arthritis virtually always have an elevated erythrocyte sedimentation rate. Mild anemia, reflecting chronic inflammatory disease, is very common. Rheumatoid factors are seen in 75 percent and antinuclear antibodies in 20 percent of patients. In individual patients one may see a variety of immunoglobulin abnormalities, including hypergammaglobulinemia or cryoglobulinemia. Radiologic evaluation may show soft tissue swelling, diffuse or periarticular osteoporosis, marginal erosions, ulnar deviation or subluxation of involved joints. Occasionally, biopsy confirmation of the presence of rheumatoid nodules in synovium or other involved tissues can be of diagnostic value.
Therapy In rheumatoid arthritis as in every other disease, diagnostic evaluation is only a prelude to therapy. The treatment of rheumatoid arthritis must be directed both against the systemic and articular manifestations of the disorder. Treat-
MANAGEMENT OF RHEUMATOID ARTHRITIS
ment of the systemic disease consists largely of pharmacologic control of specific manifestations.8 Steroids or cytotoxic agents are used to treat rheumatoid vasculitis and nodulosis. Gold, penicillamine, lithium and splenectomy have all been advocated in the therapy of Felty syndrome. The patients with Sjogren syndrome are usually treated symptomatically, although in a rare patient administration of prednisone or cytotoxic drugs may be required. Treatment of the articular manifestations is intended to decrease pain and stiffness by controlling inflammation and to maintain or increase joint function by improving muscular strength, preserving articular motion, protecting joint stability and preventing deformity. Basically, there are three therapeutic modalities available to a clinician who is treating a patient with rheumatoid arthritis. In the remainder of this presentation I discuss the roles that physical therapy9"10 and orthopedic surgical therapy" play in the treatment of a patient with rheumatoid arthritis. The third modality, pharmacologic control of inflammation, will not be discussed in this presentation. Temperature manipulation One of the keystones of physical therapy is the use of temperature manipulation. As a therapeutic modality, heat has antispasmodic, analgesic, and anti-inflammatory effects. The application of heat to an inflamed joint will increase the blood flow in and around articular tissues. Thermocouple studies have shown that the application of surface heat will decrease intraarticular temperatures and, therefore, interfere with the efficiency of the activated enzymes that mediate tissue inflammation. There are a variety of methods by which heat can be applied. Total body heat, applied simply with hot tubs or showers, is useful for the alleviation of morning stiffness and the facilitation of range of motion exercises of large joints, such as the hips. Heat can be applied to small joints by the use of hot water or paraffin baths. For larger joints, such as the shoulders or knees, hot packs are a convenient mode of heat application. Heat lamps can be used for large flat areas, such as the back, and are indicated when skin problems preclude the use of other forms of heat application. Ultrasound has proved to be an effective way of applying deep heat without burning surface tissues, but ultrasound should be used only by experienced personnel; the improper use of this
technique has been associated with significant complications. One must keep the crystal moving constantly to prevent deep tissue burns. Ultrasound should not be used in patients who have metallic implants or prosthetic devices because the metal can be heated to dangerously high temperatures. Because the metabolic demands of treated tissues will be increased, ultrasound should not be used over areas of vascular insufficiency. The brain and sense organs should not be exposed to ultrasound because of the possibility of heat coagulation. It is also recommended that ultrasound not be employed if there is a question of infection or malignancy because of the theoretical possibility of hematologic spread of pathologic factors following the microagitation that is associated with the use of ultrasound. Diathermy (ultra-high frequency radio waves of 2,450 megacycles) offers no significant benefits over ultrasound or more traditional methods of heat application. The use of cold can also be of value in patients with rheumatoid arthritis. Hypothermia is particularly effective in the treatment of bursitis, tendinitis or acutely inflamed joints that are close to the skin surface. In these instances, cold packs may directly cool inflamed tissues and decrease the efficiency of inflammatory enzymes. In addition, cold does have an analgesic effect on nerve endings. There are problems with the use of cold therapy. Prolonged application of cold packs can lead to frostbite of the skin or muscle spasm. In addition, it is difficult to effectively cool deepseated joints. Experience has