Supplement 1, Vol. 8, Aust. N.Z. J. Med. (1978), pp. 168-171
Physical Medicine in Rheumatology John Glass From the Royal Newcastle Hospital, Newcastle, NSW
Physical therapy is an integral part of the management of patients with rheumatoid arthritis. The main objectives are to obtain normal joint position, mobility and muscle strength.' The techniques used to accomplish this basically consist of (a) exercises, which are often preceded by thermotherapy, to relieve pain and muscle spasm and ( b ) splinting to correct guarding of painful joints. overloading of weak muscles, co-contractions and contractures. Much of the work attempting to give physical therapy a scientific basis was done 20 to 30 years ago. Some of the methods are antique and have not been subjected to adequate scientific evaluation. However, it is generally agreed that physical therapy is an essential part of treatment of many rheumatic diseases. Several studies assessing the benefits of comprehensive management seem to support Physicans should be aware of the limitations of physical therapy, as well as understanding the rationale and complications of the modalities used.', 6, Accurate diagnosis and functional assessment are essential. Repeated visits to a physiotherapist are often unnecessary. Adequate instruction is important to allow daily home treatment and typed instruction sheets, as used at the Mayo Clinics, will ensure that the majority of patients will continue treatment.'Other factors affecting the outcome of physical therapy include co-operation by patients and relatives, adequate explanation, psychosocial factors, occupation and continuing activity of the disease.', l 3 Thermotherapy ( H e a t and Cold) The physiological effects of local heat applications are the basis for its use in physical medicine.'" It has been shown to cause analgesia by raising pain threshold", 17; to relieve muscle spasm and associated pain, by reducing the sensitivity of the muscle spindle to stretch16; to Correspondence: Dr. J. Glass Royal Newcastle Hospital, Newcastle, N S W 2300
cause general sedation'"; to alter the properties of fibrous tissue, allowing it to yield to stretch'" ", and to relieve joint stiffness subjectively and objectively." Other local effects include an increase in metabolic rate, increase in capillary flow with heat dissipation, and an increase in capillary hydrostatic pressure.'" Therefore heat, when applied before or during therapeutic exercise, will allow more effective less painful exercise, as well as helping in the correction of flexion contractures. Conversely, there is evidence that local heat, particularly deep heat, may be detrimental in active rheumatoid arthritis. The activity of synovial collagenase increases four-fold with a five degree centigrade rise in temperature, accelerating cartilage d e s t r ~ c t i o n . ~ ' -Deep ~~ forms of heat can raise intra-articular temperature, and superficial forms of heat temporarily reduce intra-articular temperatures.'", " Therefore, there is rationale for the use of superficial heat in inflammatory synovitis, rather than deep heat; the latter may be more useful in correcting contractures in a later stage of the disease.22.26 Also, deep heat often increases pain and inflammation in active synovitis.", 27 There are many methods of heat application, including superficial heat (various forms of hot packs, radiant heat, hot water baths, parrafin wax, fluidotherapy" and the deep heat modalities (short wave diathermy, micro wave and ~ltrasound).'~ There are no proven clinical advantages of one form of heat over another". 29 3 1 , and the type of heat used depends on patient preference and ease of application.' The main contraindications to heat are anaesthesia, poor circulation, oedema, haemorrhagic disorders, local malignancy, thrombophlebitis, infection and pregnancy. Short wave and microwave can also selectively heat metallic implants causing burns, interfere with cardiac pacemakers and interfere with epiphyses of growing bone.". 3 2 There are no advantages of superficial heat
JUNE
1978
PHYSICAL MEDICINE IN RHEUMATOLOGY
over superficial cold (cold compresses or spray^)'^,^^ although cold is said to help the more acute processes.'
Hydrotherapy (Pool, Hubbard Tank, Whirlpool, Contrast Bath, Hot Showers) The beneficial features are the buoyancy of the water and moist heat.', 34 Together with the analgesia and muscle relaxation from superficial heating, the buoyancy of the water allows assisted range of motion exercises due to less resistance from gravity, gentle resistance exercises by moving against the pressure of water (the resistance can be increased by faster movements) and gradual increase in weight-bearing stress by walking into increasingly shallow water. Therapeutic This is the most important aspect of physical therapy in rheumatic diseases. To achieve the maximum benefits, pain must be relieved or exercises will aggravate the pain and stiffness and cause further protective muscle spasm. Therefore, exercises are best done after adequate antiinflammatory drug therapy (systemic and local), during or after heat or hydrotherapy and at a time when morning stiffness has subsided.', 3, Misconceptions about exercises in rheumatic diseases are common among patients, and so patient education is essential to maintain the home therapy programme. Periodic visits to physiotherapy are important to check techniques. A joint should not be overexercised as this will cause increased i n f l a m m a t i ~ n . ~ ' A ~ ' rule of thumb is that, if pain does occur, it should not last more than two hours and on the following day, the pain and stiffness should be no worse than prior to therapy.' The amount and type of exercise depends on the activity of the disease and areas involved. As the activity wanes, exercises can be increased. Exercises can be divided into: 1. Re-education of muscles to overcome inhibition, co-contractions and inco-ordination. 2. Range of motion exercises within pain tolerance, to maintain optimal joint mobility. Active and active-assisted type of exercises are normally used. Gentle prolonged stretching together with heat can be used to correct contra~tures.~~
169
3. Strengthening exercises should be isometric to gain maximum muscle contraction, and this has been shown to strengthen the quadriceps in a patient with rheumatoid arthritis in the The pain produced by resisted isotonic exercise will inhibit muscle contraction, and aggravate 3y Progressive resistant exerthe joint di~ease.~'. cises can be used3', or a brief isometric maximal contraction for 6 seconds twice daily will strengthen muscle.', 35, 44, 45 Exercise can also be incorporated into daily routine household activities.'
