Rheumatoid arthritis (RA) is a chronic, progressive disease which may lead to considerable disability. While there are no cures for RA, recent developments in biologic therapy make it possible to place many patients into remission.
In addition to medications though, it is important to add adjunctive treatments such as physical therapy and rehabilitation which help to increase functional capacity, provide pain relief, and also provide patient education.
Before starting therapy, physical assessments should include: functional assessments (what the patient is capable of at the present time), range of motion, muscle strength, posture, and level of fitness.
Cold and hot modalities are the most commonly used physical treatments in arthritis therapy. Cold application is mostly used in acute stages whereas hot is used in chronic stages of RA.
Heat works because it induces analgesia, relieves muscle spasm, and improves flexibility. Heat can be used before exercise to help loosen muscles and joints. Heat treatment may be applied as a hot-pack, infrared radiation, diathermy, paraffin, or hydrotherapy. Applications are recommended for 10-20 minutes once or twice a day. Caution should be exercised in patients with nerve damage, impaired circulation, or diabetes, since there is a risk of thermal injury.
Cold therapy is preferred in active joints where inflammation is uncontrolled. Cold packs, ice, nitrogen spray, and cryotherapy are different ways of applying cold-therapy.
Cartilage-destroying enzymes such as collagenase, elastase, hyaluronidase, and protease are produced in the inflamed joints of patients with RA. Levels of these enzymes are affected by the temperature in joints. Increasing temperature inside the joint leads to an increase in collagenase activity and cartilage damage.
Electrostimulation is used in patients with RA to relieve pain. Transcutaneous electrical nerve stimulation (TENS) therapy is the most commonly used method. TENS is a short-acting therapy and it also has a high placebo effect.
Water therapy, also known as hydrotherapy or balneotherapy” has been used for arthritis since ancient times.
Objectives of hydrotherapy are to increase range of motion, strengthen muscles, relieve painful muscle spasms, and improve a patient’s well-being.
There have been studies showing beneficial effects of hydrotherapy with pain reduction and improvement in grip strength. Because of buoyancy, water therapy allows patients to perform exercise without undue joint stress. Some studies have shown that hydrotherapy leads to muscle, tendon, and ligament relaxation and a feeling of well-being. Endorphin release may also contribute to improved pain control.
Some have suggested that water therapy may have beneficial immune system benefits with reduction in pro-inflammatory cytokines.
Physical and occupational therapists educate patients in joint protection strategies, use of assistive devices, and performance of therapeutic exercises.
Joints should be put at rest during the acute phase 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. Fortunately, bed rest is not needed as much as it once was. Splints are used to keep involved joints in a functional position. Splints help to mitigate pain and inflammation, prevent development of deformities, prevent joint stress, support joints, and decrease joint stiffness.
Wrist splints and ring splints are useful for reducing inflammation and preventing deformity in the hands.
Joint stress in the feet can be reduced by using a supporting pad at the sole of the foot and by using metatarsal pads. Visco-elastic soles may help reduce shock loading occurring in the legs with walking.
For RA patients with serious neck involvement, particularly with the first and second vertebrae, a Philadelphia collar may be needed. The Philadelphia device provides excellent immobilization and may be used in the presence of neck instability.
Patients using compression gloves have reported reduced joint swelling and pain but there is no hard evidence that they improve grip strength or hand function. Improvement may be provided by using compression gloves both during the day as well as at night in patients with inflammation in their hands or fingers.
Occupational therapy interventions such as assistive devices and adaptive equipments have beneficial effects on joint protection and energy conservation in arthritic patients. Assistive devices are used in order to improve functioning, reduce pain, and keep patients self sufficient.
Loading over the hip joint may be reduced by about 50% by using a cane. Elevated toilet seats, widened gripping handles, bathroom adjustments all help improve activities of daily living.
Massage is used to improve general well being and help diminish swelling of inflamed joints. Massage can help with depression, anxiety, mood, and pain.
Muscle weakness in patients with RA occurs as a result 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 prophylaxis of traumatic injuries. Exercise therapy has beneficial effects on RA by improving endurance and enhancing fitness.
Things to consider before launching an exercise program include: whether the involvement of the joints is local or systemic, disease stage, patient age, and patient compliance.
Range of motion exercises, stretching, strengthening, aerobic conditioning exercises, and routine daily activities all should be included in a comprehensive exercise program.
Every joint should be moved in full range of motion at least once per day in order to prevent contracture. In the case of acutely inflamed joints, isometric exercises provide muscle tone without worsening disease activity.
If the disease activity is minor, then isotonic exercises should be performed by using very low weights. 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 the program should be made less intense. Walking can aggravate knee pain in patients with active inflammation. Therefore, patients with active RA should avoid activities such as climbing stairs or weight lifting. Producing excessive stress over the tendons during the stretching exercises should be avoided.
When arthritis is controlled medically, conditioning exercises such as swimming, walking, using an elliptical trainer, and cycling with adequate resting periods are recommended. They increase muscle endurance and aerobic capacity and improve function of the patient, and they also make the patient feel better.