shown that it is better to use temperature manipulation as a therapeutic modality for short periods (10 to 30 minutes) several times a day than for a long period of time once a day. Unfortunately, in young or working patients frequent application of temperature manipulation is often impractical. Rest A second aspect of physical therapy, and one that is commonly overlooked, is the appropriate use of rest. Patients with rheumatoid arthritis characteristically complain of severe fatigue in the early afternoon. Fatigue time, which is the interval between arising in the morning and the onset of severe fatigue in the afternoon, is so characteristic that it is traditionally used by rheumatologists as a measure of disease activity. Patients with active disease should be encouraged to take an afternoon nap when severe fatigue begins, THE WESTERN JOURNAL OF MEDICINE
123
MANAGEMENT OF RHEUMATOID ARTHRITIS
so they will be able to play a more active role in evening family life. In patients with an acute systemic flare admission to hospital and total bed rest may be called for, although bed rest should never be used without a concomitant program of appropriate exercise. Splints or braces are often valuable in "resting" individual joints. Static splints simply support an inflamed joint and protect susceptible articular and periarticular supporting structures from undue stress. It is hoped that such protection will prevent or inhibit the development of deformity. Static splints can either be used at night or in the daytime and can be made more or less rigid by the use of various splinting materials. Dynamic splints will support an inflamed joint but will still allow movement and exercise. They are of particular value in the preoperative and postoperative care of patients undergoing orthopedic surgical treatment. Chronic dynamic splinting can be used to restore lost function. An example would be the use of dynamic leg braces which would automatically extend the foot in patients who have foot drop due to either vasculitis with mononeuritis multiplex or to lysis of the posterior tibial tendon. Exercise Exercise is the third major aspect of physical therapy. The goals of an aggressive exercise program are to maintain or improve muscle strength, to prevent muscle contraction, and to prevent fibrous ankylosis of periarticular and articular supporting structures. Ultimately, it is hoped that if these goals are achieved, joint function will be maintained and deformity prevented. The specific type of exercise indicated in any individual patient depends upon the clinical situation. Passive range of motion exercises done by the therapist are indicated for acutely inflamed joints. Isometric exercises can be used to maintain strength when individual joints are too inflamed for significant motion. In less acutely inflamed joints, assistive exercises-that is, exercises in which the therapist will help the patient move his own joints-are valuable. As the arthritis improves, active exercises-exercises done without the aid of a therapist-are useful in restoring muscle strength. Finally, resistive exercises done against the resistance of the therapist or weights are indicated after the articular inflammation has been controlled.
124
AUGUST 1978 * 129 * 2
Exercises, as with temperature manipulation, are most beneficial if done several times a day. The benefits of any therapeutic program in patients with rheumatoid arthritis are greatest if pharmacologic agents are used in conjunction with a solid physical therapy regimen. I have my patients take their anti-inflammatory drugs and then apply heat to affected joints for 10 to 30 minutes. Then, when the patient has received the combined anti-inflammatory, anti-spasmodic and analgesic effects of both the pharmacologic agent and the temperature manipulation, the patient will be better able to do his exercises effectively. The physician who treats patients with rheumatoid arthritis should be able to direct the physical therapy program. Prescriptions for exercises should indicate what type of exercise is to be done (passive, isometric and so on) and which muscles and joints are to be exercised. A trained therapist will know the specific exercise for each muscle group, so individual exercises do not have to be indicated. Assistive Devices Another aspect of physical therapy with which physicians should be acquainted is the use of assistive devices.'2 These devices aid a patient in accomplishing simple tasks that can become overwhelmingly difficult in the face of rheumatoid deformities. Feeding oneself, combing one's hair, brushing one's teeth, or going to the toilet can be frustrating experiences for patients with rheumatoid arthritis. Writing can become a monumental chore. Simply walking from one room to another can be a challenge. Fortunately, a variety of assistive devices, simple and complex, are available to aid debilitated patients accomplish the tasks of daily living.