Splints There are now many materials from which these can be made, instead of the usual heavy plaster of Paris (Hexelite, Orthoplast, Plastozote and various plastics and light metal).46-5' They are used to:
1. Rest an acutely inflamed joint, usuafiy the knees, ankles and hands, to help reduce inflammation and prevent flexion contractures that can occur in inflamed joints that are held in flexion to relieve pain. The splints can be left on for up to four weeks without range of motion exercises, with no loss of m ~ b i l i t y . As ~ ~synovitis - ~ ~ wanes, it is only necessary to use the splints at night. lsometric strengthening can be carried out in the splints. Splinting will not prevent hand deformities if synovitis persist^.^, 5 5
2. Stabilise a joint to improve function. Wrist stabilisation splints (volar or dorsal) assist hand function.39,56 Also, stabilising splints have been used for other joints, including interphalangeal joints57,5 8 , and knees.50,51, 59 3, Correct flexion contractures of knees using serial splint^.^. 51, 59, 6' Correction can be assisted by prior heat or intra-articular steroid before the cast is applied. In normal, relaxed standing, muscles are used for balance rather than to support body weight.35 If there are contractures of hips or knees, lower limb muscles have to support body weight, causing fatigue and less endurance, as well as increased compressive forces on the knees.35 4. Assist in post-surgery rehabilitation of the hand, using dynamic splints.48.62, 63
170
SUPPLEMENT
GLASS
Rest and Posture Rest in hospital will reduce inflammatory activity6', although there is no advantage in strict bedrest and splinting for long periods compared with a more liberal bedrest regime.s3.64, 6 5 When at home, rest periods during the day are said to be helpful.' When resting, postural therapy helps to prevent deformities. A firm mattress, firm back-rest, few pillows and periods lying prone are prerequisites to maintenance of correct posture. Pillows behind knees should not be used.'*35,39 Occupational Therapy's 66 This assists in assessment of activities of daily living and suggesting various aids (built-up toilet, high chair, rails and assistive devices), techniques to reduce stress to the hands; joint protection training67, energy saving techniques at w,qrk, co-ordination and strengthening of upper limbs, retraining patients unable to transfer le.g. from bed to chair) and increasing endurance with a programme of graded activity. Other Procedures and Devices These include: 1. Adequate well-fitting footwear and supports and leg length c ~ r r e c t i o n . ~ ~ - ~ ~ 2 . Calipers and braces to stabilise and relieve weight-bearing stress on hip, knee and ankle, with or without a Sach or cushion heel and rocker type sole to facilitate walking.', 60. 7 3 , 74 3. Canes, crutches and other walking aids to assist a m b u l a t i ~ n76. ~ ~ ~ 4. A "hand gym" for patients with rheumatoid arthritis which can be used at home.77 5. Stretch gloves to relieve morning stiffness and night pain.78.79 6. Reversed dynamic sling for knee flexion con tracture." Conclusion Physical therapy is not a stop-gap form of treatment, but one that is carried out throughout the patient's life. Repeated assessments are necessary, and therapy adjusted for changing goals. References 1. SWEZEY, R. L. (1974):Essentials of physical management and rehabilitation in arthritis, Semin. Arthr. Rheum. 3, 349. 2. DUFF,1. F., CARPENTER, J 0. and NEIJKOM, J . E. (1974): Comprehensive management of patients with rheumatoid arthritis, Arthr. and Rheum. 17, 635.
1,
VOL.
8
3 VlGNOS, P. J . J R . , THOMPSOY, H. M , K A T Z . S.. MOSKOW~TZ, R. W., FINK, S and SVEC,K. H. (1972):Comprehensive care and psycho-social factors in rehabilitation in chronic rheumatoid arthritis: A controlled study, J . chron. Dis 24, 457. 4. KARTtN. I., LEE, M. and MCEWEN,C. (1973). Rheumatoid arthritis: Five year study of rehabilitation, Arch. phq.5 Med. 54, I20 5 HARRIS, R. (1963): The rehabilitation unit in the treatment of rheumatoid arthritis, Canad. med Ass. J . 88, 139. 6. MARTIN, G . M. (1971 1: Prescribing physical and occupational therapy Handbook of physical medicine and rehabilitation, 2nd ed., W. B Saunders Co., Philadelphia, p. 510. 7. MARTIN, G . M. (1963): Physical medicine in rheumatoid arthritis, Arihr. und Rhcwm. 6, 177. 8 . Mayo Clinic Home instruction sheets for physical and occupational therapy, Muqo Foundation.
