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physio therapy modalities in R.A( rhematoid arthritis)

physio therapy modalities in R.A( rhematoid arthritis)

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Published by Mihir_Mehta_5497

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Published by: Mihir_Mehta_5497 on Jul 12, 2010
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05/16/2012

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Physiotherapy modalities are commonly used in the treatment of Arthritis.
 
1)
 
cold/hotapplications,2)
 
electrical stimulation3)
 
hydrotherapy.
Controlled studies performed with adequate numbers of cases and using validatedobjective measures to evaluate various physiotherapy and rehabilitation methods inarthritis are quite rare. This is because the disease process may be affected by variousfactors, and the actual effectiveness of the investigated agents is difficult to determine.However, various physiotherapy agents are commonly used in daily practice; most often,their use is based on personal experiences.
Cold/Hot Applications
Cold/hot modalities are the most commonly used physical agents in arthritis treatment.It is well known that cold application is mostly used in acute stages whereas hot is used inchronic stages of Arthritis.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 ortwice a day. Caution is necessary in patients with sensorial deficits and impaired vascularcirculation 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, andcryotherapy are different methods of applying cold-therapy.Cartilage-destroying enzymes are produced within the inflamed joints of patients.Levels of destructive enzymes such as collagenase, elastase, hyaluronidase, and proteaseare 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 patient. Increasing intra-articulartemperature is also related to an increase in collagenase activity and cartilage damage.Despite the inhibition of cell proliferation and metabolic activation within the synovial fluidat 41–42° Celsius, it cannot be used as a therapeutic method because of irreversible jointdamage. Various studies have investigated the changes within joints upon application of heat. Intra-articular temperature increased by superficial heat application. In the first 5minutes, the joint temperature decreased but subsequently, as expected, it began to rise. Ithas been suggested that within the first few minutes, superficial vessels become dilated andcirculation moves away from the inflamed synovial tissue. The opposite of this occurs duringthe cold application. Effects of heat application change between normal healthy subjectsand patients with inflamed joints. Accordingly, skin temperature rises with paraffin at the
 
most and intra-articular joint temperature with diathermy application. Temperatureincrease with short-wave diathermy application continues for 40 minutes. However, it hasbeen observed that increased intra-articular temperature has no beneficial effect on clinicalprognosis or radiologic progression. Skin temperature decreases the most by cold airapplication, whereas intra-articular temperature decreases the most by ice application.Increased intra-articular temperature by cold-pack application may be explained byreactional temperature rise with short-term application, which was previously mentioned.
Electrical Stimulation
Electrostimulation is used in patients with Arthritis to relieve pain. Transcutaneouselectrical nerve stimulation (TENS) therapy is the most commonly used method.Mannheimer and Carlsson applied TENS at various frequencies and reported that thehighest frequency TENS was the most beneficial, with an analgesia that persisted up to 18hours. Various studies have reported an increase in hand grip strength after dailyapplication of 15 minutes of TENS and a decrease in pain after using TENS once a week for 3weeks. Levy and colleagues observed reduction of synovial fluid and inflammatory exudatefollowing TENS application in acute arthritis and suggested that pain relief may be partiallyexplained by this effect. Postoperative pain control by TENS therapy following knee jointarthroplasty reduces need for analgesic drugs and hospital stays. Due to the variationsbetween the materials and methods of the studies, it is difficult to interpret TENSapplications. Nevertheless, TENS is generally a short-acting therapy (6–24 hours), and themost beneficial frequency is 70 Hz. It also has a high placebo effect. It cannot be used inevery painful joint simultaneously, which is a disadvantage in patients with polyarticularinvolvement.Interferential current can also be used for analgesia. Studies have shown its efficacy on painrelief, swelling, and improvement in ROM, Also, no difference was found betweeninterferential current and TENS in the magnitude of analgesia.
 
Hydrotherapy 
There has been widespread use of balneotherapy by patients with rheumatic diseasessince the old times in search of a cure for their ailment. Therefore, there are somesuggestions that the science of rheumatology has been developed in balneotherapy.Initially, the term “balneotherapy” was used to discriminate thermal and mineral watertherapy from hydrotherapy, but today these terms are often used interchangeably. Inrecent years, balneotherapy has served as one of the therapeutic alternatives in otherrheumatoid diseases, particularly in chronic degenerative diseases. Objectives of balneotherapy are to increase ROM, to strengthen muscles, to relieve painful musclespasms, and to improve the patient's well-being.Balneotherapy in arthritis treatment is a disputed issue. O'Hare and colleagues havereported an increase in diuresis, hemodilution, and a reduction in rheumatoid factor levels.
 
In contrast, Becker has attributed the main effect to a decrease in joint loading, relaxation,and an increase in general physical conditioning. There have been studies showing beneficialeffects of balneotherapies on several factors such as reduction in pain and grip strength.Effectiveness of balneotherapy is not only associated with hot water but also with theminerals contained in the water. It has been claimed that mineral waters have some positiveeffects in balneotherapy. Water has mechanical, chemical, and physical action mechanisms.Its mechanical action occurs during the bath when the body weight decreases by 50% to90% depending on the type of bath. In cases of muscle weakness or widespread painful jointinflammation, this action allows the patients to perform their exercise programs. Inaddition, various studies have shown that balneotherapy leads to muscle, tendon, andligament relaxation and a feeling of well-being. Here the action mechanism providesexponential benefits. Decreasing perception of pain by increasing the pain thresholds at freenerve endings, relieving muscle spasm by effecting gamma muscle fibers, peripheralvasodilatation, and removal of painful mediators are among these mechanisms. In addition,balneotherapy has a sedating effect by increasing acetylcholine release from the centralnervous system through activation of parasympathetic nervous system. Endorphin releasethroughout the therapy also contributes to improved action mechanisms.Effects of balneotherapy on the immune system have recently become a subject of interest.There are some speculations about its immunostimulatory and inhibitory effects. Inparticular, alterations in release of interleukin-1 and interleukin-6, tumor necrosis factor-alpha, and gamma-interferon, which have a role in etiopathogenesis of inflammatoryarthritis, have been reported.Environmental changes while at balneotherapy should also be considered. Physical andmental comfort, cessation of home duties, and vacation atmosphere are among positivefactors that may also contribute to the healing process.In conclusion, although the effects of balneotherapy are currently not clarified, it is apalliative treatment in rheumatoid diseases through various mechanisms. There is need forfurther appropriately designed studies encompassing assessment of quality of life as anoutcome measure.Physiotherapy treatment is important in helping patients with Arthritis manage theirdisease. In conjunction with occupational therapists, physiotherapists educate patients in joint protection strategies, use of assistive devices, and performance of therapeuticexercises.
Joint Protection Strategies
Joint protection strategies, such as rest and splinting, using compressive gloves, assistivedevices, and adaptive equipment, have beneficial effects in managing Arthritis symptomsand deformities.

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