Surgical Therapy Orthopedic surgical procedures are an integral part of the long range treatment of rheumatoid arthritis. As in the other therapeutic modalities discussed, the goals of orthopedic surgical treatment are to decrease inflammation and pain; prevent or repair deformity; increase joint stability, and, ultimately, maintain or to increase joint function. Some orthopedic procedures are largely prophylactic in nature; that is, they are intended to prevent deformity. Synovectomy is considered to
MANAGEMENT OF RHEUMATOID ARTHRITIS
be a prophylactic measure because it results in the removal of the articular repository of the immune complexes that mediate inflammation. By the removal of this repository, and the removal of the invasive pannus, one hopes to decrease inflammation and to inhibit the destruction of articular tissues. Synovectomy is most successful in decreasing inflammation in those joints such as the knee where all the inflamed synovium can be visualized and removed. It is less successful as prophylactic procedure in those joints where it is impossible to remove all of the inflamed tissues, such as the small joints of the hands. In certain cases, arthrodesis, or fusion of the joint, is indicated to increase joint stability or decrease pain-or both. Arthrodesis is most useful in arthritis of the foot, wrist and thumbs. Arthroplasty, or joint repair, often requires the use of joint prostheses. At present, effective prostheses are available for the hips, fingers and knees. New techniques are being developed that hold the promise of successful arthroplastic procedures in the elbows, shoulders, wrists and ankles. Orthopedic procedures can also be done to repair deformities due to loss of the integrity of periarticular supporting structures. Tendon repairs and the repair of both swan-neck and boutonniere deformities can be done in selected cases. Although rheumatologists are basically internists and constantly strive to avert the need for surgical intervention in their patients, they simply cannot ignore the fact that, in selected cases, orthopedic surgical therapy can be of inestimable value in the total care of patients with the systemic inflammatory disorder we know as rheumatoid -arthritis.
Conclusions There is a tendency for the average physician to become discouraged when treating severe, progressive rheumatoid arthritis. The disorder is chronic, the patients seem to have interminable complaints and the response of the disease to our therapeutic machinations is often painfully slow. However, the treatment of a patient with rheumatoid arthritis can be exceedingly rewarding. There is always something that we, as physicians, have to offer. Physical therapy, new anti-inflammatory agents, orthopedic surgical therapy, and our own optimism can always be used to buoy the flagging spirits of a beleaguered patient. Patients with rheumatoid arthritis tend to be young people who must face years, perhaps a lifetime, of pain and disability. They soon learn to recognize the shortcomings of medical science, but they are still tremendously grateful for what little we can do to help them. REFERENCES 1. Hollander JL, McCarty DJ: Arthritis and Allied Conditions, 8th Ed, Philadelphia, Lea & Febiger, 1972 2. Zvaifler NJ: Rheumatoid synovitis-An extravascular immune complex disease. Arth Rheum 17:297-305, 1974 3. Schmid FR, Cooper NS, Ziff M, et al: Arteritis in rheumatoid arthritis. Am J Med 30:56-83, 1961 4. Theofilopoulos AN, Burtonboy G, LoSpalluto JJ et al: IgM rheumatoid factor and low molecular weight IgM-An association with vasculitis. Arth Rheum 17:272-284, 1974 5. Moore RA, Brunner CM, Sandusky WR, et al: Felty's syndrome: Long-term follow-up after splenectomy. Ann Intern Med
75:380-385, 1971 6. Mason A, Gumpel JM, Golding PL: Sjogren's syndrome-A clinical review. Sem Arth Rheum 2:301-331, 1973 7. Stage DE, Mannik M: Rheumatoid factors in rheumatoid arthritis. Bull Rheum Dis 23:720-725, 1972-3 8. Roe RL: Drug therapy in rheumatic diseases. Med Clin N Am 61:405-418, Mar 1977 9. Ruskin AP: Psychiatry: Physical medicine and rehabilitation-Past, present and future. NY State J Med 76:1355-1359, 1976 10. Swezey RL: Dynamic factors in deformity of the rheumatoid arthritic hand. Bull Rheum Dis 22:649-656 11. Hofer H: Arthroplasty in rheumatoid arthritis. Scand J Rheumatoid 3:57-58, lS74 12. Covalt NK: Home care treatment in arthritis. S Med J 55:729-735, 1962
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