9 WRIGHT, J (1945): Physical therapy prescription, Physiotherapy Review. 25,
22. 10. SMYTH,C J. and FREYBERG, R. H. (1943): Significance and management of joint pain. J mich. med. SOC. 42, 818. I I . ERICKSON, D. J . (1964) Conservative management of cervical syndromes, Postgrud Med. 38. I94 I?. HOLLEY, L. S. (1964):Physical therapy in home Care: Community focused or patient centered. J . Amer. Phqs. Thcr. Assoc. 44,901. 13 DIITHIt, J . J . R., THOMPSON, M., WEIR, M. M. and BELLFLETCHER, w. (1955): Medical and social aspects of the treatment of rheumatoid arthritis, Ann rheum. Dis 14, 133. G . K.(1971): Therapeutic heat and cold. Handbook of physical 14. STILWEIL, medicine and rehabilitation. 2nd ed., W. B. Saunders, Philadelphia, p. 259. 15. LEHMANN, J. F., BRUNNFR,G. D. and STOW,R. W (1958): Pain threshold measurements after therapeutic application of ultrasound, mi~rowavesand infra-red. Arch. phqs. Med. 39, 560. 16. FLSCHER, E. and SOLOMON, S. (1958). Physiological responses to heat and cold. Therapeutic heat, 1st ed , Elizabeth Licht, New Haven, p. 116. 17. BENSON, T B. and COPP,E. P. ( 1974):The effects of therapeutic forms of heat and ice on the pain threshold of the normal shoulder, Rheumatol. Rrhuhil. 13, 101. 18. LEHMANN, J . F.. MASOCK, A. J., WARREN, C. G . and KOBLANSKI, J . N . (1970): Effects of therapeutic temperatures on tendon extensibility, Arch.phys Med. 51, 481. J . F., WARREN, C. G . and SCHAM,S. M. (1974): Therapeutic heat 19 LEHMANN, and cold. Clin. Orthnp. 99, 207. 20. BACKLUND, L and TISELRIS, P. (1967). Objective measurements of joint stiffness in rheumatoid arthritis, Acta. rheum. scund. 13, 275. 21. HARRIS, E. D. JR. and MCCROSKERV, P. A. (1974): Influence of temperature and fibril stability on degradation of cartilage collagen by rheumatoid synovial collagenase, Neew Engl. J. Med 290, I 22. HOLLANDER, J. L. (1974): Collagenase, cartilage and cortisol, New Engl. J . Med. 290. 50. 23. CASTOR, C. W. and YARON,M. (1976): Connective tissue activation VIII. Effects of temperature studied in vilro, Arch. phys. Med. 51, 5. 24. HOLI.AVDER, J L. and HORVATH, S . M. (1949): Influence ofphysical therapy procedures on intrdarticular temperature of normal and arthritic subjects, Amer. J . med. Sci. 218, 543. 2 5 . HORVATH, S. M. and HOLLANDER, J L (1949): lntraarticular temperature as measure of joint reaction, J . clin. Invest. 28, 469. A. (1976):Deep heating of joints: A reconsideration, 26. FEiBEi., A. and FAST, 4rch. phvr M d 57. $13 27. DORWART, B. B., HANSELL, J . R. and SCHUMACHER. tl. R. JR. (1974): Effects of cold and heat on urate crystal induced synovitis in the dog. Arrhr and Rheum. 17, 563. 2X. BORRELL, R. M., HENLEY,E. J., Ho., P. and HUBBELL, M. K. (1977): Fluidotherdpy: Evaluation of a new heat modality, Arch. phys. Med. 58.69. 29. FOL'NTAIN, P , GFRSTEN,J . and SENGIR, 0 ( I 960): Decrease in muscle spasm produced by ultrasound, hot packs and infra-red Radiation, Arch. phy.;. Med. 41, 293. 30. HARRIS, R. and MILL~RD,J. B. (1955): Paraffin wax baths in the treatment of rheumatoid arthritis, Ann. rheum. Dis. 14, 27R. 31 CLARKE: G. R., WILLIS, L. A,, STENNER, L. and NICHOLS,P. I. R . (1974): Evaluation of physiotherapy in the treatment of osteoarthrosis of the knee, Rheumatol. Rehabil. 13, 190. 32. LEHMANN, J . F. (1971). Diathermy. Handbook of physical medicine and rehabilitation, 2nd ed., W. B. Saunders Co , Philadelphia, p. 273. 33. KIRK, J . A. and KERSLEI,G. D. (1967): Heat and cold in the physical treatment of rheumatoid arthritis of the knee-A controlled clinical trial, Ann phys. Med. 9, 270. 34. ZiSLis, J . M. 11971): Hydrotherapy. Handbook of physical medicine and rehabilitation, 2nd ed., W. B. Saunders, Philadelphia, p. 346. 35. KOTTKE,F. J . 11971): Therapeutic exercise. Handbook of physical medicine and rehabilitation, 2nd ed., W. 8. Saunders, Philadelphia, p. 385. 36. HARRIS,R. (1968): Physical methods in the management of rheumatoid arthritis, Med. Clin. N. Amer. 52, 707. L. T. (1934):The orthopaedic and physical therapeutic treatments of 37 SWAIN. chronic arthritis. J Amw. med. Ars 103. 1589 38. AGUDELO, C., SVHUMACHER, H. R. and PHELPS,P. (1972): Hlect ofexercise on uratecrystal-induced inflammation incaninejoints, Arthr. undRheum. 15, 609. 39. EHRLICH, G. E. ( 1973): Rest and splinting. Total management of the arthritic patient. Lippincolt. Philadelphia, p. 47. 40. CASTILLO, B A., SALLAB,R. A. and SCOTT,J . T. (1965): Physical activity, cystic erosions and osteoporosis in rheumatoid arthritis, Ann. rheum. Dis. 24, 522. 41. THOMPSON, M. and BYWATERS, E. G. L. (1962): Unilateral rheumatoid arthritis following hemiplegia, Ann. rheum. Dir 21, 370.
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1978
PHYSICAL MEDICINE IN RHEUMATOLOGY
42. WARREN, f.G., LEHMANN. J. F. and KOBLANSKI, J. N. (1971) Elongation of rat tail tendon: Effect of load and temperature, Arch. phys. Med. 52, 465. 43. MACHOVER, S.and SAPECKY, A. J. (1966):Effect of isometric exercise on the quadriceps muscle on patients with rheumatoid arthritis, Arch. phys. Med. 47, 737. 34. SWEZEY, R. L. (1967): Exercises with a beach hall for increasing range ofjoint motion, Arch. phys. Med. 48, 253 45. LIBERSON, W. T. (1961): Brief isometric exercises. Therapeutic exercise, 2nd. ed., Elizabeth Licht., New Haven, p. 307. 46. GARRETT, T K. (1976). BXL plastozote: A useful aid in both treatment and rehabilitation, Rheumalul. Rehabil. 15, 283. 47. DAVIE,B. and DOOLEY,B. (1976): New fihreglass casting system in orthopaedic practice, Med. J. Aust. 1, 1010. 48. SCHUTT,A. H.and CAMP,G. 0. (1976): Static and dynamic splinting of the upper extremity with orthoplast. Mayo Foundation, Rochester, Minnesota. 49 SHALIT,I. E. and DECKER, I. L. (1965): Silicone foam resting splints for rheumatoid arthritis, Lancet 1, 142. 50. MOWAT,A. G. (1970): Basic medical treatment in rheumatoid arthritis, Physiotherapy 56, 450. 51. POTTER,T.A. (1972):Prevention of deformities from arthritis. Arthritis and Al/ied C'unditiuns, 8th ed.. Lea and Febiger, Philadelphia, p. 593. S.J. and SPYKER, J. M. (1969): Beneficial effect of immobilisation of 52. GAULT, joints in rheumatoid arthritis and related arthritides: A splint study using sequential analysis, Arlhr. and Rheum. 12, 34. 53. PARTRIDGE, R. E. H. and DUTHIE, J. J . R. (1963):Controlled trial ofthe effect of complete immobilisation of thejoints in rheumatoid arthritis. Ann. rheum. Dis. 22, 91 54 HARRIS,R. and COPP, E. P. (1962). lmmobilisation of the knee joint in rheumatoid arthritis. Ann. rheum. Dis.21, 353. 55 CONVERY, F. R., CONATY, 1. P. and NICKEL, V. L. (1968): Dynamic splinting of the rheumatoid hand, Orthop. Prosthet., p. 41. 56. FRIED,D. M. (1969): Splints for arthritis. Arthritis and physical medicine, Elizabeth Licht, New Haven, p. 285. 57. BENNETT, R. L. (1965):Orthotic devices to prevent deformities of the hand in rheumatoid arthritis, Arthr and Rheum. 8, 1006. 58. BENNETT, R. (1969): Wrist and hand slip-on splints. Arthritis and physical medicine, Elizabeth Licht, New Haven, p. 484. 59. DUTHIE.J. J. R. (19691: Rheumatoid arthritis. Textbook of the rheumatic diseases', 4th ed.,'E. and S. Livingstone Ltd., Edinburgh, p. 259. 60. McCOLLCUcH, N. C., FRYER, C. M., LEHNEIS, H. R. and GLANCY, J. (1971): Lower extremity bracing, part I-IV. Amencan academy of orthopaedics, Instructional Course Lectures 20, 116.
171
61. HAWKES, J., FOGDEN, J . and WRIGHT,V. (1972). Straightening the knees in rheumatoid arthritis, Physrurherapy 58, 226. 62. SWANSON, A. B. (1968): Silicone rubber implants for replacement of arthritic or destroyed joints in the hand, Surg. Clin. N. Amer. 48, 113. 63. NICOLLE, F. V. and PRESSWELL. D. R. (1975): A valuable splint for the rheumatoid hand, Hand 7 , 69. 64. MILLS,J A., PINALS, R. S. and ROPES,M. W. (1971): Value of bed rest in patients with rheumatoid arthritis. New Engl. J. Med. 284, 454. 65. LEE, P., KENNEDY, A. C., ANDERSON, J. and BUCHANAN, W. W. (1974): Benefitsof hospitalisation in rheumatoid arthritis, Quart. J. Med. XLIII, 205. 66. BOWIE,M.A. (1972):Occupational therapy in arthritis. Arthritis and allied conditions, 8th ed., Led and Febiger, Philadelphia, p. 574. J. (1977): Evaluation of joint protection training as a treatment 67 COROERY, method for patients with arthritis. X I I . Infernal. Cung. Rheum. Son Francisco. Abstr. 391 68. DIXON,A. ST. J. and FRANKLIN, A. (1968): Seamless shoes m rheumatoid arthritis, Brif. med. J. 3, 728. 69. TUCK,W. H (1972): The painful foot, Proc. ray. Sac. Med. 65, 739. 70. SHIELDS, M N. and WARD,I. R. (1968): Molded silastic foot supports for patients with rheumatoid arthritis, J. Amer. Phys. Ther. Assoc. 48, 1083. J . P.JR. (1976): Plantar pressure measurements. Rational shoe71. BARRETT, wear in patients with rheumatoid arthritis, J. Amer. med. A.LV 235, 1138. 72. POTTER,JA.(1972): Painfulfeet.Arthritisandalliedconditions,8thd., Lea and Febiger, Philadelphia, p. 1422. 73. SWEZEY, R. L.(1975):Below-knee weight bearing brace for the arthritic foot, Arch. phys. Med. 56, 176. J. A. and KLASSEN, E. G. (1965):Use of short leg braces with patella 74. BOWER, tendon hearing cuffs, Arch. phys. Med. 46, 436. 75. BOWIE,A B. (1972): Physical therapy in arthritis. Arthritis and allied conditions, 8th ed., Lea and Febiger, Philadelphia, p. 541. 76. HOLLANDER, J. L. (1960). Treatment ofosteoarthritis ofthe knees, Arthr. and Rheum. 3, 564. 77. BENS,D. E. and KREWER, S.E. (1974). The hand gym: An exercise apparatus for the patient with rheumatoid arthritis, Arch. phys. Med. 55, 477.
J. and MURPHY, C. (1977): Re ersedky 80. WILLIAMS, D., MURPHY, for knee flexion contracture in chronic rheumatic d s a s e . .I"%%: Cung. Rheum. San Francisco. Abstr. 942.
Physical Medicine in Rheumatology John Glass From the Royal Newcastle Hospital, Newcastle, NSW
Physical therapy is an integral part of the management of patients with rheumatoid arthritis. The main objectives are to obtain normal joint position, mobility and muscle strength.' The techniques used to accomplish this basically consist of (a) exercises, which are often preceded by thermotherapy, to relieve pain and muscle spasm and ( b ) splinting to correct guarding of painful joints. overloading of weak muscles, co-contractions and contractures. Much of the work attempting to give physical therapy a scientific basis was done 20 to 30 years ago. Some of the methods are antique and have not been subjected to adequate scientific evaluation. However, it is generally agreed that physical therapy is an essential part of treatment of many rheumatic diseases. Several studies assessing the benefits of comprehensive management seem to support Physicans should be aware of the limitations of physical therapy, as well as understanding the rationale and complications of the modalities used.', 6, Accurate diagnosis and functional assessment are essential. Repeated visits to a physiotherapist are often unnecessary. Adequate instruction is important to allow daily home treatment and typed instruction sheets, as used at the Mayo Clinics, will ensure that the majority of patients will continue treatment.'Other factors affecting the outcome of physical therapy include co-operation by patients and relatives, adequate explanation, psychosocial factors, occupation and continuing activity of the disease.', l 3 Thermotherapy ( H e a t and Cold) The physiological effects of local heat applications are the basis for its use in physical medicine.'" It has been shown to cause analgesia by raising pain threshold", 17; to relieve muscle spasm and associated pain, by reducing the sensitivity of the muscle spindle to stretch16; to Correspondence: Dr. J. Glass Royal Newcastle Hospital, Newcastle, N S W 2300
cause general sedation'"; to alter the properties of fibrous tissue, allowing it to yield to stretch'" ", and to relieve joint stiffness subjectively and objectively." Other local effects include an increase in metabolic rate, increase in capillary flow with heat dissipation, and an increase in capillary hydrostatic pressure.'" Therefore heat, when applied before or during therapeutic exercise, will allow more effective less painful exercise, as well as helping in the correction of flexion contractures. Conversely, there is evidence that local heat, particularly deep heat, may be detrimental in active rheumatoid arthritis. The activity of synovial collagenase increases four-fold with a five degree centigrade rise in temperature, accelerating cartilage d e s t r ~ c t i o n . ~ ' -Deep ~~ forms of heat can raise intra-articular temperature, and superficial forms of heat temporarily reduce intra-articular temperatures.'", " Therefore, there is rationale for the use of superficial heat in inflammatory synovitis, rather than deep heat; the latter may be more useful in correcting contractures in a later stage of the disease.22.26 Also, deep heat often increases pain and inflammation in active synovitis.", 27 There are many methods of heat application, including superficial heat (various forms of hot packs, radiant heat, hot water baths, parrafin wax, fluidotherapy" and the deep heat modalities (short wave diathermy, micro wave and ~ltrasound).'~ There are no proven clinical advantages of one form of heat over another". 29 3 1 , and the type of heat used depends on patient preference and ease of application.' The main contraindications to heat are anaesthesia, poor circulation, oedema, haemorrhagic disorders, local malignancy, thrombophlebitis, infection and pregnancy. Short wave and microwave can also selectively heat metallic implants causing burns, interfere with cardiac pacemakers and interfere with epiphyses of growing bone.". 3 2 There are no advantages of superficial heat
JUNE
1978
PHYSICAL MEDICINE IN RHEUMATOLOGY
over superficial cold (cold compresses or spray^)'^,^^ although cold is said to help the more acute processes.'
Hydrotherapy (Pool, Hubbard Tank, Whirlpool, Contrast Bath, Hot Showers) The beneficial features are the buoyancy of the water and moist heat.', 34 Together with the analgesia and muscle relaxation from superficial heating, the buoyancy of the water allows assisted range of motion exercises due to less resistance from gravity, gentle resistance exercises by moving against the pressure of water (the resistance can be increased by faster movements) and gradual increase in weight-bearing stress by walking into increasingly shallow water. Therapeutic This is the most important aspect of physical therapy in rheumatic diseases. To achieve the maximum benefits, pain must be relieved or exercises will aggravate the pain and stiffness and cause further protective muscle spasm. Therefore, exercises are best done after adequate antiinflammatory drug therapy (systemic and local), during or after heat or hydrotherapy and at a time when morning stiffness has subsided.', 3, Misconceptions about exercises in rheumatic diseases are common among patients, and so patient education is essential to maintain the home therapy programme. Periodic visits to physiotherapy are important to check techniques. A joint should not be overexercised as this will cause increased i n f l a m m a t i ~ n . ~ ' A ~ ' rule of thumb is that, if pain does occur, it should not last more than two hours and on the following day, the pain and stiffness should be no worse than prior to therapy.' The amount and type of exercise depends on the activity of the disease and areas involved. As the activity wanes, exercises can be increased. Exercises can be divided into: 1. Re-education of muscles to overcome inhibition, co-contractions and inco-ordination. 2. Range of motion exercises within pain tolerance, to maintain optimal joint mobility. Active and active-assisted type of exercises are normally used. Gentle prolonged stretching together with heat can be used to correct contra~tures.~~
169
3. Strengthening exercises should be isometric to gain maximum muscle contraction, and this has been shown to strengthen the quadriceps in a patient with rheumatoid arthritis in the The pain produced by resisted isotonic exercise will inhibit muscle contraction, and aggravate 3y Progressive resistant exerthe joint di~ease.~'. cises can be used3', or a brief isometric maximal contraction for 6 seconds twice daily will strengthen muscle.', 35, 44, 45 Exercise can also be incorporated into daily routine household activities.'
Splints There are now many materials from which these can be made, instead of the usual heavy plaster of Paris (Hexelite, Orthoplast, Plastozote and various plastics and light metal).46-5' They are used to:
1. Rest an acutely inflamed joint, usuafiy the knees, ankles and hands, to help reduce inflammation and prevent flexion contractures that can occur in inflamed joints that are held in flexion to relieve pain. The splints can be left on for up to four weeks without range of motion exercises, with no loss of m ~ b i l i t y . As ~ ~synovitis - ~ ~ wanes, it is only necessary to use the splints at night. lsometric strengthening can be carried out in the splints. Splinting will not prevent hand deformities if synovitis persist^.^, 5 5
2. Stabilise a joint to improve function. Wrist stabilisation splints (volar or dorsal) assist hand function.39,56 Also, stabilising splints have been used for other joints, including interphalangeal joints57,5 8 , and knees.50,51, 59 3, Correct flexion contractures of knees using serial splint^.^. 51, 59, 6' Correction can be assisted by prior heat or intra-articular steroid before the cast is applied. In normal, relaxed standing, muscles are used for balance rather than to support body weight.35 If there are contractures of hips or knees, lower limb muscles have to support body weight, causing fatigue and less endurance, as well as increased compressive forces on the knees.35 4. Assist in post-surgery rehabilitation of the hand, using dynamic splints.48.62, 63
170
SUPPLEMENT
GLASS
Rest and Posture Rest in hospital will reduce inflammatory activity6', although there is no advantage in strict bedrest and splinting for long periods compared with a more liberal bedrest regime.s3.64, 6 5 When at home, rest periods during the day are said to be helpful.' When resting, postural therapy helps to prevent deformities. A firm mattress, firm back-rest, few pillows and periods lying prone are prerequisites to maintenance of correct posture. Pillows behind knees should not be used.'*35,39 Occupational Therapy's 66 This assists in assessment of activities of daily living and suggesting various aids (built-up toilet, high chair, rails and assistive devices), techniques to reduce stress to the hands; joint protection training67, energy saving techniques at w,qrk, co-ordination and strengthening of upper limbs, retraining patients unable to transfer le.g. from bed to chair) and increasing endurance with a programme of graded activity. Other Procedures and Devices These include: 1. Adequate well-fitting footwear and supports and leg length c ~ r r e c t i o n . ~ ~ - ~ ~ 2 . Calipers and braces to stabilise and relieve weight-bearing stress on hip, knee and ankle, with or without a Sach or cushion heel and rocker type sole to facilitate walking.', 60. 7 3 , 74 3. Canes, crutches and other walking aids to assist a m b u l a t i ~ n76. ~ ~ ~ 4. A "hand gym" for patients with rheumatoid arthritis which can be used at home.77 5. Stretch gloves to relieve morning stiffness and night pain.78.79 6. Reversed dynamic sling for knee flexion con tracture." Conclusion Physical therapy is not a stop-gap form of treatment, but one that is carried out throughout the patient's life. Repeated assessments are necessary, and therapy adjusted for changing goals. References 1. SWEZEY, R. L. (1974):Essentials of physical management and rehabilitation in arthritis, Semin. Arthr. Rheum. 3, 349. 2. DUFF,1. F., CARPENTER, J 0. and NEIJKOM, J . E. (1974): Comprehensive management of patients with rheumatoid arthritis, Arthr. and Rheum. 17, 635.
1,
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3 VlGNOS, P. J . J R . , THOMPSOY, H. M , K A T Z . S.. MOSKOW~TZ, R. W., FINK, S and SVEC,K. H. (1972):Comprehensive care and psycho-social factors in rehabilitation in chronic rheumatoid arthritis: A controlled study, J . chron. Dis 24, 457. 4. KARTtN. I., LEE, M. and MCEWEN,C. (1973). Rheumatoid arthritis: Five year study of rehabilitation, Arch. phq.5 Med. 54, I20 5 HARRIS, R. (1963): The rehabilitation unit in the treatment of rheumatoid arthritis, Canad. med Ass. J . 88, 139. 6. MARTIN, G . M. (1971 1: Prescribing physical and occupational therapy Handbook of physical medicine and rehabilitation, 2nd ed., W. B Saunders Co., Philadelphia, p. 510. 7. MARTIN, G . M. (1963): Physical medicine in rheumatoid arthritis, Arihr. und Rhcwm. 6, 177. 8 . Mayo Clinic Home instruction sheets for physical and occupational therapy, Muqo Foundation.
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22. 10. SMYTH,C J. and FREYBERG, R. H. (1943): Significance and management of joint pain. J mich. med. SOC. 42, 818. I I . ERICKSON, D. J . (1964) Conservative management of cervical syndromes, Postgrud Med. 38. I94 I?. HOLLEY, L. S. (1964):Physical therapy in home Care: Community focused or patient centered. J . Amer. Phqs. Thcr. Assoc. 44,901. 13 DIITHIt, J . J . R., THOMPSON, M., WEIR, M. M. and BELLFLETCHER, w. (1955): Medical and social aspects of the treatment of rheumatoid arthritis, Ann rheum. Dis 14, 133. G . K.(1971): Therapeutic heat and cold. Handbook of physical 14. STILWEIL, medicine and rehabilitation. 2nd ed., W. B. Saunders, Philadelphia, p. 259. 15. LEHMANN, J. F., BRUNNFR,G. D. and STOW,R. W (1958): Pain threshold measurements after therapeutic application of ultrasound, mi~rowavesand infra-red. Arch. phqs. Med. 39, 560. 16. FLSCHER, E. and SOLOMON, S. (1958). Physiological responses to heat and cold. Therapeutic heat, 1st ed , Elizabeth Licht, New Haven, p. 116. 17. BENSON, T B. and COPP,E. P. ( 1974):The effects of therapeutic forms of heat and ice on the pain threshold of the normal shoulder, Rheumatol. Rrhuhil. 13, 101. 18. LEHMANN, J . F.. MASOCK, A. J., WARREN, C. G . and KOBLANSKI, J . N . (1970): Effects of therapeutic temperatures on tendon extensibility, Arch.phys Med. 51, 481. J . F., WARREN, C. G . and SCHAM,S. M. (1974): Therapeutic heat 19 LEHMANN, and cold. Clin. Orthnp. 99, 207. 20. BACKLUND, L and TISELRIS, P. (1967). Objective measurements of joint stiffness in rheumatoid arthritis, Acta. rheum. scund. 13, 275. 21. HARRIS, E. D. JR. and MCCROSKERV, P. A. (1974): Influence of temperature and fibril stability on degradation of cartilage collagen by rheumatoid synovial collagenase, Neew Engl. J. Med 290, I 22. HOLLANDER, J. L. (1974): Collagenase, cartilage and cortisol, New Engl. J . Med. 290. 50. 23. CASTOR, C. W. and YARON,M. (1976): Connective tissue activation VIII. Effects of temperature studied in vilro, Arch. phys. Med. 51, 5. 24. HOLI.AVDER, J L. and HORVATH, S . M. (1949): Influence ofphysical therapy procedures on intrdarticular temperature of normal and arthritic subjects, Amer. J . med. Sci. 218, 543. 2 5 . HORVATH, S. M. and HOLLANDER, J L (1949): lntraarticular temperature as measure of joint reaction, J . clin. Invest. 28, 469. A. (1976):Deep heating of joints: A reconsideration, 26. FEiBEi., A. and FAST, 4rch. phvr M d 57. $13 27. DORWART, B. B., HANSELL, J . R. and SCHUMACHER. tl. R. JR. (1974): Effects of cold and heat on urate crystal induced synovitis in the dog. Arrhr and Rheum. 17, 563. 2X. BORRELL, R. M., HENLEY,E. J., Ho., P. and HUBBELL, M. K. (1977): Fluidotherdpy: Evaluation of a new heat modality, Arch. phys. Med. 58.69. 29. FOL'NTAIN, P , GFRSTEN,J . and SENGIR, 0 ( I 960): Decrease in muscle spasm produced by ultrasound, hot packs and infra-red Radiation, Arch. phy.;. Med. 41, 293. 30. HARRIS, R. and MILL~RD,J. B. (1955): Paraffin wax baths in the treatment of rheumatoid arthritis, Ann. rheum. Dis. 14, 27R. 31 CLARKE: G. R., WILLIS, L. A,, STENNER, L. and NICHOLS,P. I. R . (1974): Evaluation of physiotherapy in the treatment of osteoarthrosis of the knee, Rheumatol. Rehabil. 13, 190. 32. LEHMANN, J . F. (1971). Diathermy. Handbook of physical medicine and rehabilitation, 2nd ed., W. B. Saunders Co , Philadelphia, p. 273. 33. KIRK, J . A. and KERSLEI,G. D. (1967): Heat and cold in the physical treatment of rheumatoid arthritis of the knee-A controlled clinical trial, Ann phys. Med. 9, 270. 34. ZiSLis, J . M. 11971): Hydrotherapy. Handbook of physical medicine and rehabilitation, 2nd ed., W. B. Saunders, Philadelphia, p. 346. 35. KOTTKE,F. J . 11971): Therapeutic exercise. Handbook of physical medicine and rehabilitation, 2nd ed., W. 8. Saunders, Philadelphia, p. 385. 36. HARRIS,R. (1968): Physical methods in the management of rheumatoid arthritis, Med. Clin. N. Amer. 52, 707. L. T. (1934):The orthopaedic and physical therapeutic treatments of 37 SWAIN. chronic arthritis. J Amw. med. Ars 103. 1589 38. AGUDELO, C., SVHUMACHER, H. R. and PHELPS,P. (1972): Hlect ofexercise on uratecrystal-induced inflammation incaninejoints, Arthr. undRheum. 15, 609. 39. EHRLICH, G. E. ( 1973): Rest and splinting. Total management of the arthritic patient. Lippincolt. Philadelphia, p. 47. 40. CASTILLO, B A., SALLAB,R. A. and SCOTT,J . T. (1965): Physical activity, cystic erosions and osteoporosis in rheumatoid arthritis, Ann. rheum. Dis. 24, 522. 41. THOMPSON, M. and BYWATERS, E. G. L. (1962): Unilateral rheumatoid arthritis following hemiplegia, Ann. rheum. Dir 21, 370.
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42. WARREN, f.G., LEHMANN. J. F. and KOBLANSKI, J. N. (1971) Elongation of rat tail tendon: Effect of load and temperature, Arch. phys. Med. 52, 465. 43. MACHOVER, S.and SAPECKY, A. J. (1966):Effect of isometric exercise on the quadriceps muscle on patients with rheumatoid arthritis, Arch. phys. Med. 47, 737. 34. SWEZEY, R. L. (1967): Exercises with a beach hall for increasing range ofjoint motion, Arch. phys. Med. 48, 253 45. LIBERSON, W. T. (1961): Brief isometric exercises. Therapeutic exercise, 2nd. ed., Elizabeth Licht., New Haven, p. 307. 46. GARRETT, T K. (1976). BXL plastozote: A useful aid in both treatment and rehabilitation, Rheumalul. Rehabil. 15, 283. 47. DAVIE,B. and DOOLEY,B. (1976): New fihreglass casting system in orthopaedic practice, Med. J. Aust. 1, 1010. 48. SCHUTT,A. H.and CAMP,G. 0. (1976): Static and dynamic splinting of the upper extremity with orthoplast. Mayo Foundation, Rochester, Minnesota. 49 SHALIT,I. E. and DECKER, I. L. (1965): Silicone foam resting splints for rheumatoid arthritis, Lancet 1, 142. 50. MOWAT,A. G. (1970): Basic medical treatment in rheumatoid arthritis, Physiotherapy 56, 450. 51. POTTER,T.A. (1972):Prevention of deformities from arthritis. Arthritis and Al/ied C'unditiuns, 8th ed.. Lea and Febiger, Philadelphia, p. 593. S.J. and SPYKER, J. M. (1969): Beneficial effect of immobilisation of 52. GAULT, joints in rheumatoid arthritis and related arthritides: A splint study using sequential analysis, Arlhr. and Rheum. 12, 34. 53. PARTRIDGE, R. E. H. and DUTHIE, J. J . R. (1963):Controlled trial ofthe effect of complete immobilisation of thejoints in rheumatoid arthritis. Ann. rheum. Dis. 22, 91 54 HARRIS,R. and COPP, E. P. (1962). lmmobilisation of the knee joint in rheumatoid arthritis. Ann. rheum. Dis.21, 353. 55 CONVERY, F. R., CONATY, 1. P. and NICKEL, V. L. (1968): Dynamic splinting of the rheumatoid hand, Orthop. Prosthet., p. 41. 56. FRIED,D. M. (1969): Splints for arthritis. Arthritis and physical medicine, Elizabeth Licht, New Haven, p. 285. 57. BENNETT, R. L. (1965):Orthotic devices to prevent deformities of the hand in rheumatoid arthritis, Arthr and Rheum. 8, 1006. 58. BENNETT, R. (1969): Wrist and hand slip-on splints. Arthritis and physical medicine, Elizabeth Licht, New Haven, p. 484. 59. DUTHIE.J. J. R. (19691: Rheumatoid arthritis. Textbook of the rheumatic diseases', 4th ed.,'E. and S. Livingstone Ltd., Edinburgh, p. 259. 60. McCOLLCUcH, N. C., FRYER, C. M., LEHNEIS, H. R. and GLANCY, J. (1971): Lower extremity bracing, part I-IV. Amencan academy of orthopaedics, Instructional Course Lectures 20, 116.
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